Archive for the ‘Medical Professionals’ Category

Robotic Thyroid Surgery Now Offered at Nebraska Medicine

 

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After being diagnosed with thyroid cancer, 24-year-old Katie O’Callaghan of Hastings, Nebraska, underwent a robotic thyroidectomy at Nebraska Medicine. The incision was made behind her earlobe. 

Katie O’Callaghan was working the checkout line at her parents’ grocery store in Hastings, Nebraska, when a customer noticed a lump on O’Callaghan’s neck. The 24 year old, who was four months pregnant with her first child, brought it up at her next OBGYN appointment. A biopsy later revealed she had thyroid cancer.

“I couldn’t believe it,” says O’Callaghan. “Being pregnant with my first child was intimidating enough, let alone discovering I had cancer.”

Wanting a second opinion, O’Callaghan was referred to Estelle Chang, MD, a former Otolaryngology Head and Neck surgeon at Nebraska Medicine, who completed a six-month Advanced Robotic Head and Neck Endocrine Surgery Fellowship at Severance Hospital of the Yonsei University Health System in Seoul, South Korea. During her fellowship, Dr. Chang studied the latest, minimally invasive, thyroid and parathyroid surgery techniques.

“Traditionally, thyroidectomy has been performed using a 4 to 8 cm incision in the front of the neck, which can leave a visible scar,” explains Dr. Chang. “Robotic thyroidectomy is a minimally invasive surgical technique that is used to remove all or part of a thyroid gland without leaving a visible scar. This is the future and we should be at the forefront.”

At Nebraska Medicine, three robotic thyroidectomy approaches are offered for patients:

  • Underarm

  • Facelift (behind the earlobe)

    • If the patient wants a complete facelift at the end of the procedure, that’s a possibility

  • Through the mouth

“We can tailor to the patient, depending on the size of the tumor and the patient’s physical characteristics,” explains Dr. Chang. “This type of surgery is a great option for Caucasians who tan easily, African Americans and Asians. They all tend to have a difficult time with scarring.”

 

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Estelle Chang, MD

Not wanting a scar on her neck, O’Callaghan opted for Dr. Chang to perform the facelift approach. For the safety of the baby, surgery was put on hold until after O’Callaghan gave birth to her son. On May 22, O’Callaghan became the first patient to undergo a robotic thyroidectomy at Nebraska Medicine. Dr. Chang made the incision behind O’Callaghan’s earlobe and surgery took approximately three hours. O’Callaghan was kept overnight for observation and released the next day.

“I knew I was in good hands at Nebraska Medicine,” says O’Callaghan. “Currently, I have no cancer in my body and I feel great. By looking at me, you’d never know I had thyroid surgery. I’m really happy with the outcome.”

Thyroid nodules are very common and occur in approximately 30 percent of all people in the United States. By the age of 60, more than half of women will have a thyroid nodule. The vast majority of the nodules are benign, with about 5-10 percent being cancerous. Symptoms of thyroid cancer can involve swollen lymph nodes in the neck, difficulty swallowing or breathing – but most patients don’t experience any symptoms.

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Abbey Fingeret, MD

“While thyroid cancer can be seen in people of any background, age or gender, most cases occur in women, people less than 55 years old, and those with Caucasian or Asian backgrounds,” says Nebraska Medicine surgical oncologist Abbey Fingeret, MD. “Fortunately, in most cases, it can be completely cured with surgery.”

Dr. Fingeret is currently the only Endocrine Surgery Fellowship trained surgeon in the state of Nebraska. She completed her fellowship at Harvard University and Massachusetts General Hospital, performing more than 500 thyroid operations. Dr. Fingeret also finished a three-month Advanced Robotic Endocrine Surgery Fellowship in South Korea. This summer, she looks to perform her first robotic thyroidectomy at Nebraska Medicine.

 

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Not wanting a scar on her neck, O’Callaghan opted for the facelift approach. “By looking at me, you’d never know I had thyroid surgery. I’m really happy with the outcome.”

“I truly believe in the mission of Nebraska Medicine,” says Dr. Fingeret. “We are here to offer state-of-the-art care, where the patient always comes first. It’s my honor and privilege to be part of this exceptional team of ancillary staff, clinicians and researchers.”

