TOXIC TALES – Page 4

IMMEDIATE CARE urgent care CLINICS – WHY WAIT IN THE ER * MINOR EMERGENCY WALK IN * URGENT CARE * INJURY ILLNESS – WORKER OCCUPATIONAL CARE – DRUG-FREE WORKPLACE TESTING – MRO REVIEW – SPORTS CARE – FAMILY CARE – URGENT CARE

OVER THE PAST DECADE AT LEAST 400 (FOUR HUNDRED) OR MORE EMERGENCY ROOMS HAVE CLOSED
GREATER 120 MILLION PEOPLE WERE TREATED IN ERS A FEW YEARS AGO – GROWING
GROWTH IS AN ALARMING 20-30% EVERY 5-10 YEARS
COMPLICATED PATIENTS CONTINUE TO GROW – AIDS, TB, CANCER, ADVANCED DIABETES, STROKE, HEART DISEASE COMPLICATIONS, TRAUMA, SHOOTINGS, DRUGS OF ABUSE
NEARLY 50 MILLION AMERICANS HAVE NO INSURANCE OR LIMITED ACCESS

http://thehistoryhacker.com/2012/05/09/top-eight-weird-facts-about-famous-and-infamous-people-in-no-particular-order-and-yes-henry-tudor-is-among-them-though-luke-skywalker-is-not/ click on link – http://www.nimcc.com

Wieluń WHAT TO DO:

BRING A LIST OF YOUR ALLERGIES, MEDICATIONS, PAST MEDICAL HISTORY, EKG IF YOU HAVE IT, AND NAMES AND PHONE NUMBERS OF SIGNIFICANT OTHERS, AND INSURANCE INFO IF IN DATE

GO TO IMMEDIATE CARE IF UNSURE – IF NOT SEVERELY ILL OR INJURED

IF YOU MUST GO TO THE ER, GO IN THE MORNING…LESS BUSY USUALLY

WHEN IN DOUBT – IF ILLNESS OR INJURY IS SEVERE…CALL 911

TELL THE TRIAGE NURSE YOUR SYMPTOMS…ALL OF THEM

KNOW THE CREDENTIALS OF YOUR DOCTOR…EXPERIENCE

IS THE EMERGENCY PHYSICIAN RESIDENCY TRAINED IN EMERGENCY MEDICINE

IS THE EMERGENCY PHYSICIAN BOARD-CERTIFIED IN EMERGENCY MEDICINE

BRING AN ADVOCATE TO WATCH, LISTEN, AND ASK QUESTIONS – ESPECIALLY IF VERY ILL

MANY IMMEDIATE CARE CLINICS CAN TAKE CARE OF MANY ILLNESSES AND MINOR EMERGENCIES – CALL IF UNSURE

MANY IMMEDIATE CARE CLINICS CAN STABILIZE AND TRANSFER TO THE HOSPITAL

MANY IMMEDIATE CARE CLINICS HAVE BOARD CERTIFIED ER DOCS AND ER EXPERIENCED DOCS

CARBON MONOXIDE (CO) POISONING EPIDEMIC * prevention – WARNING – CAUSES – SYMPTOMS – THERAPY – GOAL – LONG TERM EFFECTS – **mandatory reporting effort by Washington State Public Health and Washington Posion Center

Preventing Carbon Monoxide Poisoning * Emergency

(fires photos from: nifc.gov)
(product photos from: web general sites)
(house photo from: kltv, texas)

Generators, grills, camp stoves, or other gasoline, propane, natural gas, or charcoal-burning devices should never be used inside a home, basement, garage, or camper – or even outside near an open window.

Every home should have at least one working carbon monoxide detector. The detector’s batteries should be checked twice annually, at the same time smoke detector batteries are checked.

Carbon monoxide (CO) is an odorless, colorless gas that can cause sudden illness and death if inhaled.
When power outages occur during emergencies such as hurricanes or winter storms, the use of alternative sources of fuel or electricity for heating, cooling, or cooking can cause CO to build up in a home, garage, or camper and to poison the people and animals inside.

Every year, more than 500 people die in the U. S. from accidental CO poisoning.
CO is found in combustion fumes, such as those produced by small gasoline engines, stoves, generators, lanterns, and gas ranges, or by burning charcoal and wood. CO from these sources can build up in enclosed or partially enclosed spaces. People and animals in these spaces can be poisoned and can die from breathing CO.

