dr afrin protocol

Well, obviously, in the universe we live in, its more likely theres one thing going on. Like I said, happy to come back at any point and share Im always happy to share with patients, with other professionals what Ive learned about this. So the integument, the GI tract, the respiratory tractanother environmental interface. At present, you cant cure it. Back around 2008 is when I started kind of serendipitously getting into this area, making the diagnosis in my first patient. In others, symptoms may develop from a young age and slowly become worse over time. Theres, as you well know, a wide variety of so-called low histamine diets that one can pursue. Recently, he has given up soccer due to the discomfort the amount of running causes him ( nausea and fatigue) and has seemed to develop some anxiety and insomnia. You brought up earlier that theres an awful lot of interaction between the GI tract and the rest of the body. I think theres definitely a subset of patients that dont respond to some of the therapies that were doing in complementary and alternative or integrative medicine. I have been disabled by this condition and have not been able to work for years now- I need help but the reports I hear back from other patients of your clinic clearly indicate that care there is out of reach for me fiscally. Yeah. And by the time youre done doing all that coning down, youre left with roughly eight or nine mediators. To my way of thinking, that actually fits fairly well with a lot of observations of the way the disease behaves not only in the individual but also within families and in the population. After Montelukast, there are a several other cancer drugs and powerful drugs that Dr. Afrin uses and writes about. And then, beyond the chronic inflammation, there may or may not be various allergic-type phenomena in the individual patient with this disease. My dna test tells me I have a dao deficiency as well. Dr. Afrin consulted on my daughter's case, then referred us to Dr. Mark Renneker, a mast cell specialist at the University of California, San Francisco. I been using pycnogenol for 25 years and had a histamine issue that was corrected using 200 to 230mg daily. We are still hopeful. Dr. Michael Ruscio, DC. You can find information regarding CIRS and mold here. And then the genitourinary tract is another environmental interface. I dont expect you do but in case. Mast Cell Inhibitors Montelukast (Singulair), Zafirlukast (Accolate) and Zileuton (Zyflo). Supplement with 500 mg (175 mg of ECGC) twice daily, Curcumin (Meriva is a common brand name) 1 to 4 g daily, dose divided, Chamomile tea (Apigenin, luteolin) 1 to 2 cups before bed, Diamine oxidase enzymes (DAO) 2 capsules with each meal, Vitamin C may need a non-citrus source such as rose hips 1 to 3 g daily, Silymarin 500-1000 mg daily, doses divided, Magnolia/Honokiol 200 to 250 mg twice daily, Parthenolide (Feverfew) 200 to 400 mg twice daily, Mangostin (often taken as a juice) 500 to 1000 mg daily, Xanthium (dihydroleucodeine, also known as cocklebur) 6 to 9 capsules daily, Isatis (indoline) 6 to 9 capsules daily, Found naturally in stinging nettle, grapefruits, onions, apples, black tea, leafy green vegetables and beans, Downregulates the enzyme that converts the protein histidine to histaminehistidine decarboxylase, Inhibits the release of histamine, prostaglandins and leukotrienes three of the most common inflammatory mediators found in MCAS, Decreases the production and release of inflammatory cytokinesthe inflammatory mediators responsible for many of the symptoms of inflammation related to MCAS, Often used as a primary therapyhas been shown to be more effective than the pharmaceutical Cromolyn, Treats allergies, contact dermatitis, photosensitivity and inflammation, The dihydrate form has the best bioavailability. A benefit of using natural treatments for MCAS is that you can take these on your own and they do not require a prescription. You just have to understand these labs may not be actually running all of these tests in house. Even if its not ideal, is it still usable? Now, what about treatment? Calming the immune system and reducing inflammation is a critical part of any MCAS protocol. I think youre really going to help a lot of people with this conversation today. He is a certified Functional Medicine Practitioner (IFM), is board certified with a fellowship in anti-aging (hormones) and regenerative medicine (A4M), a certified Shoemaker Mold Treatment Protocol Practitioner (CIRS) and ILADS trained in the treatment of Lyme disease and co-infections. Benadryl is the prototype. Our team of licensed nutritionists and dietitians strive to be objective, unbiased, honest and to present both sides of the argument. Incorrect collection of specimens may also lead to false negative testing. Glad the article helped you out! Dr. and Ms. Sackler died in 2017 and 2019, respectively. Therere going to continue to be ups and downs with the disease. I would like to thank you for your afforts and appreciate any updates on the matter. Written by