Fall 2007 - The Campbell Foundation
Transcription
Fall 2007 - The Campbell Foundation
The Campbell Foundation Momentum Enhancing Quality of Life Through the Science of Orthopaedic Medicine • Fall 2007 Simple act of walking on two feet gives patient reason to celebrate A devastating accident broke every bone in Martha Moosmann’s foot. She will forever be grateful to the Campbell Clinic surgeon who believed her foot could be saved. W hen Martha Moosmann gets dressed for church next Sunday, the only part of her ladylike wardrobe that will look a little less than perfect will be the neat white tennis shoes on her feet. “Oh, it will be nice if one day I can wear dressy shoes to church again,” Martha says with a smile. “But right now, I’m just happy to be wearing any kind of shoes at all.” In January of 2006, on a Sunday morning as she was driving home from church, Martha was hit head-on by another driver. Every bone in her right foot was broken, and some were crushed. Doctors considered amputation. “I believe my faith in God and Campbell Clinic are the reasons I still have my foot and can walk on it again,” said Martha. “Having to wear less-thanpretty shoes doesn’t seem like much when you consider what might have been.” Every bone was broken In the accident almost two years ago that changed Martha’s life, the other driver’s SUV slid on a rainslicked roadway, crossed the center lane, and slammed into Martha’s small convertible. In the impact, the dashboard of Martha’s car collapsed onto her right foot, breaking all the bones and dislocating her ankle. Martha also suffered head injuries, broken ribs, and facial cuts. “I was taken to The Med (the Regional Medical Center at Memphis) and was unconscious until the next day,” she said. “One of the first things I remember was seeing about six doctors standing at the foot of my bed, with their arms crossed, looking at my foot and ankle. They said they had looked at my x-rays and they thought I would be better off if they amputated my foot.” Campbell Clinic provides orthopaedic services to The Med. On call that Sunday afternoon was Dr. Susan Ishikawa, a foot and ankle specialist who served a fellowship at Campbell Clinic in 1999 and joined the Clinic’s staff in 2005. “Mrs. Moosmann had one of the worst foot injuries I had ever seen,” said Dr. Ishikawa, who treated numerous blast injuries while serving as an orthopaedic surgeon at a surgical station outside Bagdad. “She had severe fractures and dislocations of the hind foot and mid-foot.” “Dr. Sue (Ishikawa) was very straightforward,” Martha said. “She agreed with the other doctors that the injury was severe. She didn’t make any promises, but she was willing to try to save my foot. I had a lot of confidence in her, in part because of past experience I had with Campbell Clinic.” continued on page 2 Martha Moosmann has resumed many of her favorite activities, including gardening. On the road to recovery, Martha accumulated a large collection of tennis shoes, the only footwear comfortable on her injured foot. A good feeling about Campbell Clinic Dr. Susan Ishikawa In 2002, Martha fell in an icy parking lot at a local mall on New Year’s Day. She heard a loud pop and was unable to get up. At a nearby emergency room, x-rays revealed she had a shattered patella. “When they asked if I knew an orthopaedic doctor that they should call, I remembered Dr. David LaVelle of Campbell Clinic, who had treated my son’s football injury some time ago,” Martha said. “Dr. LaVelle came right on, even though it was a holiday. I had surgery involving pins and rods, but in time, I was able to resume my normal activities. So I had a good feeling about Campbell Clinic.” Martha retired in 2003 after a busy career as a bank manager in Germantown, and she began filling her days with activities she enjoys: sewing, “Through all this, Dr. Sue always gave me hope. She and her staff were always so encouraging.” — Martha Moosmann gardening, bike riding, walking for fitness and pleasure, and traveling. A widow who remarried several years ago, Martha and her husband Pete spent a month in Paris in the summer of 2005. “We hiked all over Paris. We both enjoyed walking,” Martha said. “I just couldn’t imagine losing my foot and how my life would change. I promised Dr. Sue that if she would do everything she could to save my foot, I would do everything I could to get better. And I will forever be grateful that she was willing to try.” Many steps to recovery During the 17 days she was hospitalized at The Med, Mrs. Moosmann underwent three surgeries in which Dr. Ishikawa worked to realign the foot and ankle. The realignment required that Dr. Ishikawa insert screws inside Martha’s foot and a frame outside the foot. The frame is an external fixation device that provides greater stabilization