How to Recognize CO Poisoning
Exposure to CO can cause loss of consciousness and death. The most common symptoms of CO poisoning are headache, dizziness, weakness, nausea, vomiting, chest pain, and confusion. People who are sleeping or who have been drinking alcohol can die from CO poisoning before ever having symptoms.

Important CO Poisoning Prevention Tips

Never use a gas range or oven to heat a home.
Never use a charcoal grill, hibachi, lantern, or portable camping stove inside a home, tent, or camper.
Never run a generator, pressure washer, or any gasoline-powered engine inside a basement, garage, or other enclosed structure, even if the doors or windows are open, unless the equipment is professionally installed and vented. Keep vents and flues free of debris, especially if winds are high. Flying debris can block ventilation lines.
Never run a motor vehicle, generator, pressure washer, or any gasoline-powered engine outside an open window, door, or vent where exhaust can vent into an enclosed area.
Never leave the motor running in a vehicle parked in an enclosed or partially enclosed space, such as a garage.
If conditions are too hot or too cold, seek shelter with friends or at a community shelter.
If CO poisoning is suspected, consult a health care professional right away.

Educational materials

Flyers and door hangers http://www.bt.cdc.gov/disasters/co-materials.asp
Public Service Announcements http://www.cdc.gov/co/psa.htm
CO Poisoning Prevention Guidelines http://www.cdc.gov/co/guidelines.htm
(Available in 16 languages)

(adapted from CDC website)

Indications for Hyperbaric Oxygen

Hyperbaric oxygen therapy is a specialized medical treatment in which the patient breathes 100 per cent oxygen while inside a chamber at increased atmospheric pressure. HBO is used for specific medical conditions. HBO has long been (PHOTO: hcmc hbo ctr) recognized as vital in the resolution of critical medical conditions such as gas gangrene, carbon monoxide poisoning, air embolism due to diving, trauma, or surgical procedures, and decompression sickness. It is also an important adjunct for specific wound healing conditions.

The Hyperbaric Oxygen Committee of the Undersea and Hyperbaric Medical Society (UHMS) lists the following indications: approved uses for Hyperbaric Oxygen therapy:

Air or gas embolism
Carbon monoxide poisoning and smoke inhalation
Clostridial myonecrosis (gas gangrene)
Crush injury, compartment syndrome, and other acute traumatic ischemias
Decompression sickness
Enhancement of selected problem wounds
Exceptional blood loss anemia
Necrotizing soft tissue infections
Chronic refractory osteomyelitis
Radiation tissue damage (Osteoradionecrosis)
Skin grafts and flaps (compromised)
Thermal burns
Adjunctive HBO in intracranial abscess

(adapted from: HCMC HBO Ctr)

Carbon monoxide poisoning: Reporting required

Due to the ongoing severe cold weather conditions and associated increase in carbon monoxide (CO) poisoning among King County (PHOTO: hcmc hbo ctr) residents, Public Health is making suspected CO poisoning immediately reportable to Public Health by hospitals and healthcare provi
ders for seven days from today, through Dec. 24, 2006. This period will be extended if necessary.

The most common symptoms of CO poisoning are headache, dizziness, weakness, nausea, vomiting, chest pain, and confusion. Inhalation of carbon monoxide gas typically leads to headache, dizziness, and confusion, which might progress to dyspnea, tachypnea, syncope, and metabolic acidosis. Laboratory criteria for diagnosis: A case in which carboxyhemoglobin concentration exists >5% in venous or arterial blood in nonsmokers and >10% in smokers, as determined by hospital or commercial laboratory tests. The typical range of carboxyhemoglobin concentrations in smokers is 6%-10%.

Advice regarding diagnosis and treatment management of CO intoxication is available 24/7 through Washington State Poison Center at 1-800-222-1222.

This health order impacts primarily emergency departments (ED) and the information should be disseminated to all ED staff in King County hospitals immediately. A designated person on each shift should be identified to report cases of CO poisoning to Public Health.

(adapted from the Seattle/King County Public Health Announcement)

THE CONTROVERSY CONTINUES: DOES THE HYPERBARIC OXYGEN HELP?