Dr. Michael Ruscio, DC on April 18, 2018. You mentioned tryptase. Thank you. And its kind of curious that some of that work suggests that these mutations, actually most of these mutations, are not inherited or in-born but, rather, are acquired relatively early in life. Dr. Jannatun Afrin is a Internist in Havertown, PA. Find Dr. Afrin's phone number, address, hospital affiliations and more. Those drugs are the keepers. But like I said, it only takes about a month with each therapy. https://www.ncbi.nlm.nih.gov/pubmed/25095772 These two reports add to a growing body of evidence that antihistamines may be helpful for treating long COVID, said Dr. Lawrence Afrin, senior consultant in hematology/oncology at the AIM Center . I was basically a case for care takers vor 3 months, one of which I spent in hospital after being brought to the ER 3 times in one week. So oftentimes, I start with the fundamentals, see what symptoms clear, and then reevaluate. Just curious, can some people tolerate these with cromyln are they ok regardless? A low FODMAP diet has shown the ability to cause an eight-fold decrease in histamine. The more you can narrow it down, the more you can pay attention to living the life you desire. Thank you for the information. And is there a certain timeframe in which they should be noticing a response and, if they dont, they should be moving on? Then went on faculty there for nearly 20 years. And there are certain reasons why it might be a little more useful to measure N-methylhistamine instead of histamine in the urine. Glutamine supplementation has been shown to lower histamine. And again, everybodys heard of these medicines. For example, loratadine or Claritin at 20 mg instead of the entry-level 10 mg. And there are occasional mast cell patients who notice a pattern where, lets say, Claritin 10 mg really does help them significantly. And its just toxic and unsustainable for all sorts of reasons. But at the same time, again, cromolyn is not absorbed to any significant extent. Today, I am here with Dr. Lawrence Afrin. But if you do, all of that rule-outs and you still find an elevated chromogranin level, pretty good bet that its coming from mast cell activation. Is this patient really so uniquely unlucky as to have coincidentally acquired so many different problems, all of them developing independently of one another? Here is some further information about select products that are used most often. Coming back just to that for a moment, the dosing. DrMR: Gotcha. And then, below the waterline, as we started coming to recognize in just the last decade, there is this much larger assortment of diseases that all have the common theme of inappropriate activation of the mast cells in one fashion or another. DrMR: Well said. Are you recommending people use kind of the standard dose range? MCAS is a type of mast cell activation disorder (MCAD) characterised by an abnormal activation of mast cells resulting in chronic multisystem polymorbidity of a general inflammatory nature, with or without an allergic nature. My daughter has salicylate sensitivity so low histamine foods are often triggers for low sals. Revive a sluggish thyroid by knowing what lab values and treatments to pursue. Famotidine is chosen most often because it has fewer drug interactions than Tagamet. Quite often, you dont even have to have a conversation with them because its so obvious that this drug is a keeper. And some patients even get or make compounded cromolyn cream for application on the skin. (3) Amazon and the Amazon logo are trademarks of Amazon.com, Inc, or its affiliates. Benzodiazepenes Addresses the inhibitory mast cell benzodiazepine receptors. And its way too complex of a disorder for it to be rational to expect to get to the point of feeling perfect. Please take a look at this newly published peer-reviewed article by Dr. Lawrence Afrin of which I was a co-author, on the revised criteria for the diagnosis of mast cell activation syndrome (MCAS):. Aspirin is the most commonly used NSAID. And that can also be a marker of mast cell activation. Your thoughts? And theres a long subtitle to it. With MCAS, this function becomes upregulated and chronic, occurring at inappropriate times in response to substances that are not necessary a threat. Written by Dr. Michael Ruscio, DC on See what symptoms abate. Z=_N`P38_/r5gg.Q }4@SYUE.Cp)\|"L5?7b0{V*?v5oN4?5 5_Op%~^oh? Glutamine, Immunolin, vitamin C (timed release), natural antihistamine blends, quercetin. And what Im more so curious to get your take on is for people who fail out of those therapies and we need to kind of escalate up perhaps a level of the ladder to mast cell activation syndrome, where should they go? Alcohol may be tolerated by many but some people are quite sensitive to it and prefer glycerin based herbal tinctures. Do not take anymore than is beneficial, Best practice, start with less expensive drugs first. Now, to be sure, there certainly are certain medication classes which themselves can have a propensity for driving mast cell activation. Calming the immune