KU Radiology - Alumni Newsletter Issue 5

ISSUE KU Radiology

05

JUL

2016

KU Faculty this issue

Philip Johnson, MD Letter from the Chairman P.1
Chairman Quality Initiative P.2

Ryan Ash, MD Clinical Advances P.3
Vice Chairman Imaging in the Ozarks P.4
Medical Director Update on Alumni Events P.5
Update on Education P.6
Judson Bertsch, MD
Shaun Best, MD Update on Faculty P.7

Kevin Brown, MD Letter from the Chairman

Zachary Collins, MD “The most dangerous phrase in language is ‘We’ve always changes in training, safety, performance and teamwork
Interventional Section Head done it that way.” prompting some to consider the United 173 accident one of the
most important in aviation history.
Glendon Cox, MD -Grace Hopper, American Computer Scientist and Navy Rear
Admiral Medicine has its own watershed moment, with the Institute
Joy Darrah, MD of Medicine’s 1999 report “To Err is Human”, which provided
On December 28, 1978, United Airlines flight 173 evidence of an epidemic of medical errors resulting in 100,000
Reginald Dusing, MD departed Denver, Colorado en-route to Portland, Oregon deaths annually. In a second Institute of Medicine report,
Nuclear Medicine Section Head with 189 people on board. The aircraft ran out of fuel and “Crossing the Quality Chasm,” six aims were proposed,
crashed in a suburban Portland neighborhood killing 10 including patient safety, effectiveness, efficiency, timeliness,
Brian Everist, MD people and severely injuring 23 others. Flight 173 was equity and patient centeredness. As David Larson, Vice
piloted by an experienced cockpit crew. The captain had been Chairman and Director of Quality Improvement at Stanford
Thomas Fahrbach, MD with United for 27 years with more than 27,600 hours of flight University, aptly put it, “Modern improvement paradigms
time. The first officer and flight engineer had been with the recognize that deficiencies in quality, service, and efficiencies
Shelby Fishback, MD airline for 13 years and 11 years, respectively. The total amount are a natural byproduct of normal day-to-day work in a complex
Residency Program Director of fuel required for the flight from Denver was 31,900 lbs. There system and not due to aberrant performance. Therefore, those
was 46,700 lbs. of fuel on board at takeoff, enough for the flight who wish to significantly improve quality, service, and efficiency
Jason Gatewood, MD plus reserve fuel for 65 more minutes. As the aircraft must have this mission integrated into the core structure of their
approached Portland, the green indicator light which indicates organization. Fixing problems as they arise simply results in
Crosby Gernon, MD the landing gear is down and locked did not come on, which led putting out fires rather than removing the causes of fires. To be
the captain to abort the landing, so that the crew would have effective, quality cannot live at the periphery of the organization;
Jacqueline Hill, MPH, CHES time to diagnose the problem and prepare passengers for an it must be a core philosophy around which operational
Director of Research emergency landing. The plane banked and went into a holding decisions are made.”
pattern. By the time the crew decided they were ready to land, a
Gary Hinson, MD full seventy minutes had elapsed, five minutes beyond their The KUMC Department of Radiology has made quality
Musculoskeletal Section Head spare fuel capacity. As the pilot made visual contact with the and process improvement a core philosophy of our department.
runway, the first officer informed him, “I think you just lost I want to thank Dr. Neville Irani for his hard work and innovation
Marc Inciardi, MD [engine] number four buddy.” Then they lost another engine, leading this critically important program. See page 2 for
Breast Imaging Section Head moments later they lost the remaining two engines. They additional information about KU’s Quality and Process
literally ran out of gas midair. The pilot radioed, “Portland tower, Improvement Program. I am also pleased to announce that we
Neville Irani, MD United 173 heavy Mayday – the engines are flaming out – we’re have begun fund-raising for the Glen and Karen Cox Endowed
Director of Quality going down – we’re not going to make the airport.” United 173 Radiology Professorship for Quality and Outcomes. As always,
crashed despite having 1) an hour of spare fuel, 2) no I invite your thoughts, comments and/or suggestions and hope
Jill Jones, MD incapacitating technical issues, and 3) clear protocols for to see many of you in the near future.
landing gear failure. This tragedy was a watershed moment in
Luke Ledbetter, MD the aviation industry and led to revolutionary and systematic

