Survivor Spotlight: Proton alum and teammates win national title at USTA Championship

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National Champions Tennis 8.0 Seniors. Honored to play with these guys! An Undefeated Team in 16 Matches. Pictured from l to r: Dickie Anderson, Howard Rugaber, Randy Scott, Mark Levy, Jimmy Parker, Joe Simon, not pictured Ron Hale

A recreational tennis player since his thirties, proton alum (2009) Howard Rugaber didn’t expect that at age 66 he would be a national champion. But, to his surprise, he and his doubles teammates rose through the ranks to win the National USTA 8.0 championships held in Surprise, Ariz., in April.

“I was asked to be on the team in June of last year,” said Howard who lives in St. Simons Island, Ga., where he owns and operates a landscaping company. “A friend of mine who I play tennis with from Columbus, Ga., was putting together a team to beat the other GA teams in the state tournament. When he asked me, I said, ‘I don’t play much doubles, but I’ll be happy to be on the team.’ I learned a lot on the way.”

The way ended up being a state tournament win in Savannah, Ga., that led to a regional tournament win in Dothan, Ala., ending in the national title win in Arizona.

Howard said the team practiced hard between tournaments to be ready for the competitions. Judging by their athletic achievement, you would never know that some of the players had previously had knee replacements, hip replacements, and proton therapy for prostate cancer.

When Howard was diagnosed with prostate cancer, he talked to friends and a fellow tennis player about it and they told him about their success in beating the disease with proton therapy at UF Health Proton Therapy Institute. As a University of Florida alum, it was an easy decision for him to have proton therapy in Jacksonville. 

“I was very fortunate. I was kind of a poster child for all the treatments. I had no negatives associated with it,” Howard said. Even with a three-hour round-trip commute to receive daily treatment he maintained his regular schedule. “I worked every day, and I played tennis almost every day. I didn’t really get tired like some people do who get radiation.”

More than six years post-treatment, Howard and his wife Trish, whom he met while in college at UF, enjoy spending long weekends in the Jacksonville area at the beaches in Ponte Vedra and playing tennis with friends.

Play Golf. Fight Cancer.® registration is now open

We invite you to register as a sponsor or player at the 12th Annual Play Golf. Fight Cancer.® Classic: October 9-10, 2016. The event will take place at the World Golf Village in St. Augustine, Fla. A celebratory dinner and silent auction will take place on October 9, 6 p.m., at the World Golf Village Renaissance Hotel. Golf will be played October 10 on both the Slammer & Squire and King & Bear courses. Registration begins on course at 7 a.m. An awards party will be held at the Slammer & Squire Clubhouse immediately following play.

For information on sponsorships and tickets, please visit

The research program at UF Health Proton Therapy Institute

For an overview of the research program, how it works and why it matters, we invite you to watch this online video.

Executive Director Message

StuartKlein.pngNurses are the most trusted professionals in the United States according to the most recent Gallup survey.1,2  Eighty-five percent of respondents rated nurses as having very high or high “honesty and ethical standards.” In fact, nurses have ranked number one on the list since they were added to the survey in 1999. The bond between patient and nurse is undeniable and never more apparent than at UF Health Proton Therapy Institute.

May is the traditional time of year that we honor nurses as National Nurses Week is observed May 6-12. Our highly skilled nursing professionals include specialists in adult radiation oncology, pediatric radiation oncology and clinical research. As case managers, nurses are involved from day one in developing every patient’s care plan. They counsel patients on what to expect during treatment and beyond. They set patients at ease by providing knowledgeable answers and effective solutions to health concerns that may develop during or after the course of treatment. It is common for our nurses to go the extra mile to give patients that added bit of comfort, support or encouragement to keep on track with treatment for the best possible outcome. We thank all of our nurses for their commitment to excellence.


Stuart L. Klein


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Patient Spotlight: Noah Edgar

By Theresa Edwards Makrush

Family_0.JPGAt just 20 months old, Noah Edgar of Colchester, England, is a happy, curious, busy toddler playing at the beach. Passersby may think he is in Jacksonville, Florida, with his family for vacation. They would be surprised to discover Noah is here for cancer treatment.