of multiple fractures in patients with severe trauma to the foot than is possible through screws alone. Later, Dr. Ishikawa performed two additional surgeries at Campbell Clinic Surgery Center to remove pins and screws. “During the course of my recovery, I went from a wheelchair to a walker to crutches to a cane, and now to a brace on my foot,” Martha said. “There was a time when I had rods sticking out of my foot like some kind of laboratory monster, and I had to cut my pants legs to get them over the rods. There was tremendous swelling, so that my foot looked like a loaf of bread. “Through all this, Dr. Sue always gave me hope,” Martha said. “I knew, because she was with Campbell Clinic, that she was a skilled and able surgeon. But she was also patient. She and her staff were always so encouraging. Each time I would ask if I would ever be able to walk on the foot again, she would say, ‘You still have a ways to go, but you are ahead of where I thought you would be at this point in your recovery.’” At one time, Martha had a cast up to her knee. Then she wore a medical boot so heavy that she couldn’t turn over in the bed at night. Missing her active life, Martha compensated by crocheting and knitting. She responded to dozens of get-well cards from friends who followed her progress. She also kept a journal. Foot & Ankle Facts Nearly one-fourth of all bones in your body are in your feet. The feet of the average adult log more than 1,000 miles each year. A recent National Hospital Ambulatory Medical Care Survey indicated that foot or ankle symptoms accounted for 12.8 million physician visits annually. Common types of non-traumatic foot and ankle injuries include: Ankle sprains, often caused by sports injuries. Achilles tendon injuries. Sports that tighten the calf muscles, such as basketball and running, can overstress this tendon. Overuse injuries. Excessive training, such as running long distances without rest, places repeated stress on the foot and ankle. The result can be stress fractures and muscle/tendon strains. Shin splints. Pain in front of the shin bone (tibia) usually is caused by a stress fracture, called shin splints. Overtraining, poorly fitting athletic shoes, and a change in running surface can cause shin splints. SOURCE: American Academy of Orthopaedic Surgeons; American Orthopaedic Foot and Ankle Society. “Mrs. Moosmann was an excellent patient,” Dr. Ishikawa said. “She was very proactive, always following directions and remaining optimistic. Her positive attitude played an important role in her recovery.” “It was more than a year before I could put my weight on my right foot again,” Martha said. “I had days and months with pain and anxiety. But now I thank God for every step I take.” Walking without pain Today Martha can walk without pain. She still has occasional swelling when she is on her feet for a long time, “but I can live with that,” Martha said. Her footwear consists solely of tennis shoes with special inserts to support her foot. A brace that fits into the shoe supports her ankle. Martha’s husband Pete underwent hip replacement surgery performed by Dr. John Crockarell of Campbell Clinic in July 2007, and the two of them now make swimming in their backyard pool a primary fitness activity. Martha still enjoys shopping with her granddaughter, although the trips are shorter than before. “I believe in prayer,” Martha said, “and I believe it is a miracle that I am using my foot again, considering how badly I was injured. My husband, my family, my church, and my friends were always there for me. And I credit God and Dr. Sue. If it were not for them, I wouldn’t be walking on two feet today.” During 2006, Campbell Clinic foot and 13,000 patient visits. ankle surgeons recorded over DePuy renews support for Campbell Foundation’s physician education programs DePuy Orthopaedics, Inc., a global leader in joint replacement products, has renewed its sponsorship of the E. Greer Richardson, M.D. Foot and Ankle Fellowship and the E. Greer Richardson, M.D. Foot and Ankle Rotation in the UT-Campbell Clinic orthopaedic residency program. The fellowship, established by DePuy in 2006, annually enables one or two talented orthopaedic surgeons to complete an intensive 12-month fellowship in surgery of the adult foot and ankle. Dr. Jay Womack, the 2007-08 E. Greer Richardson, M.D. Foot and Ankle Fellow, was a Campbell Clinic resident prior to beginning the fellowship. Dr. Jay Womack DePuy’s sponsorship of the E. Greer Richardson, M.D. Foot and Ankle Rotation supports a period of focused training in foot and ankle for all physicians in the Campbell Clinic residency program. The rotation and fellowship honor Dr. Greer Richardson, a Campbell Clinic physician since 1977 and a past president of the American Orthopaedic