John Leever, MD

Steven Lemons, MD

John Madarang, MD

Bradford McCrary, MD

Lucas Meek, MD
Cardiothoracic Section Head

Kirk Miller, DO
Pediatric Section Head

Douglas Nelson, MD

Mark Perry, MD
Oncology Section Head

Kristen Pope, MD

Mark Redick, MD
Alan Reeves, MD

Neuroradiology Section Head

Stanton Rosenthal, MD
Ultrasound Section Head

Pauline Sleder, MD

John Vadaparampil, MD
Louis Wetzel, MD

Body Imaging Section Head
Vanessa Williams, MD
Onalisa Winblad, MD

Wendell Yap, MD

New Faculty

KU Radiology’s New Quality Initiative

Jill Jones, MD, Class of 2015 Neville Irani, MD participant perspectives (we have staff physicians, residents,
Ultrasound and Body Imaging techs, nurses, support staff, pharmacy, and supervisors
Residency: Univ of Kansas Earlier this year, the KU Radiology department launched a involved in these efforts) enables a better appreciation of the
Fellowship: Body – Univ of Kansas program to develop a structured method for implementing variety of events that may cause a simple fix to fail.
and sustaining improvements as a step towards higher
Vanessa Williams, MD reliability. This program - known as Realizing Improvement In order to communicate and monitor progress over the
Body Imaging through Team Empowerment (RITE) - was originally program, we used a run chart to visualize how effective or
Residency: Northwestern University developed at Stanford by David Larson, MD. The central ineffective interventions were in practice. Two run charts from
Fellowship: Body/MSK – Northwestern premise of this program is that improving outcomes in a our cohort are shown below.
complex environment requires a team (optimally 5-7
University individuals representing all relevant stakeholders) that are The first run chart demonstrates an increase in the
guided to learn and apply core principles of continuous percentage of diagnostic breast imaging appointments that are
Faculty Promotions improvement to attain a meaningful goal within a 6 month completed within the allotted time. Over the course of the
timeframe. program, the team exceeded its goal of having 90% of all
Zachary Collins, MD, Class of 2008 appointments completed within the scheduled time, in part by
Interventional Radiology We have four teams in our first cohort, each with a achieving more consistent performance. Looking at the right
Promoted to Associate Professor focused Specific, Measurable, Achievable, Relevant, and half of the graph, there are fewer days that fall below the
Time-Bound (SMART) goal. Our current focus areas are to: previous median.
(1) reduce delays in diagnostic exams for breast imaging,
(2) increase timely retrievals of IVC filters, (3) optimize and The second run chart shows how consistent execution of
standardize run times for Neuro MRI protocols, and (4) reduce optimized sequences for our Neuro protocols decreased the
the incidence of contrast reactions at our Westwood campus. average run times per week for one of our most frequently
The goals are defined by a metric and tracked in the form of a performed examinations. Reducing average exam scanner
run chart (performance over time) and measured against a time by 8 minutes while maintaining image quality translates to
goal that was established at the outset by each team’s significant operational improvement. By dropping below the
leadership sponsor. critical 30 minute threshold, we may be able to eventually take
down appointment times from our current 45 minutes to 30
None of these problems has a clean, linear “if-then” minutes for many of our MRI examinations. In the meantime,
solution. Each has multiple variables in the current this improvement has allowed previously overworked staff to
environment that contribute to significant variation from the actually run closer to scheduled times as optimized neuro
intended goal. In order to be successful, each team required exams offset exams in areas that have yet to be optimized.
an appreciation for complex system analysis. During the first
half of the RITE program, our teams spent much of their time Continued on Page 8.
understanding the problem and collecting baseline data. The
next steps involve communication and validation of planned
interventions based upon an understanding of current state
and the multiple contributing factors. The diversity of

Marc Inciardi, MD
Breast Imaging
Promoted to Associate Professor

P.2

Interventional and Neuroradiology Updates

Zachary Collins, MD – Class of 2008 and Alan Reeves, MD

2015-2016 has seen new growth and innovation in Interventional Radiology. We continue to be ranked number one in overall patient visits nationally by the United
Healthcare Consortium. We were approved by the ACGME late last year for the integrated IR/DR program. This, in essence, establishes a new IR residency. In sum,
IR/DR residents will do 3 years of diagnostic radiology and 2 years of IR as opposed to the traditional route of a one year fellowship. This new program starts July 2016,
and we are proud of the fact that we are one of only 6 programs in the nation to start this soon. Neuroradiology successfully matched its first fellow that will begin July 1,
2017.