Last December, Noah had an eye infection. His parents Gemma and Rob took him to the doctor. After the infection was healed his doctor detected a tumor in the retina. 

Retinoblastoma is an uncommon pediatric cancer of the eye. It begins in the retina, ocular tissue that lines the back of the eye, senses light and sends images to the brain. In the United States, retinoblastoma accounts for about 3 percent of cancers in children younger than 15 years – about 4 cases per million. Retinoblastoma is sometimes caused by an inherited gene mutation; when it occurs in both eyes, it is always the result of a gene mutation. It most often occurs before the age of two, with 95 percent of retinoblastoma diagnosed before the age of five. The tumor may affect one eye (about 75 percent of cases), or both eyes (25 percent of cases). The prognosis for retinoblastoma is good if the tumor is identified early. More than 90 percent of retinoblastomas that do not spread beyond the eye will be cured.

In Noah’s case, the tumor had become so large that it had detached his retina causing him to lose sight in the affected eye. It was decided his best chance for cure was to remove his eye surgically and follow it up with proton therapy and chemotherapy.

This news was a jolt to the family. “It’s the worst thing as a parent to hear that your child has cancer,” said Noah’s dad Rob. But the Edgars said they are confident in Noah’s prognosis after having surgery by the top specialists in England and now proton therapy at UF Health Proton Therapy Institute.

Proton therapy will deliver targeted radiation to the area where the tumor was removed in order to reduce the chance for recurrence. Because proton therapy does not penetrate beyond the treatment area, there is little chance of unnecessary radiation exposure to Noah’s remaining eye or brain allowing him to retain his sight and IQ.

Rob said that people should be aware of symptoms of retinoblastoma. If one of your child’s eyes look unusual in a flash photograph, it could indicate a tumor is present in the eye that is not reflecting light. The earlier a tumor is detected, the better. He recommends taking your child to an optician on a regular basis to have their eyes checked.

While they are in Florida, the Edgars are making the most of every day. It’s an attitude the couple chose when Gemma was treated for a brain tumor just months after Noah was born. “It’s hard, but we both have a positive outlook,” she said. Rob added, “Yes. There have been dark days and sad days. But we want to live for every day. Our other son Dylan is four years old and we try to carry on as normal.”

Most days after Noah’s proton therapy session, the family plays at the beach or the pool. One weekend they went to an amusement park in Orlando and to the Silver Springs State Park in Ocala, Florida. They have plans to visit Savannah, Georgia. “We try to have fun whenever we’re not in hospital,” said Gemma.

Ray Lewis named a Champion of Veterans Honoree

By Theresa Edwards Makrush

Ray Lewis_0.JPGEach year the National Association of Veterans and Families (NAVF) honors companies and organizations that support the veteran community and honors a standout employee who exemplifies the true meaning of values taught by the military: sacrifice; passion for what they do; one who demonstrates the ability to improvise; adapt and overcome; and most importantly leadership characteristics in their daily work.

UF Health Proton Therapy Institute’s machinist Ray Lewis was selected as a 2016 Champion of Veterans honoree. He was honored at an awards banquet on May 6 at The University Club in Jacksonville.

One of the essential components of a proton therapy patient’s treatment is the creation of customized devices — compensators and apertures — that are made in the exact size and shape of the tumor area being treated. The aperture is milled out of solid brass and matches the width of the treatment area. The compensator is milled out of clear Lucite that matches the height of the treatment area. Stacked and attached to the end of the treatment nozzle during each treatment, these custom devices shape the proton beam as it passes from the proton beam line into the patient.

Ray Lewis is one of the people responsible for fabricating these devices. Ray joined the UF Health Proton Therapy Institute staff as one of its first employees, after retiring in 2005 from a 20-year career in the Navy. “I’m what you call a conventional machinist. Lathe, milling machines, shaping machines, boring mills, grinders. Typical machines you would find in a good size machine shop,” said Ray. He planned from the beginning to make this a job he could stay with until he retires from civilian work. “I love the job. I remember when I came in and did the interview I told Dr. Li [Zuefong Li, DSc, director of medical physics], like a lot of military people, I commit and stick with it.”