Foot and Ankle Society. DePuy has also renewed its support of the Marcus J. Stewart, M.D. Rotation in Anatomy and Pathology in the UT-Campbell Clinic residency training program. A Johnson & Johnson company, DePuy designs, manufactures, and distributes orthopaedic devices and supplies. The company is committed to helping surgeons achieve excellence in surgical practice and to Restoring the Joy of Motion™ for patients whose mobility is restricted by severe osteoarthritis or other debilitating injury. Dr. Frederick Azar, Director of Resident Education for The Campbell Foundation, said, “DePuy’s continuing commitment to education and research through the UT-Campbell Clinic program is having a positive impact on thousands of patients in the present and into the future.” I n M e m o r i am Fund honors Dr. Rocco Calandruccio, a pioneer in adult joint reconstruction Patients remember Dr. Rocco Calandruccio “In addition to being a skilled surgeon, Dr. Cal had a great bedside manner. He was always smiling when he came into my room. He told you exactly what your condition was and how he was going to make you better. And, in my case, he did make me better!” —Josh Bell III of M emphis, who broke his neck in a diving accident as a college student. A fter Dr. Calandruccio performed surgery, Bell recovered and has led a full , active life. “My gift to The Campbell Foundation in honor of Dr. Calandruccio reflects my respect and admiration for him as a surgeon, administrator and friend. I wanted to support orthopaedic research and education because I know those are things he cared about.” —Diana Crump of M emphis, a Campbell Clinic patient Dr. Rocco A. Calandruccio The Rocco A. Calandruccio Research and Education Fund has been established at The Campbell Foundation in honor of a Campbell Clinic surgeon widely admired for his achievements in research, his commitment to training future orthopaedic surgeons, and his devotion to quality patient care. Dr. Calandruccio, who died this summer at the age of 84, served as Campbell Clinic’s Chief of Staff and as chairman of the UTCampbell Clinic Department of Orthopaedic Surgery during the 36 years he practiced at Campbell Clinic. He authored numerous scientific articles and contributed to several editions of Campbell’s Operative Orthopaedics. One of his sons, Dr. James Calandruccio, currently practices orthopaedic surgery at Campbell Clinic as a hand specialist. Of the fund established in memory of his father, Dr. Jim Calandruccio said, “If my dad had written his own obituary, he would have reached out to those who supported his life work and suggested they contribute to promote research and education at The Campbell Foundation.” Dr. and Mrs. Arsen Manugian have made a gift to the fund at The Campbell Foundation honoring Dr. Calandruccio. Dr. Manugian, a surgeon with Memphis Orthopaedic Group, said, “I feel privileged to have had Dr. Cal as a teacher. He will be fondly remembered as a great educator and mentor who had a significant impact on generations of budding young orthopaedists. He will always be considered one of the outstanding surgeons of his time.” “Dr. Cal,” as he was known by colleagues and patients alike, became a pioneer in adult joint reconstruction in the United States after studying under Sir John Charnley, inventor of the first hip implant. Dr. Calandruccio developed procedures and implants that enhanced patient care, including a triangular clamp used to fuse the ankle joint. Dr. Robert Tooms, who serves on The Campbell Foundation’s board of trustees and practiced with Dr. Calandruccio at Campbell Clinic, said, “Dr. Rocco Calandruccio was regarded nationally and internationally as one of our most outstanding orthopaedic surgeons. He was an excellent clinician, academician and researcher.” Dr. Tooms worked with Dr. Calandruccio for one year in the research lab at UT-Campbell Clinic prior to beginning his residency in orthopaedic surgery. “Cal was responsible in great measure for my obtaining a residency at Campbell Clinic,” Dr. Tooms said. “After I joined the Clinic’s staff, we became close colleagues and good friends over the years. He had quite an influence on me. Orthopaedic surgery — and I personally — will miss him very much.” A graduate of Yale Medical School, Dr. Calandruccio served as president of the American Academy of Orthopaedic Surgeons in 1977. During his presidential address to the group, Dr. Calandruccio emphasized the importance of research in advancing the field. “Research is the lifeline of orthopaedic surgery,” he said. “Patient care is improved by clinical observation and correlation as well as by the refinement of surgical procedures, but the giant steps are based on physiologic and biologic observations and experiments.” Donations in memory of Dr. Calandruccio