system and reducing inflammation is a critical part of any MCAS protocol. Is that something that you would advise people as theyre wading into this? A low histamine diet, as you alluded to earlier, certainly can be helpful. I certainly see patients who have signs of histamine intolerance improve after treating SIBO, small intestinal bacterial overgrowth. Dr. Afrin earned a B.S. Or are these just different names essentially for the same thing? About the Author. Thank you very much for your generous contribution to those of us who suffer with this difficult, mysterious and widely-misunderstood illness. DrLA: Well, loratadine is Claritin. Are you giving them prescriptions? It is getting more often now too. And I have to say, I feel probably the best on his line of products out of any that Ive tried. Its been terrific, and well definitely look forward to having you back on. Its not going to circulate. Simone JV, Afrin LB, Byers T, et al. 3. The one company I can say I had the least bloating, been very impressed with his products. MCAS is something to consider when you haven't responded to anything else: diet, lifestyle, gut treatments, thyroid. I start with inexpensive treatments, and I proceed, for the most partthere are always exceptions of course. So I dont always have the time to make a home crockpot of food and of broth. And I just want to get out there the notion that were actually very fortunate with this disease in spite of how little we understand about it at present. Mon - Sat : 04:00 PM to 05:00 PM. I guess that brings me to my next question, if you are closely following a low histamine diet, can you cheat a little with DAO suppliments or cromyln sodium. And above the waterline of this iceberg, at the very tip youve got the rare disease of mastocytosis, sort of a cancerous overgrowth of mast cells together with inappropriate mast cell activation. Comprehensive information about mast cell disorder. I have recently returned from a most stimulating conference/think tank with Dr. Afrin and 30 other leading clinicians on Mast Cell Activation Syndrome (MCAS) at Commonweala cancer retreat centre in northern California.MCAS is a type of mast cell activation disorder (MCAD) characterised by an abnorm. And finally, theres a molecule sort of at the end of the leukotriene metabolism pathway, a molecule called leukotriene E4 that can be measured in the urine. And although not all of them are going to be open access, a good number of them are. stream Hello: Thanks for posting this. We learn, all in all, probably a few thousand diseases. DrLA: In my experience, most patients figure out within a month at most if any given medication being tried for MCAS is going to be significantly helpful or not. Can you just give people kind of the brief synopsis on your background and your current involvement with mast cell disorders? Always looking for a more holistic approach And I could go on to the other systems in the body, but I think you get the point that its just a bewilderingly large array of potential symptoms. Once recognizing that mast cell activation may be occurring for any individual. DrMR: I completely appreciate that. And so, you have to ask When youre faced with a patient who has 20 or 30 entries on the problem list, and you look at it and you think about it and you realize that most of these problems are of a chronic inflammatory nature or an allergic-type nature or perhaps some problems relating to abnormal growth or development, youve got to ask yourself, whats more likely? NOTE:Dr. Lawrence Afrin works with Dr. Tania Dempsey at Armonk Integrative Medicine. One can burn off the alcohol in tinctures by placing the remedy in a small amount of water that has just been brought to the boil and is cooling off. Dr. Afrin is a clinical practitioner and researcher of MCAD and MCAS, Distinguishing histamine intolerance versus MCAD, Episode Intro 00:00:39Mast Cell Activation Disorder (MCAD) 00:02:51Mast Cell Activation Syndrome (MCAS) 00:05:47Common Symptoms & Systems Affected by MCAS 00:08:49Effects on the Immune System 00:13:23Moving Forward with a Proper Diagnosis 00:15:21MCAS and Histamine Intolerance 00:19:05Factors That May Lead to MCAS 00:24:15Relevant Testing and Treatments for MCAS 00:27:44Specific Markers for Mast Cell Disease 00:34:40Finding Reliable Labs for Testing 00:38:13Natural vs. So I think just having written a book myself I really realize that you get such a tremendous value for such a little cost. DrMR: And can you get this at a LabCorps or a Quest, or do you need a specialty center to do this assay? We usually see tryptase levels elevated at least double the upper limit of normal and quite often much higher than that in mastocytosis. Are there any of those that you find more effective? 