The Cambridge North Tower is under construction, slated for occupancy in October 2017. It will focus on neuro-sciences and oncology. The tower essentially
represents a new sub-specialty hospital, with 11 floors featuring a full pharmacy, a café, 11 ORs, an entire ICU floor, a step-down unit, and multiple patient rooms.
Radiology will occupy almost the entire second floor, with two bi-plane flouro rooms, two MRI units (3T and intro-operative), CT, Sonography, radiography units, as well as
state-of-the-art reading rooms and 9 pre/post bays for IR. For Neuro/Interventional Radiology, this will represent the best medicine can offer.

Meanwhile, construction is set to begin on a large expansion of the Indian Creek. This expansion will include two new GE Discovery robotic IR suites. We have
adopted a new RIS called Radiant which has effectively merged PACS with our EMR. This has streamlined workflow with a completely integrated system.

Neuro/Interventional Radiology continues to grow with KU increasingly becoming recognized as a national site for trials of new products. This is huge, as only high-
volume site are even considered for these trials. We currently are evaluating new aneurysm treatment devices. The Diagnostic Neuroradiology section is also growing
rapidly with increasing points-of-service and neuro-oncology, as KU is a nationally-recognized cancer center. We have initiated the RESIN trial which is a prospective data
registry on the use of Y-90 and will be the largest of its kind ever performed in the field of Interventional Radiology. We have just started the CARE trial which is a
prospective multicenter case study to assess radiation exposure in patients treated with Penumbra coils. We are also in discussions on a new study called the SOLACE
trial which will evaluate patients treated with a brand new drug eluting bead called Oncozene.

Researcher Highlight Update in Research

Aaron Rohr, MD – Class of 2018 Previous publications:
x Rohr, A et al. (2012). “Spectrum of Radiological Manifestations of
Aaron is a current radiology resident interested in interventional radiology with pediatric cat-scratch disease” Pediatric Radiology, (11):1380-4. doi:
the following current publications: 10.1007/s00247-012-2451-x.
x Joe Vavricek, Saad Iqbal, Aaron Rohr, L Rock, B Lang, S Hunt, J Wick, x Williams, R., Rohr, A. et al. (2011). “Iron Deposition is
Independent of Cellular Inflammation in a Cerebral Model of
A Robinson, Sarah Schroeppel DeBacker, Trent James, Jacqueline Hill, Multiple Sclerosis” BMC Neuroscience, 12, 59. doi: 10.1186/1471-
Zach Collins. Treatment Response in Glass Versus Resin 2202-12-59
Radioembolization of Nonresectable Hepatic Metastasis. Annual
International Symposium of Endovascular Therapy (ISET). 2015 Activity over the past year:
x Aaron Rohr, Aaron Kovaleski, Jacqueline Hill, Philip Johnson. Thyroid “Recently, I’ve dedicated my free time to a part time job as a night janitor at a
Arterial Embolization as an Adjunctive Therapy in a Patient with Thyroid local well-renowned mathematical institute where I secretly solve impossible
Storm. JVIR. 2016 Mar; 3(27): 449-453. math problems at night….much to the chagrin of my best friend, Ben Affleck.”
x Aaron Rohr, Ryan Ash, John Vadaparampil, Jacqueline Hill, Louis
Wetzel. Disseminated cat-scratch disease in an adult with selective IgA P.3P.3
deficiency. Radiology Case Reports. 2016 Apr 8; 11(2): 54-7.

x Aaron Rohr, Shaun Best, Ryan Ash. The duplicated pancreas: Imaging

evaluation of a rare anomaly presenting as acute pancreatitis.
(Manuscript submitted for publication)
x Aaron Rohr, Jacqueline Hill, Carissa Walter, Lucas Meek, Shelby
Fishback, Ryan Ash, Kirk Miller. Impact of Case-Based Radiology
Education on First-Year Medical Students Knowledge, Perceptions, and
Interests in the Field of Radiology. (Manuscript submitted for publication)
x Aaron Rohr, Carissa Walter, Jacqueline Hill, Shaun Best, Kirk Miller,
Ryan Ash. Reducing patient radiation exposure after the addition of
Iterative Reconstruction (IR) software: Is the juice worth the squeeze?
(Poster presentation KU research forum, possible RSNA, and
manuscript underway)
x Aaron Rohr, Meggon Koger, Neville Irani, Tim Schneider, Zach Collins,
Philip Johnson. RITE program working on quality improvement for
efficiency of IVC Filter Retrieval (on-going course with goal of submitting
manuscript for publication)