may be sent to the Rocco A. Calandruccio Research and Education Fund at The Campbell Foundation, 1400 South Germantown Parkway, Germantown, TN 38138. Call The Campbell Foundation at (901) 759-5490, or e-mail jstrain@ campbell-foundation.org. Dr. Marcus Stewart, sports medicine leader, leaves a legacy of achievements and caring Dr. Marcus Stewart, the last surviving Campbell Clinic surgeon who studied under Dr. Willis C. Campbell, died August 1, 2007, at the age of 96. During his distinguished career, Dr. Stewart founded the American Orthopaedic Society for Sports Medicine and served as its president, served on the U.S. Olympic Committee’s sports medicine council, was orthopaedic surgeon for Ole Miss sports teams for 20 years, and published numerous articles on orthopaedic and sports medicine topics, including his contributions to several editions of Campbell’s Operative Orthopaedics. He began his residency at Campbell Clinic in 1938 and retired from Campbell Clinic in 1981. Dr. Stewart’s daughter, Dr. Jeanne Jemison, said, “My father’s passion for teaching was the driving force behind his desire to join the staff of the Campbell Clinic. Teaching residents and medical students energized his entire career at Campbell and brought him joy in retirement through on-going relationships with those he had taught and mentored. The educational mission of The Campbell Foundation fosters the desire to promote the best in orthopedics, which motivated my father and other pioneers of the Campbell Clinic.” “A positive attitude and a cheerful countenance will often relieve and cure a patient as efficiently as your scalpel.” — Dr. Marcus Stewart During World War II, Dr. Stewart directed a large Allied rehabilitation hospital in England and set new standards for the rehabilitation of injured soldiers. He was awarded the Army’s Legion of Merit for that work. Athletic and an avid sportsman who hunted well into his 90s, Dr. Stewart began each day with a 45minute exercise routine. He believed in the power of good health and a positive attitude. “A positive attitude and a cheerful countenance will often relieve and cure a patient as efficiently as your scalpel,” he said. In his autobiography, One More Step, Dr. Stewart wrote that regardless of one’s previous accomplishments, it is “always possible to take one more step toward greater achievement and helping others.” Proud of his association with Campbell Clinic, Dr. Stewart once told a class of the Clinic’s graduating residents that “an immeasurable heritage of honesty and integrity” was the greatest gift made by the founders of Campbell Clinic. Dr. Marcus Stewart, who trained under Dr. Willis Campbell and was a Campbell Clinic surgeon for more than 40 years, founded the American Orthopaedic Society for Sports Medicine. “The giants of orthopaedics who developed Campbell Clinic were also giants of the human race,” he said. “From them, residents learn and inherit not just technical knowledge but a quality of life, of tolerance, of pride, of justice, of self-respect and even of reverence that so permeates their teaching that it will stimulate and sustain you throughout life.” Colleagues, patients and friends who wish to honor Dr. Marcus Stewart’s lifetime dedication to orthopaedic medicine may do so by making a gift to an organization Dr. Stewart supported: The Campbell Foundation. To make a gift in Dr. Stewart’s memory, contact the Development Office of The Campbell Foundation at (901) 759-5490, or e-mail [email protected]. Educ at ion News Global audience welcomes new edition of Campbell’s Operative Orthopaedics The 11th edition of Campbell’s Canale and Dr. James Beaty are the book’s editors. Operative Orthopaedics may not sell as Kay Daugherty, one of the book’s scientific many copies as the latest thriller from editors, said medical professionals throughout the John Grisham or Tom Clancy. But for United States and around the world often refer to the dedicated audience that depends Campbell’s Operative Orthopaedics as “the bible of on each new edition of Campbell’s orthopaedic surgery.” famed textbook to keep them up-to“There are thousands of doctors who only have date on developments in orthopaedic one book on orthopaedics in their offices or clinics, surgery, the 11th edition is as eagerly and that book is Campbell’s Operative Orthopaedics,” anticipated as a new volume from a Daugherty said. superstar author. The 11th edition marks the first time the book Available in December 2007, the will be printed in full color, which allows for better 11th edition features updates on depiction of intra-operative photographs and the more than 1,800 procedures, as well use of color to denote emphasis in illustrations and as completely new material on 90 graphics. An on-line edition of the book and the