Current assessment and treatment of CO poisoning in the
emergency department is grossly inadequate to prevent serious
neurologic complications. HBOT speeds removal of CO from
tissues and counters a number of its deleterious effects. Past studies
have demonstrated efficacy of HBOT for reducing the incidence of
neurologic sequelae, even though only three sessions of HBOT
were used. Clinical experience such as that reported here shows that
HBOTtreatment late in the course of established impairments from
CO can lead to clinical improvements. Improvement is documented
by evidence of increased brain metabolism on functional brain
imaging by SPECT after HBOT. Further study as well as wider
availability of HBOT, particularly for persons such as firefighters
who are at high occupational risk of CO poisoning, is warranted.

AND THESE TREATMENTS ARE NOT CONCLUSIVE IN MANY STUDIES THUS FAR…(editorial comment by castMD.com)

Richard A. Neubauer, M.D.
Virginia Neubauer
Alan Ko Chi Nu,
M.D. William S.
Maxfield, M.D., FACNM
, is Medical Director, Ocean Hyperbaric
Neurologic Center, Lauderdale-by-the-Sea, FL. is
Research Director, Ocean Hyperbaric Neurologic Center.
, is a hyperbaric physician practicing in Taipei, Taiwan.
, is a radiologist and Chief of Nuclear Medicine at
Ocean Hyperbaric Neurologic Center.

(adapted from: Journal of American Physicians and Surgeons Volume 11 Number 2 Summer 2006)

FIBER – SOLUBLE FIBER AND WEIGHT CONTROL DIETING WITHOUT PILLS, DRUGS OR METH HIGH VOLUME soluble FIBER SUPPLEMENTS happy healthy holidays

Over the past 20 – 30 years, fiber has been a leading dietary factor connected to worsening weight control. Less fiber, less control has been the health risk. You should have noticed on "The Biggest Loser" tv show in 2006 that dietary fiber amounts were noticeable. So this idea of weight control and dieting with its relationship to fiber intake is not a new idea. The real concern with increasing obesity, diabetes, cancer, and childhood obesity and its complications, is the amount of fiber, and the type of fiber that is of special focus today.

Generally, obese men and women have less fiber in their diets. In fact, overweight persons generally consume about one-half of the fiber that is recommended. Many times, programs for weight loss find that the "client" is not using enough fiber to assist in weight loss management, therefore causing increased risk of failure of the weight loss program.

Many persons do not like high-fiber in general. Why? Foods like beans, whole grains, fruits, and vegetables can cause bloating and gas; and they just do not like that feeling. Many jokes of such problems exist, but what really happens is tolerance to fiber does occur…it gets better.

High-fiber diets help your body making contents inside the bowel bulkier with water holding properties. It helps distend your stomach, small and large bowel – helping you feel fuller longer. It also causes the feeling of hunger to go away.

Soluble fiber especially causes a viscous suspension. (See previous castMD detail at the link http://www.castmd.com/?p=36 . These slurries delay stomach emptying and allows nutrient absorption. Hunger pains are minimized. In addition, some fats are held in the fiber, allowing yet the proteins and carbohydrates to be absorbed. This slowing, and delaying, and changing the food load is called "spreading the nutrient load."

Fiber helps change the hormones that control food metabolism. Sugar in your system is more stable, and even; and the metabolism is more controlled with insulin avoiding the highs and lows of sugar and its rebound in the blood stream.

With this better and longer control of your glycemic load, energy is maintained on lesser calories. There are fewer "hunger signals" to the appetitie centers, allowing more work with less calories. You're not eating as much and you are using calories already "on board."

Many parents with CAD (coronary artery disease) have overweight children. And those kids had more complications of health risks that other kids. With the addition of high-fiber, better control of weight, cholesterol, blood sugar, and insulin release was maintained. Risk of "metabolic syndrome" or "syndrome X" goes down with high-fiber supplementation. With this, insulin resistance goes down; – while hyperlipidemia, hypertension, hypercholesterolemia and type 1 and type 2 diabetes all have improvement.

Obesity continues as diets are high in fats, high in added sugars, and low in soluble fibers.

At least 25 to 30 grams of soluble fiber is recommended daily, slowly added from about 5 grams per day over 2-3 months – to maintain a healthy weight.