“Nebraska Medicine treats all aspects of thyroid ailments and endocrine-related disorders,” adds Harris Frankel, MD, chief medical officer at Nebraska Medicine. “We have a large and experienced multidisciplinary team, which includes physicians from ENT, Endocrinology, General Surgery and Cancer Services. When you walk in the door, you can be seen by an endocrinologist and thyroid surgeon on the same day.”

Nebraska Medicine is one of a few academic medical centers in the country offering robotic thyroidectomies. Patients with multiple medical problems who shouldn’t be under anesthesia for extended periods of time are not ideal candidates. Robotic surgery can also be used to remove other benign masses of the neck, such as lipomas and thyroglossal duct cysts.

To schedule an appointment with a specialist at Nebraska Medicine, call +1-402-559-3090 or OIHS@nebraskamed.com.

Unique Treatment Crafted for Multiple Myeloma Patient

Muhamed Baljevic, MD, is seen with patient Vincenzo Neri. Dr. Baljevic and his team were able to respect his religious beliefs and perform a bloodless stem cell transplant.

For the first time at Nebraska Medicine, a bloodless stem cell transplant has been performed on a Jehovah’s Witness.

“I’m surprised, excited, relieved and thankful they respected my beliefs and I congratulate them for helping me through this difficult time.”

Vincenzo Neri was diagnosed with ultra-high risk multiple myeloma and needed an autologous stem cell transplant to survive. Autologous transplantation is a process where the patient’s own stem cells are collected and reinfused. During the transplant process, most patients depend on red blood cells and platelets to protect themselves against infection, bleeding and organ failure. Jehovah’s Witnesses don’t believe in accepting any blood products, so Neri’s case was more difficult in many ways.

“He can’t get any of the red blood cells or platelets – normally, every patient depends on these products during the transplant process because red blood cells can go very low and platelets can go very low,” says Muhamed Baljevic, MD, multiple myeloma specialist. “However, we cannot depend on these blood products in this patient’s case because he’s a Jehovah’s Witness and his religious beliefs don’t allow him to accept any blood products.”

Through sign language interpreters, Dr. Baljevic explained in detail how Neri’s transplantation would work.

“We modified almost every single step in the transplantation process for him and his needs,” says Dr. Baljevic. “We had these plans in place where we used particular medicines, to try to prevent him from bleeding, where we stimulated his own bone marrow with stimulating medicine and building blocks for red blood cells as much as we could – such that we avoided all together the need for any blood products.”

Neri’s recovery went extremely well and he was discharged one week earlier than expected. Only a few health systems across the country perform stem cell transplants on Jehovah’s Witnesses. Nebraska Medicine is now one of them.

“In looking back when I was first diagnosed with cancer, I went down quickly, but now I feel freedom – the sick body is gone – I feel healthy again, active to do anything – makes me feel built up and excited,” says Neri. “Everyone here respected my religion and I’m impressed that everyone was respectful of my faith.”

“We hope other patients, who share same believes, other Jehovah’s Witnesses, or patients who cannot get blood products, know that we are very committed to provide top quality care, multidisciplinary care and care that can meet the biggest challenges of modern medicine – and this is certainly one of them,” says Dr. Baljevic.

Watch more of this amazing story in this video below.

 

To schedule an appointment with a specialist at Nebraska Medicine, call +1-402-559-3090 or OIHS@nebraskamed.com.

WATCHMAN Device Offers Breakthrough Treatment for Atrial Fibrillation Patients

After suffering five strokes in a matter of months, Tom Keeling and his wife Sandy began to wonder if life would ever be normal again.

The 65-year-old Keeling suffered from a type of irregular heartbeat called atrial fibrillation. Atrial fibrillation can lead to the formation of dangerous clots that increase your risk for stroke. Keeling’s condition was doubly serious because doctors were also having difficulty regulating his blood thinners, which are critical to helping reduce clot formation.

Keeling recently became one of the first handful of people at Nebraska Medical Center to receive an implant device called the WATCHMAN™, an alternative to long-term blood thinners for people with atrial fibrillation. Since having the device implanted several months ago, Keeling’s strokes have come to a screeching halt.

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Tom Keeling and his wife, Sandy, celebrate after a successful surgery reduced Tom’s stroke risk.