procedures. More than 9,000 drawings, diagnostic videos will be available on the Internet. images, and clinical photographs are included in the book, which is published in four “There are thousands of doctors who only volumes. The edition also includes two CDROMS, one of which presents video clips of have one book on orthopaedics in their Campbell Clinic surgeons demonstrating key offices or clinics, and that book is Campbell’s procedures. The 10th edition of Campbell’s Operative Operative Orthopaedics.” — Kay Daugherty Orthopaedics was published in 2002. New material in the 11th edition includes discussions of minimally-invasive approaches to total hip The first edition of Campbell’s Operative Orthoand total knee replacement, information on lowpaedics, published in 1939, was written in longhand profile implants for fracture fixation, descriptions by Dr. Willis C. Campbell, based on his vast knowof new devices for spine instrumentation, in-depth ledge of orthopaedics. commentary on new bone grafting materials, and “The mission of The Campbell Foundation is details on expanded use of arthroscopy and endoscopy. to promote the advancement of orthopaedics, and The Campbell Foundation provides all the Campbell’s Operative Orthopaedics is a key resource in research, editorial, graphics, and clerical support helping us fulfill that mission,” Dr. Canale said. “We for the publication. The text is written entirely by know that surgeons here and abroad count on the Campbell Clinic surgeons, with 23 of the Clinic’s book to help them in treating their patients, so we feel physicians contributing to the 11th edition. Dr. Terry an obligation to make every edition the best it can be.” 2007 graduates of the Campbell Clinic Residency Program (Seated, from left) Dr. Duane Belongie, Gener al Orthopaedic Pr actice, Tampa, FL; Dr. Judd Cummings, Orthopaedic Oncology Fellowship, University of Utah/ Huntsman Cancer Center , Salt L ake City, UT; Dr. John Balbas, Sports M edicine Fellowship, Hughston Clinic, Columbus, GA; Dr. Paul Whatley, Sports M edicine Fellowship, Hughston Clinic, Columbus, GA (Standing, from left) Dr. M att M ayfield, Pediatric Orthopaedic Fellowship, Children’s Hospital Boston, Boston, MA; Dr. Dan Fletcher , H and Surgery Fellowship, The H and Center , San A ntonio, TX; Dr. John Babb, Sports M edicine Fellowship, Cincinnati Sports M edicine Center , Cincinnati, OH; Dr. Jay Womack, Foot & A nkle Fellowship, Campbell Clinic, M emphis, TN; Dr. M ark Pierce, Orthopaedic Pr actice, A nderson, SC Late surgeon continues to help patients through his estate gift The life of Dr. Robert Knight was tragically cut short in an automobile accident in 1958. But his devotion to orthopaedic medicine and orthopaedic patients lives on, thanks to a gift to The Campbell Foundation that Dr. Knight included in his will. Dr. Knight, a Campbell Clinic surgeon from 1942 until his death, created a trust that provided income for his wife during her lifetime. When Mrs. Angela Knight Owen died earlier this year, the principal was left to the Foundation. A gifted surgeon, Dr. Robert Knight was one of three physicians who staffed Campbell Clinic during World War II, while most of the Clinic’s surgeons were serving in military assignments. Dr. Knight worked long days and weekends for more than three years, until the war ended. A tribute in The Campbell Journal after his death described Dr. Knight as “kind, warm and personable” New book in evolving field of interventional spine includes chapter by Campbell’s Dr. Ashley Park A Campbell Clinic physician who specializes in non-operative approaches to treating spinal pain is among the contributors to a new textbook designed to help doctors evaluate spinal pain treatment options less haphazardly. Dr. Ashley Park, who joined Campbell Clinic in 1998 as the clinic’s first interventional spine physician, wrote the chapter on lumbar instability for Interventional Spine: an algorithmic approach, published in August 2007. For information about making an estate gift to The Campbell Foundation, ask your financial advisor to contact Carol Kirby at the Foundation at (901) 759-5490, or e-mail [email protected]. and said that he “combined high intelligence with strong motivation, seemingly boundless energy and enthusiasm, and a deep and thorough knowledge of the orthopaedic literature, which was enviously admired by all.” Dr. and Mrs. Knight were committed to The Campbell Foundation during his lifetime. Now Dr. Knight’s estate gift will continue to support The Campbell Foundation’s mission of advancing orthopaedic research, physician education, and community healthcare. Dr. James Beaty, Chief of Staff of Campbell Clinic and a member of the Foundation’s board of trustees, said, “Dr. Knight’s generous gift is evidence of his dedication