143: Dr. Jill Interviews Dr. Vincent Pedre on the Gut SMART Protocol and the Gut-Brain Connection 142: Dr. Jill interviews Dr. Pamela Wartian Smith, MD on her new book, Optimizing Your Male Hormones https://www.ncbi.nlm.nih.gov/pubmed/17490952 No patient should be taking one more milligram of one more medication than is clearly significantly benefiting them. Typically, these patients are going to be on antihistamines for a very long time to come. DrMR: Hey, guys. You just dont see anything useful either at the cellular level, under the microscope, all the way on down to the molecular level. You really dont need to be a specialist to prescribe and manage most of the drugs that make sense to try for this. And to my way of thinking, kind of unlikely that if you look at all the problems that a patient with so-called histamine intolerance has, it just seems kind of unlikely that all of those problems would be attributable to just an excessive responsiveness to histamine alone. And Im very curious in a little bit to get your perspective on the guts impact. DrMR: So its fair to say that youre both participating in this area from a clinician perspective, treating patients, and youre also performing research. If you need a comprehensive overview MCAS, I encourage you to read my article:Mast Cell Activation Syndrome and Histamine: When Your Immune System Runs Rampant. When relevant differential diagnoses of a mast cell activation disease (Table 4) which may present mast cell mediator-induced symptoms by activation of normal mast cells (e.g., allergy) or as result of non-mast-cell-specific expression of mediators (e.g., neuroendocrine cancer) are excluded, the cause of the mast cell mediator release syndrome must lie in the uncontrolled increase in activity . I hope that more doctors will be able to share this kind of knowledge all around the world so that we may all be able to better serve people of all backgrounds. Thats a possibility, but there are also some other studies out there, some intriguing work particularly coming out of the University of Bonn that is suggesting that virtually every one of these patients may have assorted mutations in the various regulatory elements in their mast cells. Are there some other medications? Other things to consider in MCAS patients: Diamine oxidase (DAO) stabilises mast cells, but more importantly, it is the predominant enzyme thatbreaks down histamine. DrLA: Boy, thats not only the 64,000-dollar question. Dr. Lawrence Afrin: Thanks, Michael. Take the time, figure out which antihistamines are going to serve you best. As I said, the mast cell puts out more than 200 mediators. Also wanted to say thank you to Kettle & Fire. Thats about it that we can measure at present in the clinical laboratory and which are relatively specific to the mast cell. Does anyone know of a MCAS/Histamine Intolerance specialist in the United States? His treatment protocols have ended years of patient suffering and offer much needed hope to the chronic illness community. Thank you again for this valuable information. Welcome to Dr. Ruscio Radio. So Im very grateful that you said that. Dr. Afrin is sharing with us his experience with . In contrast to most drugs, it is not absorbed to any significant extent. And lots of people forget about the other one. So its certainly a good idea to check a tryptase level. All of these pages are at the drruscio.com URL, which is D-R-R-U-S-C-I-O dot com, then slash either gethelp, gutbook, or review. Okay, back to the show. With a chronic illness such as MCAS, it is possible to live a full lifethe treatment just requires a careful, comprehensive approach. OXYMETAZOLINE (Afrin) Protocols: UP 9-Epistaxis Type of drug: Nasal Decongestant Mechanism of Action: Constricts blood vessels in the nostrils and dilates the air passages Indications: Nasal Intubation and Epistaxis Contraindications: Relative contraindication is significant hypertension Precautions: Route and Dosage: Adults - 2 Sprays inaffected nostril. We are glad that you were able to find new and useful information from our post. Because mast cells are located throughout the body, symptoms can affect the eyes, nose, ears, throat, skin, heart, blood, lungs, gastrointestinal tract and the nervous, endocrine and musculoskeletal systems. Most of what Ive seen has been relative to really histamine and histamine intolerance. When we consider making changes simply with gut health and diet, it can be the stepping stone in the right direction to a long term solution. And I think much of our audience may have heard of some natural treatments. I have recently returned from a most stimulating conference/think tank with Dr. Afrin and 30 other leading clinicians on Mast Cell Activation Syndrome (MCAS) at Commonweala cancer retreat centre in northern California. And of course, if youre talking about the central nervous system being affected, its certainly possible there could be psychiatric issues. And this discussion I think will really help people find some solutions that are helpful for them and get something different than maybe pursuing some of the typical secondary and tertiary diagnoses we consider, things like Lyme or heavy metals or mold toxicity. His protocol as completely changed my life, and I'm finally starting to get my life back. Theres the GI tract; all sorts of issues in the GI tract with reflux and nausea, sometimes