The Nebraska Medical Center is the first hospital in Omaha to offer patients the WATCHMAN implant. The device reduces the risk of stroke by closing off an area of the heart called the left atrial appendage. This helps keeps harmful blood clots from forming here, entering the bloodstream and potentially causing a stroke. Over time, patients should also be able to stop taking blood thinners.

“This new device provides doctors with a breakthrough stroke risk reduction option for patients,” said Andrew Goldsweig, MD, interventional cardiologist at Nebraska Medicine. “Blood thinners are one of the biggest challenges for managing people with atrial fibrillation. Although patients need blood thinners to help prevent clot formation, blood thinners can cause bleeding as well as other adverse reactions or interactions with other medications. Forty-five days after the WATCHMAN is implanted, patients should be able to stop taking blood thinners while receiving stroke protection from the device that is equivalent to a full-dose thinner.”

Atrial fibrillation is the most common type of arrhythmia. It increases with age and occurs in as many as one in 10 people over 80. As the disease progresses, it can significantly increase your risk for stroke and congestive heart failure. In fact, people with atrial fibrillation are five times more likely to have a stroke than the general population.

To implant the device, the doctor inserts a small needle in the upper leg, followed by a narrow tube, similar to a standard stent procedure. The doctor then guides the device into the left atrial appendage of the heart. Patients commonly stay in the hospital overnight and leave the next day.

Nebraska Medicine has a specialized clinic established to evaluate if WATCHMAN is the right course of treatment.

“This gives us another tool to elevate our already high level of cardiac care,” says Jessica Delaney, MD, Nebraska Medicine cardiac electrophysiologist.

“We are both looking forward to getting back to a life of normalcy again,” says Sandy. “We’re still young. I thought we still had a lot of time to do things in our lives.” Since Tom’s surgery, Sandy says planning a cruise is back on the bucket list. “We are so grateful for all of the care we’ve received at Nebraska Medicine. Everyone was so nice and put us at ease. The care was wonderful.”

This article was first featured in Advancing Health, a quarterly magazine from Nebraska Medicine with information about innovative treatment options, prevention tips and making better choices for a long healthy life. Sign up below to join our mailing list and receive the next edition of Advancing Health straight to your mailbox.

To schedule an appointment with a specialist at Nebraska Medicine, call +1-402-559-3090 or OIHS@nebraskamed.com.

Dr. Zhen Named an American Society for Radiation Oncology Fellow

Weining “Ken” Zhen, MD

Weining “Ken” Zhen, MD, radiation oncologist at Nebraska Medicine and professor of radiation oncology at UNMC, has been named an American Society for Radiation Oncology Fellow.

The society is the world’s largest society for radiation oncology professionals. The ASTRO Fellows designation, or FASTRO, honors individuals who have significantly added to the field of radiation oncology in the areas of research, education, patient care or service and leadership.

Dr. Zhen will receive his FASTRO designation at an awards ceremony Oct. 23, during ASTRO’S 60th Annual Meeting in San Antonio, Texas.

“The honor really goes to all faculty of our department of radiation oncology and the excellent cancer program at UNMC and Nebraska Medicine,” says Dr. Zhen.

Charles Enke, MD, chair of the Department of Radiology, was complimentary of Dr. Zhen’s latest achievement.

“Dr. Zhen is an internationally recognized expert in head and neck oncology, although his clinical skills go well beyond a single disease site,” says Dr. Enke. “Ken has contributed significantly to the education of residents and practicing radiation oncologists, and he has worked with ASTRO and SANTRO (the Sino-American Network for Therapeutic Radiology and Oncology) to optimize the delivery of radiation therapy for patients in China. We are fortunate to have Ken at UNMC and Nebraska Medicine.”

Awarded annually since 2006, the ASTRO Fellows program recognizes individuals who have made significant contributions to radiation oncology through research, education, patient care and/or service to the field. Since its inception, the FASTRO designation has been awarded to just 327 of ASTRO’s more than 10,000 members worldwide; the 2018 class of Fellows comprises 35 individuals.

To schedule an appointment with a specialist at Nebraska Medicine, call +1-402-559-3090 or OIHS@nebraskamed.com.

First Leukemia Patient Receives CAR T-cell Therapy at Nebraska Medicine

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John Stenike has been fighting cancer since the age of 12. Now he and his family have new hope with this new therapy that uses a patient’s modified white blood cells to fight the cancer. John is a patient of hematologist/oncologist Krishna Gundabolu, MBBS. 