IN SUMMARY: ENJOY THE HOLIDAYS HEALTHIER *

SOLUBLE FIBER HELPS SLOW DOWN THE RATE THAT FOOD NUTRIENTS ARE ABSORBED

SOLUBLE FIBER HELPS YOU FEEL LESS HUNGRY

SOLUBLE FIBER HELPS REDUCE THE AMOUNT OF CALORIES YOU TAKE IN

SOLUBLE FIBER HELPS PROTECT YOU FROM THE RISKS OF SEVERAL SERIOUS DISEASES.

(excerpts from: Soluble Fiber – Saving Your Health, Saving Your Money. Winter & Crane)

Wii INJURIES – UNIQUE STORIES 911 COMMENTARY OF nintendo Wii EMERGENCIES * EXCITED, RABID, FROTHING – TELL YOUR STORY

MANY PERSONS AND STORIES OF PERSONS HAVE RELATED UNIQUE AND FUNNY STORIES OF THIS HOT DEVICE IN THE NEXT NEO-GAMING LEVEL OF ENTHUSIASM. SOME ARE EMERGENT, SOME REQUIRE IMMEDIATE CARE, AND SOME ARE NON-EMERGENT. FUNNY, UNUSUAL, AND CHAOTIC !

WHAT IS YOUR STORY………CLICK ON COMMENTS BELOW AND WRITE TO THE BLOGOSPHERE !

UPDATE: After adding your emergency story or injury in comments below – go to www.wiihaveaproblem.com as it is hilarious!

PHARMACEUTICAL ADVERTISING TO THE PUBLIC – GAO WEIGHS IN ON THE FDA – WWW GROWTH TOO FAST – PATIENTS SMOTHERING IN DRUG ADS

WWW.CASTMD.COM HAS BEEN HOT TRACKING THIS ONGOING MASSIVE PATIENT BOMBARDMENT.

NOW YOU TOO CAN READ THE WARNING LETTERS FROM THE FDA SITE.

http://www.fda.gov/cder/warn/warn2006.htm

http://www.fda.gov/foi/warning.htm

LIKE PREVIOUS CASTMD.COM BLOGS, http://www.castmd.com/?p=86 THIS LEVEL OF MARKETING PLACES RISK ON PATIENTS AND PHYSICIANS THROUGH THE USE OF THE OLD MARKETING PLOYS AND SILENT ADVERTISING – "SUBLIMINAL SUGGESTION." http://www.castmd.com/?p=79

FDA officials are issuing fewer offense warnings to drug companies for false and misleading advertisements and are taking longer to do it, a congressional report says.

Annual spending on direct-to-consumer drug advertisements at $4.2 billion and growing, the government has limited ability to curb distribution of ads that violate federal rules, according to the report being released Thursday.

From 2002 through 2005, it took the FDA four months on average to draft, approve and send warning letters and other correspondence to companies that were in violation of the rules, government auditors said.

Between 1997 and 2001, before FDA lawyers began reviewing the letters as a matter of policy, it took just two weeks on average to issue the letters. The number of letters fell off by about half between the two time periods.

The GAO also said the FDA lacks an effective way to screen, review and track the more than 10,000 ads and Web sites brought to the agency's attention each year. The amount has doubled in just four years.

(adapted from fxnws/fda/gao)

smokers CALL 911 * LIFE-SAVING DISTANCE ADDED TO SMOKERS BAN BUBBLE – SOME SMOKE IS HEALTHIER THAN OTHER SMOKE IN COEUR D ALENE AND THE IDAHO LEGISLATORS AND LOBBYISTS

AS CASTMD.COM HAS OPINED PRIOR ON THE ONGOING LUNG ASSAULT FROM THE AGENTS OF FIELD BURNING IN NORTHERN IDAHO AND OTHER CLOSE AREAS, NOW THE COUNTY COMMISSIONERS ARE ADDING "LIFE-SAVING" DISTANCE TO THE CIGARETTE SMOKERS BANNED AREAS.

I BELIEVE, IDAHO STATE LAW STATES THAT SMOKING IS ALLOWED ONLY BEYOND 20 FEET FROM A PUBLIC DOORWAY OR ENTRANCE. THE KOOTENAI COUNTY COMMISSIONERS CHANGED IT TO 20 FEET FROM ANY BUILDING.

ONE OF THE LOCAL PAPERS QUOTED A COMMISSIONER SAYING, "IT'S AN EMPLOYEEE, RISK MANAGEMENT ISSUE."