vomiting and diarrhea or constipation or, even more commonly, sort of an alternating back and forth between diarrhea and constipation, which is just one example of the many opposites you can see with this disease. Hi Laura, I dont know where you are in California, but I live in California and am MCAS positive. Dr. Lawrence B. Afrin is a Oncologist in Armonk, NY. Larry, please. The protocol . But nevertheless, there are a lot of things we tried, and actually the majorityat least in my experience, the majority of patients with mast cell activation syndrome are able to eventually find significantly helpful therapy. Sure, its frustrating for both the patient and the practitioner at present that we dont yet have any methods for predicting which treatment will be most likely to help which patients. Thank you for sharing and commenting on our post, I hope that natural remedies are a step towards the answers youre looking for. GI When you think about the biology of this, where do mast cells reside in the body? But actually, even before I get into the testing, I just want to loop back to a brief comment you mentioned in that question about the treatments. That doesnt say, of course, that every system will be affected by the disease. https://hoffmancentre.com/2017/11/12-tips-living-mast-cell-activation-syndrome/. Dermatologic: Common dermatologic symptoms of . Histamine 2 blockers Famotidine (Pepcid, Pepcid AC), Cimetidine (Tagamet, Tagamet HB) and Ranitidine (Zantac). Distinct from mastocytosis and simple allergy and characterized by constitutive mast cell (MC) activation and aberrant MC reactivity with little to no excessive MC accumulation, MC activation syndrome (MCAS) presents as acute-on-chronic multisystem polymorbidity of generally inflammatory allergic theme and may be epidemically prevalent (PLoS ONE 2013;8(9):e76241). Well put the link to your book in there. You can just start imagining just how many permutations there might be of mast cell activation syndrome with just different patterns of inappropriate mast cell mediator expression together with inappropriate patterns of inappropriate mast cell reactivity. DrLA: Feel a little bit better. Nope. Biiig very big thanks). The main thing that happens to me sometimes if I have too much of these powdered products, I get a little bit bloated. This article contains scientific references. Other manufacturers have their own trade names for it. Theoharides' lecture on mast cell . Not to take anything away from them, but this seems like a fairly reasonable and not incredibly hard or expensive therapeutic avenue to at least give a trial to and may help people find what really they are needing if its not one of these other different diagnoses. DrLA: I think there are a lot of different ways to approach this very nebulous beast. Thank you for mentioning that. So in the skin you get all sorts of rashes. About this Location. Is there any other option? DrMR: Keep people busy. So the little bit extra that has to be spent to actually make a firm diagnosis, based on the lab testing, in these very complicated patients, its really a drop in the bucket compared to whats already been spent on their behalf over the years and the decades. There are histamine receptors on a wide variety of cells in the human body, including actually the mast cells. Many greetings from Germany. But you want to really qualify that for an individual. Just wondering if you have any ideas. The download was just a link to this site & contact info. To read more about living with MCAS, check out12 Tips for Living With Mast Cell Activation Syndrome. And the only other mast cell diseases we knew about were the rare disease of mastocytosis that oncologists dealt with and an allergy that any primary doctor and allergist, too, can manage. There are maybe one or two reference labs to which you can send specimens for all of this testing. And Im very excited to discuss mast cell activation disorder and/or histamine intolerance and kind of pick into some of these specifics and where to draw the line between the two and how we can diagnose, how we can treat, and really delve into this gentlemans brain, who has quite a bit of expertise in that area. No product order inquiries. But if you get to the end of, say, a two to four-week period with that and you cant honestly say that youre doing significantly better at the higher dose or frequency than you were doing at the lower dose or frequency, then forget it. Something that Ive noticed in the clinic is patients want to cling to a therapy that theyve read is supposed to help, even though its not helping them. Theres that approach. Thank you Brittany for taking the time to read the article, we hope you may consider sharing it among your friends and family so they may also find it useful! A plant based, non-dairy, gluten-free, non-processed diet has been paramount. DrMR: Great. We are only able to answer medical questions if you are a patient and we have a medical history and are working with Dr. Hoffman as a patient. And, oh boy, do I wish there was a shorter