At the age of 12, John Steinke started his first full-time job.

“Fighting cancer,” the now 22-year-old says.

On March 1, 2008, Steinke was diagnosed with acute lymphoblastic leukemia (ALL) and went through more than three years of treatment, which included chemotherapy. Six years later, he relapsed in April 2017, followed by another relapse in January 2018.

“We tried more chemotherapy and some alternative therapies, but he kept relapsing,” says Steinke’s dad, John. “We knew about CAR T-cell therapy, but at the time, it wasn’t commercially available yet.”

In February, Nebraska Medicine publicly announced chimeric antigen receptor (CAR) T-cell therapy was available for commercial use for patients with recurring non-Hodgkin lymphoma and pediatric/young adult acute lymphoblastic leukemia. Nebraska Medicine is one of the first health networks in the Midwest and the only one in Nebraska to offer the therapy, which harnesses the body’s own immune system to attack a tumor.

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John and his parents, John and Anna Steinke, on the Special Care Unit inside Nebraska Medicine’s Fred & Pamela Buffett Cancer Center. 

“T cells are white blood cells that help our bodies fight infection and cancer,” explains Julie Vose, MD, chief of Hematology/Oncology at Nebraska Medicine. “In some patients with lymphomas and leukemias, their T cells don’t recognize the cancer as being abnormal and this allows the cancers to grow. This new therapy allows us to take the patient’s own T cells outside the body and re-stimulate them to fight their own cancer.”

On Aug. 1, Steinke became the first leukemia patient to receive commercial CAR T-cell therapy at Nebraska Medicine.

“I’m really hopeful that this will work,” Steinke said, as his modified T cells were placed back into his blood stream – just a few weeks shy of his 23rd birthday.

“John has been so brave and strong throughout his cancer journey,” says his mom, Anna. “Living here in Omaha, we’re so grateful to have Nebraska Medicine in our own backyard.”

“In my opinion, there’s no need to travel anywhere else for cancer care,” adds Steinke’s dad. “The entire team has been amazing.”

U.S. News Ranks Nebraska Medical Center as the Best Hospital in Nebraska

U.S. News & World Report evaluates nearly 5,000 hospitals nationwide to come up with their annual list of Best Hospitals. And once again, for the seventh straight year, Nebraska Medical Center is the No. 1 rated hospital in the state. Additionally, the Nebraska Medical Center Gynecology Program received a national ranking, the only hospital in the state to have a nationally ranked specialty.

U.S. News also rated Nebraska Medical Center as high performing in eight other specialties, receiving more high-performing rankings than any other facility in Nebraska. Those specialties are:

  • Cancer
  • Gastroenterology and GI Surgery
  • Geriatrics
  • Nephrology
  • Neurology and Neurosurgery
  • Orthopaedics
  • Pulmonology
  • Urology

Finally, the medical center received the highest ranking possible in five procedures/conditions:

  • Abdominal Aortic Aneurysm Repair
  • Colon Cancer Surgery
  • Heart Bypass Surgery
  • Heart Failure
  • Hip Replacement

“This ranking is because of the dedication of our physicians, caregivers and staff who care for patients every day. I have the highest respect for their commitment,” says CEO James Linder, MD. “To again earn this recognition reflects our belief that continual improvement allows us to provide the highest quality services for the people of Nebraska, the surrounding region, and referred patients from around the world. My thanks to everyone at Nebraska Medicine who makes this possible.”

The annual Best Hospitals rankings, now in their 29th year, are designed to assist patients and their doctors in making informed decisions about where to receive care for challenging health conditions or for common elective procedures.

For the 2018-19 rankings, U.S. News evaluated medical centers nationwide in 25 specialties, procedures and conditions. In the 16 specialty areas, 158 hospitals were ranked in at least one specialty. In rankings by state and metro area, U.S. News recognized hospitals as high performing across multiple areas of care.

The U.S. News Best Hospitals methodologies in most areas of care are based largely or entirely on objective measures such as risk-adjusted survival and readmission rates, volume, patient experience, patient safety and quality of nursing, among other care-related indicators.

Nebraska Medical Center Earns Chest Pain Accreditation

Nebraska Medical Center has again earned full accreditation as a Chest Pain Center with Primary PCI (percutaneous coronary intervention) from the American College of Cardiology (ACC). The designation is awarded based on a rigorous on-site evaluation of the staff’s ability to evaluate, diagnose and treat patients who may be experiencing a heart attack.