KU Radiology Leadership Institute Lecture Series

Sponsored by the University of Kansas Department of Radiology in conjunction with the American College of Radiology – Radiology Leadership Institute

Lectures are hosted at the Beller Conference Center, Lied Auditorium, or Wahl Hall West.

8/30/16 – 7-8AM 2/21/17 – 7-8AM
Beller Conference Center Wahl Hall West
Philip Johnson, MD Jim Rawson, MD
Importance of Leadership Quality Metrics in Action

9/22-16 – 7-8AM 3/7/17 – 7-8AM
Beller Conference Center Wahl Hall West
Cheri Canon, MD Giles Bowland, MD
Mentorship Strategic Case Scenarios

10/25-16 – 7-8AM 4/5/17 – 7-8AM
Beller Conference Center Lied Auditorium
Leonard Berlin, MD Richard Gunderman, MD, PhD
Risk Management Ethics

1/24/17 – 7-8AM 5/9/17 – 7-8AM
Beller Conference Center Beller Conference Center
Glen Cox, MD David Laszkovits, MBA
Importance of Quality Improvement and select alumni
Life After Training

P.4

Former Faculty Spotlight – Don Eckard, MD Glendon G. and
Karen E. Cox
Radiology has been a great career choice for me and Professorship in
I am happy to share my experience. After completing Radiology
medical school at the University of Utah and an
internship at LDS Hospital in Salt Lake City, I travelled to The Department of Radiology is proud
Charlottesville, VA for radiology residency followed by a to announce the establishment of the
fellowship in diagnostic and interventional neuroradiology. Glendon G. and Karen Cox
I was lucky to be only a select handful of people trained Professorship in Radiology. This fund
in interventional neuroradiology at the time. After my honors the legacy of the Cox family to
training, I spent one year at The University of Texas the KU School of Medicine and Dr.
Southwestern Medical Center in Dallas, TX, but then Cox’s contributions to the Department
was persuaded to relocate to the University of Kansas by of Radiology.
my good friend Ed Siegel who at the time had just taken
over the interventional radiology program at the Dr. Cox’s has served in various
University of Kansas where he also taught me all of the leadership roles during his time as a
peripheral interventional radiology procedures. faculty member, including leading the
School of Medicine’s reaccreditation
At the University of Kansas, I was able to enjoy a great career in interventional neuroradiology and also peripheral process in 2013.
interventional radiology with the strong support of the physicians throughout the KU Hospital. Tumor embolization, AVM
embolization, carotid, vertebral and intracranial angioplasty and stenting were all widely supported followed by aneurysm This professorship provides
coiling when that treatment became available. In fact, if there was a way we could treat the disorder using interventional annual financial support for a faculty
neuroradiology or peripheral interventional radiology, the KU physicians were largely very supportive. Unfortunately I think my member who demonstrates excellence
success at interventional radiology procedures also eventually became my downfall in that it was so busy that I finally decided in teaching and research in quality
that I needed to get out to enjoy other aspects of my life. healthcare outcomes.

After 15 ½ years at the University of Kansas, I took an abrupt turn and joined NightHawk Radiology in order to do If you would like to make a
teleradiology, primarily for emergency rooms throughout the United States. As my wife, Valerie Eckard, is also a radiologist she contribution to this fund, or for more
was able to help me make the transition. In January 2007, we moved to Sydney, Australia to start a career in Emergency information, please contact David
Radiology and the topsy-turvy world of teleradiology. Teleradiology has changed quite a bit over the years, unfortunately Ochoa of the KU Endowment
mostly for the worst, but it allows us to live in San Diego where I have wanted to live ever since I was a child. Plus, with our 1 Association at 832-562-2704 or
week on and 1 week off schedule, and a few extra weeks off here and there, we have been able to travel the world which is [email protected]. 100% of
also something that I had always wanted to do. your gift is tax deductible.