to the mission of the Foundation. We hope his estate gift will inspire others to create a legacy supporting advancements in orthopaedic care through a gift to The Campbell Foundation.” Dr. Robert Knight Editors and contributors to the book, including Dr. Park, believe that patients deserve the most conservative care feasible, but the alternatives must be wisely considered and balanced by an individual’s physician. “Doctors in a wide variety of specialties practice spine care,” Dr. Park said. “Our goal is to provide those physicians with something that has been lacking, which is a step-wise approach to evaluating diagnostic and treatment interventions and therapeutic alternatives.” Dr. Park studied under the book’s principal editor, Dr. Curtis Slipman, during a residency at The Hospital of the University of Pennsylvania. “Dr. Slipman’s vision was to publish a comprehensive evidencedbased approach on the diagnosis and treatment of patients with spinal pain, incorporating contributions from top clinically-active interventional spine physicians,” Dr. Park said. “Since interventional spine Dr. Ashley Park is an integral part of the spine program at Campbell Clinic, one of the foremost orthopaedic centers in the world, the editors felt that my input toward the topic of lumbar instability would be insightful.” Interventional, or non-surgical, treatment for spinal pain is a growing field. During the past 20 years, a number of studies have indicated that non-operative management of spine-related problems may be preferable to surgery for some patients. “One aspect of non-surgical treatment within the scope of an interventional spine practice is the use of diagnostic and therapeutic spinal injection procedures performed under x-ray guidance,” Dr. Park said. “These injections are valuable in diagnosing the specific structure responsible for a patient’s spinal pain and, in many cases, used in conjunction with other nonsurgical treatment, are curative.” Dr. Park contributed a chapter on interventional spine treatment options to the 11th edition of Campbell’s Operative Orthopaedics, which will be released in December 2007. “Those of us who have experience in an evolving field such as interventional spine have an obligation to share this newfound knowledge with the rest of the medical community for the advancement of patient care,” Dr. Park said. Fou n dat ion News Synthes supports trauma fellowship at Campbell Synthes, provider of skeletal fixation instruments and implants, renewed its grant to The Campbell Foundation to support surgeon education and training with the Synthes Trauma Fellowship. The 2007-2008 Synthes Trauma Fellow is Dr. Mark Parrella, who graduated from Georgetown University School of Medicine and completed his residency at Drexel University School of Medicine. Representatives from Synthes were recognized for their generous support at a residents’ training meeting. From left: Dr. Frederick Azar, Director of Resident Education at The Campbell Foundation; Jerry Sheally, Synthes Memphis-area sales consultant; Tim Akers, Synthes Regional Manager; Dr. James Beaty, Campbell Clinic Chief of Staff; Jevon Sisnett, Synthes Memphisarea sales consultant; Dr. Mark Parrella, Synthes Trauma Fellow; Dan Clark, Synthes Memphis-area sales consultant; and Dr. Edward Perez, Campbell Clinic trauma surgeon. C am p b e l l F o u n d a t i o n Mission statement Our mission is to restore quality of life through the science of orthopaedic medicine worldwide. Since 1946, we have been committed to advancing surgeon education, orthopaedic research, and community healthcare. How you can help Your tax-deductible gift will: Educate the next generation of outstanding orthopaedic surgeons through our distinguished residency and fellowship programs. Support promising research to discover new solutions in areas such as osteoarthritis, joint replacement, cartilage regeneration, spinal disorders, trauma care, and children’s bone and joint diseases. of others for generations to come. Donors who remember The Campbell Foundation through their bequests will be recognized and honored as members of the Campbell Legacy Society. Provide orthopaedic care to children and adults, regardless of their financial circumstances, through our community outreach clinics. For more information Carol Kirby Executive Director of Development 1400 S. Germantown Road Germantown, TN 38138 (901) 759-5490 [email protected] Consider making a gift... to The Campbell Foundation in your will or other estate plans and you will be making a difference in the lives For a fuller life. For a better future. Support The Campbell Foundation. The Campbell Foundation www.campbell-foundation.org O rt h o pa e d i c Re s e a r c h • Su r g e o n Ed u c at i o n • Co m m u n i t y He a lt h c a r e