Evidence of his level of commitment started from day one. Ray recalled, “I started on the seventh of August and the following week was when they were going to treat the first patient. When I started and we were doing orientation in the Tower [a separate building from the proton therapy institute], they called me out of the orientation to fabricate the device for the first patient.” He willingly left orientation and made the devices that would be used to treat the first patient on August 14, 2006. From that point forward he has milled countless devices for hundreds of patients.

During his nine years at the institute, Ray has gained the admiration and respect of everyone he works with. He has been nominated for the UFHPTI Shining Star Award, a peer-recognition program at the institute for employees who exemplify excellence.

Jeff Rexford is the site manager for IBA, the manufacturer of the proton therapy equipment. Jeff and his team are responsible for running and maintaining the proton therapy system. Jeff said, “I have known Ray since I first began working for IBA in January of 2007.  In that time I have had the pleasure of working closely with him on many technical projects. Ray has taken his position to something much higher than a normal machinist’s position. He has shown great inventiveness and dedication to improve many aspects of the machining process. Ray’s dedication and professional expertise has driven a few important improvements to the development of patient plans. It is with Ray’s knowledge that we will also increase the efficiency of the in-house fabrication, and reduce the outsourcing of patient specific devices.”

Ray is known for going above and beyond the call of duty. He says it is because he enjoys the work. “As with most places what makes it enjoyable it’s usually the people that you work with. The people I interact with, the dosimetrists, the quality assurance people, the physicists, I haven’t really had a bad experience with any of these people. Basically, they let me do my job. I know what my job is and they allow me to do it, and I like that,” Ray said.

The chief dosimetrist Debbie Louis oversees the department that uses computers to design and program the treatment plans. These are then transferred to the machine shop to create the devices. 

Debbie said, “Ray is always willing to adjust his work schedule to accommodate clinic needs, even at the last minute and always with a smile. If he says he can get something done, you can be sure it will be done. Ray is a pleasure to work with and a real asset to UF Health Proton Therapy Institute and our patients.”

As the senior-level machinist, he is often called upon to make the more complex patient-specific devices. Even on his days off and vacation days, Ray willingly comes in to help if needed. Holly Mostoller is the human resources director and recalled one such occasion. “On August 8, 2014 in the early morning Dr. Hunter was in need of having new apertures made for an eye patient. The machinist on duty that day did not start until later in the afternoon and Ray was on vacation. I was unable to reach the on-duty machinist first and then reluctantly called Ray to see if he would be willing to come in to quickly produce the equipment for Dr. Hunter so the patient could start treatment right away. Ray gladly agreed and came right in and completed the process allowing the patient to start. All on his last day of vacation and right before the weekend. Ray is a very dedicated employee who helped out in a time of need when it was not required of him."

“I have personally always found Ray to have the most positive attitude every day he comes to work. He is exceptionally loyal to UF Health Proton Therapy Institute and very passionate about the cancer treatment we deliver here,” said Holly.

Ray’s military service spanned a period that included several significant historic events. He remembers in 1991 transporting and loading ammo on submarines to support Operation Desert Storm. He was at Guantanamo Bay when the mass migration from Cuba and Haiti in 1994 occurred and the whole base was covered in tents and camps as people sought asylum in the U.S. In 2001 he volunteered to do a second tour at Guantanamo in support of Operation Enduring Freedom. An old friend of his had returned there working at the brig and he needed some people to help. So Ray volunteered and served as Assistant Brig Officer in Charge, including a six-month stint as Officer in Charge while waiting for a replacement due to personnel retirement. He stayed there until 2005 when he retired as a Petty Officer First Class after 20 years of Navy service.

Ray settled down in Jacksonville, where he had purchased a home while he was stationed at Mayport (1998-2001). During his time in Guantanamo Bay, he formed many close friendships, people who have also retired from the Navy and settled in Jacksonville. His best friend still lives in Guantanamo, a Cuban exile and his wife who live on the base. His best friend has cancer, and Ray helps by sending essential medical supplies. “I’m always anxious when I take the medicine to the base for shipment. I worry about missing the transport. He needs it to keep alive,” Ray said.