WHAT IS THIS? THE COMMISSIONERS CONTINUE TO ALLOW FIELD BURNING SO PATIENTS, EVEN WITH SEVERE LUNG DISEASE AND HEART DISEASE AND KIDS WITH CYSTIC FIBROSIS, ASTHMA, AND ALLERGIES – CAN BREATHE POLLUTED AIR IN THE BEAUTIFUL SUMMER AND FALL MONTHS.

IN THE LOCAL PAPER, THE STORY CONTINUED THAT SOMEONE EVEN STATED IT [THE SMOKE] "PERMEATES THE BUILDING." AMAZING TO SAY THE LEAST……

RISE UP FOLKS…DO THE FIELD BURNING AND THE FOREST FIRES BOTHER YOU? CALL YOUR LEGISLATORS ABOUT THE THOUSANDS OF TONS OF PARTICULATES CREATED AND THAT YOU MUST INHALE WITH THOSE PROBLEMS. (SEE PREVIOUS BLOGS FROM WWW.CASTMD.COM)

SO, IT IS NOT A MYTH. IT IS TRUE.

IN IDAHO'S LEGISLATORS AND LOBBYISTS, SOME SMOKE IS HEALTHIER THAN OTHER TYPES. SIMPLY AMAZING !

OSTEOPOROSIS AND TREATMENT SIDE-EFFECTS * Jaw Osteonecrosis

THE GOOGLE SEARCH FOR FOSAMAX AND OTHERS BRINGS FORWARD MANY PAID ADVERTISING LAW FIRMS REGARDING LAWSUIT INVITATION AND CONSULTATION REGARDING THIS CONCERN.

WWW.CASTMD.COM LOOKED TO SEE IF THIS IS A PROBABILITY OR POSSIBILITY FOR LITIGATION AND JURY AWARD. WHAT DOES SOME OF THE LITERATURE SAY?

MANY COMMENTS ARE BEING MADE OF THE RISK OF TAKING OSTEOPOROSIS MEDICATION FOR PREVENTING BONE LOSS, AND REBUILDING BONE. MOST, IF NOT ALL OF THE CONTROVERSY IS RELATED TO JAW BONE LOSS, OSTEONECROSIS OF THE JAW. THE CONTROVERSY ALSO RELATES TO THE POSSIBILITY OF THE MEDICINES CALLED "BIPHOSPHONATES" SUCH AS FOSAMAX, AREDIA, AND ZOMETA, AND POSSIBLY OTHERS.

OSTEONECROSIS OF THE JAW IS A DEVASTATING CONDITION. THE BONE LOOKS AND ACTS INFECTED. MOST CASES COME FROM THE ILL EFFECTS OF INFECTION DUE TO DENTAL PROBLEMS OR DENTAL SURGERIES. MANY CASES, IF NOT ALMOST ALL, COME FROM THE USE OF INTRAVENOUS USE OF THE MEDICINES, WITH CASES OF METASTATIC BONE CANCER.

MERCK PUBLISHED THEIR CONTROLLED TRIALS OF OVER 17,000 PATIENTS, WITH 10 YEARS' DATA USING FOSAMAX, SHOWING NO REPORTS OF ONJ. IN POST-MARKETING USE, MERCK ESTIMATES BY MARCH 31, 2006 THE CUMMULATIVE RISK FROM ALL SOURCES OF CAUSE WAS ESTIMATED AT LESS THAN 1/100,000 PATIENT-TREATMENT YEARS.

CURRENTLY, THE NATIONAL OSTEOPOROSIS FOUNDATION SEES THE RISK AS RARE IN PERSONS TAKING ANY ORAL FORM OF THE MEDICINE FOR OSTEOPOROSIS. THE FOUNDATION ALSO STATES THAT IT BELIEVES THAT THE RISK OF FRACTURES AND BONE LOSS IS MUCH GREATER TO MOST PATIENTS THAN ANY RISK OF DEVELOPING THE ONJ PROBLEM DUE TO THE MEDICINES FOR OSTEOPOROSIS.

PLEASE, IF YOU ARE ON A MEDICINE FOR REDUCTION OF OSTEOPOROSIS RISK, A BIPHOSPHONATE, TALK WITH YOUR DOCTOR AND STAY INFORMED. HOPEFULLY THIS HAS ASSISTED YOU IN YOUR DECISION TO BE AND STAY HEALTHY.