PCI is also known as a coronary angioplasty. It is a non-surgical procedure that opens narrowed or blocked coronary arteries with a balloon to relieve symptoms of heart disease or reduce heart damage during or after a heart attack.

Hospitals that have earned ACC Chest Pain Center with Primary PCI Accreditation have proven exceptional competency in their ability to integrate evidence-based science, clinical best practices, and the latest ACC/AHA guidelines to deliver consistent, reliable, safe, and high-quality care to heart and vascular patients.

“This designation is an important distinction for Nebraska Medicine and is especially relevant in our journey in becoming a highly reliable organization,” says Melissa Lederer, manager, Heart and Vascular Quality and Outcomes. “The ACC’s framework has allowed us to demonstrate our commitment and continued efforts around performance improvement, standardization, education, and community outreach. The end result is a dedicated team providing state-of-the-art heart and vascular care to patients presenting with heart attack symptoms. I am extremely proud of the Chest Pain team for their effort and dedication to improving outcomes for this patient population.”

According to the Centers for Disease Control and Prevention (CDC), more than 735,000 Americans suffer a heart attack each year. The most common symptom of a heart attack for both men and women is chest pain or discomfort. However, women are more likely to have atypical symptoms. Other heart attack symptoms include, but are not limited to, tingling or discomfort in one or both arms, back, shoulder, neck or jaw, shortness of breath, cold sweat, unusual tiredness, heartburn-like feeling, nausea or vomiting, sudden dizziness and fainting.

New Radioactive Cancer Drug Available at Nebraska Medicine

Marilyn Cody became the first Nebraska Medicine patient to receive Lutathera, a newly approved radioactive cancer drug, which is flown in from Italy.

Marilyn Cody loves being outside on her 400-acre farm and hopes her new cancer drug treatment will allow her to continue to mow and garden.

Marilyn Cody may be one of the most optimistic people you’ll ever meet.

“I rely on God, my church and my family – you just have to have faith!”

After losing her husband, sister, son and son-in-law, to different forms of cancer, the 74 year old was diagnosed with stage 4 liver cancer. Cody underwent surgery and chemotherapy, which prolonged her life for four years. Until recently, the Griswold, Iowa, woman thought she was out of options – until her team at Nebraska Medicine suggested a new therapy.

“I like being the guinea pig,” smiles Cody.

On June 14, Cody became the first Nebraska Medicine patient to receive Lutathera, a newly approved radioactive cancer drug, which is flown in from Italy. It’s used to treat a type of cancer that affects the pancreas or gastrointestinal tract, called gastroenteropancreatic neuroendocrine tumors (GEP-NETs).

“This is one of the newest types of drugs, which are directed at specific molecules on the cancer cells,” explains radiologist Neil Hansen, MD. “It’s radiation, but it goes inside the patient, gets targeted directly to the cancer, and hones in on that cancer to deliver it without the side effects of radiation to other parts of the body.”

“I feel so much better with this therapy,” adds Cody. “Chemotherapy was hard, but this is better.”

Because the drug is radioactive, radiation safety officers are there to monitor the risk of radiation exposure. The nurses also have a device that measures the amount of radioactivity in the room, emitting from the patient.

“We have a great team here – our infusion nurses, radiation safety officers and nuclear medicine technologists; everyone is on board and we’ve kept the dose very safe,” says Dr. Hansen.

Cody will receive the treatment three more times – in August, October and November. She’s hopeful it will give her extra years with her family, and the ability to do the things she loves the most such as gardening and mowing the lawn.

“I live on a farm with 400 acres, so I love being outside,” says Cody. “With this treatment, I really do think it will prolong my life. I just have to go for it.”

“This is the future of medicine,” adds Dr. Hansen. “We have a big neuroendocrine tumor clinic here at Nebraska Medicine and this is going to be a great therapy for those who don’t have a lot of options. It’s an exciting time.”

To learn more, watch this story from KMTV.

 

Enhancing Sexual Health After Cancer

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Christopher Deibert, MD, urological surgeon

Receiving a cancer diagnosis can be difficult for anyone to endure. But even after treatment is over, some people may still have to deal with the lingering health effects that cancer treatments may cause.