name for that. But, nevertheless, itll be an obvious, significant improvement. So hopefully, I can twist your arm into getting you maybe some point six months from now to come back on, and we can do a part two to this discussion. xr#u} Re$IY#C'sP 84c}XMRXeSUeGl&zbVGd^I1RzVG(oweUbEQF]_`eU\[jM]5q0LwzJ\(GY>A| `ZW3V$p1 cy~./Y1,]@bjZSRr:m:w7i1nyQ)?RzFf Many specimens need to be chilled with a refrigerated centrifuge, which is not available in every lab or doctors office. So I absolutely appreciate your thinking here. This article is based on scientific evidence, written by experts and fact checked by experts. %PDF-1.3 While there is no cure for MCAS, there is a lot you can do to minimise the conditions impact on your life. Why would you want to be on suboptimal therapy for the next two, three, four decades? Valium and Midazolam are also sometimes used. DrLA: But that is measurable at some reference laboratories and also as a marker of mast cell activation. Conceived and singlehandedly written by Dr. Afrin 2013-2015.) Might be most effective for GI, Comes in various forms: oral, eye drops, nasal, nebulizer, cream, A month at most to clearly notice effect; if not, move on to trying a different medication, Follow the dosing listed on label at first, but often for MCAS patients its best to take twice per day. Hey, everyone, in case youre someone who is in need of help or would like to learn more, I just wanted to take a moment to let you know what resources are available. << /Length 5 0 R /Filter /FlateDecode >> And in the meantime, the term MCAS is what we apply to these more nebulous disorders of activation that dont otherwise fit all that well with the other forms of mast cell disease, which we had known about for a long time previously. But for the most part, I tend to proceed in order of cost. And you have to make sure, of course, if you find a really elevated chromogranin A level, you have to do diligence and make sure the patient doesnt have a neuroendocrine cancer. Selective Serotonin Reuptake Inhibitors may occasionally be of benefit. Electronic Clinical Trial Protocol . So maybe a good transition there then would be to try to listand I know this may be challengingsome of the most common symptoms. Its a lot of work to write a book, and its a lot of benefit. Thank you million times over for this information, could you tell me what to eat more in mastocytosis to reduce histamine. Such doctors like you are currently still rare in Germany. And because whats been appearing so far is that different patients present with very different patterns of mast cell activation, that gets us a situation clinically where different patients are presenting very differently. The average patient is somewhere in the middle. The most common drugs that are prescribed for treating MCAS include: While your doctor may prescribe you some of these mast cell stabilizer drugs to help your symptoms, there are also several natural treatment options. DrMR: And where can people, if they wanted to, read some of your papers or hear more from you and/or just learn more about this area at large? So you make your way through the H1 blockers, the H2 blockers. So there are some patients with mast cell disease who respond well to histamine-directed therapies, whether youre talking about trying to block the histamine receptors or youre talking about decreasing the amount of histamine that the body is producing. And the symptoms that it does improve, it may not completely get rid of those symptoms. Right now Im trying N-Acy Glucosamine (NAG) Longvida Curcumin (Crosses BBB) , Melatonin 1mg before bed and L-Thenaine. https://www.ncbi.nlm.nih.gov/pubmed/9421440 Its not going to help control other mast cells. Theres the cardiovascular system with all sorts of autonomic issues, a lot of variability in pulse and blood pressure, palpitations, tachycardia. Of course, youve got the sedating H1 blockers. One study in particular showed 22% of patients with non- or idiopathic gastrointestinal symptoms had histamine intolerance. Im assuming Dr Afrin is the real deal and can help? Agreed. DrMR: What are the trade names on those, because Im sure for people listening it would take a step out of the equation for them just to know that? This is Dr. Ruscio. The recommendations above . But theres a nebulized cromolyn that you can inhale into the lungs. When it comes to natural treatments for MCAS and mast cell activation disorder, the most effective work in the following ways: With that in mind, here are some of thebest natural treatments for MCASaccording to the mechanisms they influence. Book an Appointment. So if you find that its helpful in one area of the body, the GI tract being the example, then it makes all the sense in the world to try it in other areas of the body. I hope Dr Afrin and the group we belong to will put together such a list in the not too distant future. transparent music player png gifstrike crossword clue, primary care physicians of atlanta patient portal, moran and goebel obituaries,

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