THE PRESTIGIOUS NEW ENGLAND JNL OF MED WILL SPEAK TO THE ISSUE THIS NEXT WEEK, I AM ANTICIPATING.

BABY BOOMER BREAKDOWN MEDICAL CLINIC & OXYGEN BAR *** A Health Screening Survey A MEDICAL PARODY

HEALTH SCREENING SURVEY

ARE YOUR HEMORRHOIDS HURTIN’ FROM TOO MUCH HARLEY RIDIN’

ARE YOU DRINKIN' MORE PRUNE JUICE THAN BEER

ARE YOU ASKIN' FOR DIRECTIONS CUZ YOU CAN’T SEE

ARE YOU PALPITATIN’ WHEN MAMA ISN’T EVEN THERE

ARE YOU CREAKIN’ MORE THAN THE FLOOR

ARE YOU BEDDIN’ DOWN BEFORE THE ‘LATE SHOW’

ARE YOU WONDERIN' ABOUT BUYIN’ THE RV

ARE YOU BUYIN' CROAKIES FOR YOUR READIN’ GLASSES

ARE YOU INVESTIN' IN FLAX AND FIBER COMPANIES

ARE YOU DRIBBLIN’ UNTIMELY INSTEAD OF BASKETBALLS

ARE YOU SHOPPIN’ WALMART AND GETTIN’ LOST

ARE YOU BORN BETWEEN '46 AND '64

IF YES

COME TO THE NEW AND UNIQUE

“BABY BOOMER BREAKDOWN

(a select pathway)

(Based on the Vegas Oxygen Bars only with Medicare coverage)

YOU’LL LOVE THE TALKIN’

WITH LITTLE WALKIN’

SIP YOUR JUICE

AND PLAY SOME FOOS

NOT ONLY MEDICARE D CLASSES

BUT KENO AND LOTTO FOR THE MASSES

COME ONE COME ALL

BEFORE YOU TAKE THAT NEXT FALL

CALL FOR APPOINTMENTS NOW…BEFORE YOU FORGET

COCAINE “ENERGY DRINK” IS CAFFEINE BASED – ALOT ! OVERDOSE potential ?

THE LASTEST CRAZE OF ENERGY DRINKS IS THIS PRODUCT BY REDUX BEVERAGES FROM LAS VEGAS. IT IS NOT COCAINE. IT IS CAFFEINE BASED. EACH UNIT HAS ABOUT 280 MG OF CAFFEINE. THE AVERAGE COFFEE CUP HAS ABOUT 80 MG.

THE QUESTION IS: IS IT UNETHICAL ADVERTISING TO HIGHLIGHT AND ENTICE THE "ABUSE" OF OVERUSE, OVERDOSE, AND GETTING HIGH WITH SUCH PRODUCTS?

CAFFEINE OVERDOSE IS A SERIOUS MATTER. MANY TIMES THE KIDS THAT RELY ON THE "HIGH" MAY ALSO BE ABUSING OTHER AGENTS OF TOXICITY.

SHOULD WE ADVERTISE THE "HIGH" OF SNIFFING PAINT, PAINT IS A LEGAL PRODUCT ?

SHOULD WE ADVERTISE THE "HIGH" OF HUFFING COMPUTER AIR, AIR IS A LEGAL PRODUCT?

SHOULD WE ADVERTISE THE "HIGH" OF ALCOHOL, ALCOHOL IS A LEGAL PRODUCT?

THE ANSWER IS THAT THIS PRODUCT AND OTHERS, I BELIEVE, HIGHLIGHT ABUSE AND OVERUSE.

TELLING A PARENT THAT THEIR SON OR DAUGHTER HAS DIED IN THE ER OR WAS D.O.A. IS A REAL EXPERIENCE THAT SOME OF US HAVE HAD TO BARE…

THE ANSWER IS: YES, IT IS UNETHICAL ADVERTISING AND MARKETING. THE COMPANIES SHOULD BE HELD RESPONSIBLE FOR THE "ENTICING" APPROACH.

DEATH BY CAFFEINE IS NOT ANY MORE CALMING THAN DEATH BY OTHER OVERDOSE MEANS. PARENTS BEWARE.

(adapted: aceommroupdt)