Cancer can dramatically change a person’s life. It can affect your self-image. It can physically change your body’s appearance. It can suppress your sexual desire, and for men, it can reduce testosterone production. All of these can lead to erectile dysfunction (ED).

Cancers in the pelvic area such as the prostate, bladder, rectum or colon, typically have the greatest impact on a man’s sexual health. That’s because surgery or radiation therapy for these cancers are more likely to affect the nerves and blood vessels that are responsible for an erection. Some chemotherapies can also cause some degree of ED. These issues can be short or long term. If nerves are damaged during surgery, sometimes they may heal with time and your ED issue will be resolved.

The good news is in many cases, we can improve the situation with one of several treatments.

When I evaluate a man for ED after they’ve completed cancer treatment, I like to discuss the types of changes they are experiencing and try to quantify these. The type of cancer treatment you received, as well as any history of diabetes or high blood pressure are also discussed. This includes physical changes, sexual desire and erectile issues. I may recommend testosterone testing to determine if it’s a hormonal problem.

At the Nebraska Medicine Men’s Health Program, we can offer many options to help you. Sometimes putting men on testosterone replacement therapy is all that is needed. However, if ED is not due to decreased testosterone production, there are other possible treatments. Oral medications that fall into a class of drugs called phosphodiesterase inhibitors (Viagra and Cialis), can relax muscles and increase blood flow to the penis, making it easier to get an erection and maintain it. Another procedure involves a vacuum erectile device that slides over the penis. The device pulls air out of the cylinder, which helps pull blood into the penis. A suppository can be placed inside the penis to stimulate an erection or medication can be injected with a tiny needle into the penis. If none of these medical options are effective or they have stopped working, surgery may be an option. Surgery involves the placement of a prosthetic implant inside the penis that includes an activation pump that will produce an erection when activated.

As part of the treatment and recovery process, men need to recognize that they may experience significant sexual changes and these need to be discussed with their doctors. I also encourage men to have frank, sexual-intimacy conversations with their partners. They should discuss how their body image has changed, what their desires and expectations are and how they feel mentally and physically. Sometimes intimacy in the relationship may change but it can still be meaningful even if it doesn’t look the same. When this is discussed with their partners, and both understand these issues, many couples can continue to have a deep and rich intimate relationship.

To schedule an appointment with a specialist at Nebraska Medicine, call +1-402-559-3090 or OIHS@nebraskamed.com.

About the Author

Christopher Deibert, MD, urological surgeon
Urological surgeon, co-director, Men’s Health Program

Pancreas Disease Program Expands beyond Omaha Metro

Luciano Vargas, MD

The Pancreas Disease Program continues to grow and is now expanding outside of the greater Omaha metro. Patients in Hastings, Nebraska, and the surrounding area, can receive expert and specialized care for complex hepatobiliary diseases at the Nebraska Medicine Liver and Pancreas Diseases Clinic at Mary Lanning Healthcare.

Surgical director, Luciano Vargas, MD, and Shaheed Merani, MD, are spearheading the clinic, which specializes in the clinical evaluation and surgical management of liver, pancreatic and biliary disorders. The goal of the clinic is to limit undesired travel for patients and to offer diagnostic, evaluative and follow-up appointments close to home.

“Aside from being in much closer proximity to patients living in the Hastings area, our outreach clinic allows patients to meet their physicians prior to coming to Omaha in the event that their treatment plan requires a surgical procedure that cannot be performed at Mary Lanning,” says Dr. Vargas. “This helps decrease anxiety when patients do need to travel to Omaha for follow-up care.”

Shaheed Merani, MD

Drs. Vargas and Merani are the only specialty-trained liver and pancreas surgeons in the tri-city region (Hastings, Grand Island and Kearney). Physicians with patients in the area who need liver, biliary and pancreatic surgical evaluation or for those who have patients seeking a second opinion can refer their patients to the clinic.

The Liver and Pancreas Diseases Clinic is an expansion of the Pancreas Disease Program, the only program in the region that is recognized and designated as a National Pancreas Foundation Center. Drs. Vargas and Merani are currently at the outreach clinic on the second and fourth Thursdays of the month.

To schedule an appointment with a specialist at Nebraska Medicine, call +1-402-559-3090 or OIHS@nebraskamed.com.

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