Our flexible schedule has also given us the time to write a book on health and fitness - a blueprint for living that we try to P.5
practice every day. We also travel frequently to Cabo San Lucas, Mexico, where we now own Baja’s Stop, a restaurant and
market, and Rockstone Tavern, a bar and live music venue. We frequently travel to Japan and Southeast Asia, since my older
son now lives in Tokyo after marrying a beautiful Japanese girl. My younger son lives in Kansas City. I am not sure where life
will take us in the future, but I know it will be an amazing adventure.

In Memoriam

Dr. Arch W. Templeton, Professor Emeritus of Radiology and former
Chairman of the Department of Radiology at the University of Kansas
Medical Center, died peacefully with his family by his side on February
23, 2016, after a brief illness. Dr. Templeton was Professor and Chair of
Radiology from 1967 to 1992. He was largely responsible for the creation of
the modern academic radiology department at KUMC. A well-known expert
in his field, Dr. Templeton authored nearly 175 papers, books and book
chapters. He won numerous professional awards and was an invited visiting
professor throughout the world. He was responsible for training over 100
radiology residents and countless radiology technologists. Dr. Templeton
has an endowed professorship in radiology in his honor. He will be dearly
missed by his family, friends and colleagues. He is survived by his sister
Elizabeth Larson, five children (Debra Cooper, Scott Templeton, Karen Cox,
Mark Templeton and Craig Templeton), and eleven grandchildren.

Clinical Imaging Update on Education
Update
Shelby Fishback, MD, Program Director - Class of 2010
Ryan Ash, MD – Class of 2010
Residency Program Celebrates Its Graduates
The coming years are going to be
an exciting time for the radiology Class of 2016 Radiology Residency Graduates
department. The hospital system
continues to expand, and with it so Front Row (L-R):
does our imaging capabilities. Over Jonathan Lindquist, MD – Interventional Fellowship
the next year we will add two new
GE PET/CT scanners with 64 slice Northwestern University
CT scanners, TOV PET imaging, Irfan Haider, MD – Breast Fellowship
and the ability to upgrade to Q-
Clear. These new scanners will be University of Utah
placed at our Westwood and Amy McCann, MD – Body Fellowship
Overland Park campuses. A 3T
intra-operative GE magnet and 3T University of Kansas
Siemens magnet will be placed in
the new Cambridge Tower, just Back Row (L-R):
north of Bell Hospital. 3T and 1.5T David Creed, MD – Neuroradiology Fellowship
Siemens magnets will be placed at
the Indian Creek campus, replacing Oregon Health & Science University
an outdated 3T Philips magnet that Brandon Welsh, MD – Body Fellowship
came with the purchase of that
campus. These new scanners will University of Wisconsin
drastically improve our imaging Trent James, MD – Interventional Fellowship
abilities for improved clinical care as
well as advanced research. Vanderbilt University

While awaiting these new Resident Highlight
purchases and physical
expansions, our demand for Jayden Spencer, MD - Class of 2019
imaging continues to rise. In order
to meet the current demand, we are x Interested in MSK Radiology
planning to extend our hours of x Married 12/12/15 to his High School sweetheart, Quince
operation for outpatient scanning at x Unanimous first team all-district center field in baseball and 2 time district champion in pole vault.
the Westwood campus to include
weeknight and weekend scanning, Now enjoys golf.
as well as continue weekend x Graduated summa cum laude from Texas Tech
scanning in the Medical Office x Primary author of Case in Point publication 'Tuberculous meningitis mimicking subarachnoid
Building.
hemorrhage' as medical student at UTMB.
The addition of 2 new
fellowship-trained radiologists to our First Year Residents (PGY 2 – Class of 2020)
practice this summer will help
match the growth our clinical Nick Christine Luke Frager, Aaron Sam Hund, Melissa Smith, Kyle Werth,
practice as well as provide new Barnthouse, Boatright, MD MD Frenette, MD MD MD MD
expertise in clinical diagnostics,
research and teaching. These MD Univ of Univ of Kansas Univ of North Univ of Kansas Univ of Kansas Univ of Kansas
highly trained radiologists and Oklahoma SOM Dakota SOM
advanced imaging scanners will Univ of Kansas SOM SOM SOM
help KU Radiology continue our SOM COM
mission for teaching, research and
community health. Body Imaging Fellow Breast Imaging Musculoskeletal Vasc/Int Radiology Vasc/Int Radiology
2016-2017 Fellow Radiology Fellow Fellow Fellow

2016-2017 2016-2017 2016-2017 2016-2017

Amy McCann, MD Ryan Tran, MD Mark Flajole, MD Ben Havercamp, MD Billy Pedersen, MD

Univ of Kansas – Baptist Memorial Wayne State Univ – Univ of Missouri, Case Western
Diag Rad Hospital, Memphis – Diag Rad Kansas City – Reserve-
Diag Rad Diag Rad
Diag Rad

P.6

Construction Updates

Cambridge North Tower

Construction began on the $250 million Cambridge North Tower, located at the corner of 39th
Street and State Line Road (Northwest corner) in 2015. The new tower will expand access to
healthcare in Kansas City and be home to highly specialized surgical services for oncology,
neurosciences and otolaryngology. Construction is expected to be complete in late 2017. The
Tower will add 124 beds, 28 intensive care beds and 96 a cute beds, 11 operating rooms,
500,000 total square feet, 100 physicians on staff, and 600 health care jobs. There are already
two bridge structures crossing over 39th street framed in and walls will soon go up on the level 2,
where radiology will be housed.

Health Education Building

In September 2015, KUMC broke ground on a $75 million Health Education building project. The
171,000-square-foot building will facilitate the education of a greater number of physicians,
nurses and allied health professionals. The building will serve as the primary teaching facility for
KUMC and will include significant simulation space and flexible, state of-the-art learning space to
support inter professional education and other new models of teaching. The project is expected
to be completed in the fall of 2017.

Faculty Spotlight

Ryan Ash, MD - Class of 2010

Dr. Ryan Ash attended Kansas State University, since 2015. He is also taking strides to advance
completing his B.A. in 2001. He subsequently his effectiveness in administration and leadership,
attended the University of Kansas Medical School, completing the Leadership Development for
completing his M.D. in 2005 and then radiology Physicians in Academic Health Centers course at
residency in 2010. Following residency, a Body the Harvard School of Public Health in 2014 as well
Imaging fellowship took him west to San Diego, as being a degree candidate for a Masters in
California and UCSD where he developed a strong Health Care Management at the Harvard School of
clinical interest in liver imaging. Since his time in Public Health, which he is scheduled to complete in
San Diego, he has been active in national May 2017.
committees and workgroups related to liver
imaging, such as the Society of Abdominal Imaging Dr. Ash hopes to be a part of KU radiology
HCC disease focus panel as well as the ACR LI- for many years to come. He believes the
RADS atlas and lexicon working group. coordinated missions of clinical care, teaching and
research will continue to help set the department
Dr. Ash began his career as a staff apart both regionally and nationally. “We have
radiologist here with KU Radiology in July some fantastic individuals working in our
2011. Though still early in his career, Dr. Ash has department, and seem to have added great people
found himself more and more involved in the each and every year since I started in 2011. It’s
administrative and leadership side of really these individuals that have helped set us
medicine. This includes serving as the radiology apart.”
medical director since 2012 and vice-chairman

P.7

We want to KU Radiology’s New Quality Initiative Continued from pg. 2
know where
you are now! Ultimately, our patients don’t experience an individual provider but rather a complex (and hopefully continuously
improving) system. One of the strongest predictors of patient loyalty in satisfaction surveys is “How well did your providers
Recently married? New work together as a team?” Thinking about team sports, there is significant pre-game preparation and training with dedicated
child? New promotion? New coaches for each position. We hope that the training our healthcare delivery teams receive through the RITE program will
publication? enable them to think differently about the complexities our patients face and know how to engage their colleagues in smooth
handoffs as would be expected from a winning team. As most national reimbursement trends place a greater emphasis on
Let us know! value, quality and high reliability will take a seat as the co-pilot for driving growth in future reimbursement models.

Dept of Radiology
3901 Rainbow Blvd
MS 4032
Kansas City, KS 66160
(913) 588-6805
[email protected]

P.8
KU Radiology Issue 05 Jul 2016

3901 Rainbow Boulevard
Mailstop 4032
Kansas City, Kansas 66160
913.588.6805 ph
913.588.7899 fax
www.kumc.edu/rad

891027

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