It’s the ultimate care package from a man who always goes above and beyond the call of duty.

Aloe Plants

Aloe horizontal close_0.JPGThe Men’s Garden Club of Jacksonville is putting its green thumb to work for the good of patients having radiation treatment for cancer. Several aloe vera plants are nestled in the tropical garden located in the main lobby below the staircase for patients to take home with them. Check with your medical team to see if this natural balm is right for you. Then help yourself to an aloe plant.

The sap of the aloe plant is easy to use. Simply snap off a leaf and squeeze to extract the gel-like fluid onto the affected skin. The most common benefit is a cooling or soothing sensation that eases discomfort from minor burns.

Here are some tips for tending your aloe plant:

Unless you live in an area with a very mild climate, it's best to leave your aloe plant in the pot and place it near a window that gets a lot of sun. Aloe vera is a succulent, and as such, stores a large quantity of water within its leaves and root system.

During the winter months, the plant will become somewhat dormant, and utilize very little moisture. During this period watering should be minimal. Allow the soil to become completely dry before giving the plant a cup or two of water, just enough to moisten the soil.

During the summer months, the soil should be completely soaked, but then be allowed to dry again before re-watering. Aloes have a shallow, spreading root system so when it is time to repot choose a wide planter, rather than a deep one. Use a planter with a drainage hole, or provide a 1-2 inch layer of gravel in the bottom of the pot to ensure adequate drainage. Use a good commercial potting mix with extra perlite, granite grit, or coarse sand added. You may also use a packaged 'cacti mix' soil.

Aloe vera plants are propagated by removing the offsets which are produced around the base of mature plants, when they are a couple inches tall (or larger).

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Message from the Executive Director


StuartKlein.pngClinical care and clinical research are essential to the UF Health Proton Therapy Institute’s mission. Our purpose is to give patients the best quality cancer treatment. Careful planning and attention to detail goes into every single patient treatment, beginning with the development of treatment protocols and clinical trials. We invest heavily in research because we want to see a day when all patients with cancer are cured and none are burdened with side effects of treatment.

Since opening in 2006, our clinical researchers have published more than 130 articles in peer-reviewed journals. The best available evidence in the field of proton therapy is presented in the current issue of the International Journal of Radiation Oncology Biology Physics. Among more than 70 articles accepted for publication in the issue, only 20 deal with actual treatment outcomes, including six UF Health Proton Therapy Institute articles reporting patient outcomes following proton therapy for five types of cancers – stage IIA - IIIB breast cancers; sinonasal cancers such as olfactory neuroblastoma, squamous carcinoma and adenoid cystic carcinoma; chordoma and chondrosarcomas of the sacrum, cervical spine and thoracolumbar spine; stage III non-small cell lung cancer; and stage T1 - T3 prostate cancers.

Our investment is paying off. Meaningful data is being generated that helps us understand the effect of proton therapy on many kinds of cancer and how patients’ bodies respond to the treatment. We are encouraged that proton therapy is able to meet or exceed standard treatment cure rates, often with a reduced risk of side effects. These discoveries lead to more exploration and will continuously improve patient treatment for years to come.


Stuart L. Klein

Patient Spotlight: Sophia Gall

Australian teen packs positive attitude in dealing with osteosarcoma

By Theresa Edwards Makrush

IMG_5504.JPG A positive attitude has taken 14-year-old Sophia Gall far. Even through a tough year of cancer diagnosis and treatment, Sophia continues smiling and is determined to find the good in a bad situation.

Her desire to make others aware of proton therapy and encourage other cancer patients, especially teens, prompted her to start a YouTube channel. She has posted several videos since the first week of January 2016 that describe her medical journey.

 “A lot of people go through stuff like this. And people don’t know what to expect and I want to show others about it,” she said following one of her last proton therapy sessions for osteosarcoma. “When you’re dealing with cancer, it doesn’t just stop you. You still get good things that happen.”

Because of the location of the tumor in her pelvis, Sophia was not a candidate for surgery. Her treatment option was a combination of chemotherapy and radiation therapy.

Sophia’s dad began researching radiation therapy options and discovered the benefits of proton therapy. Unfortunately, it is not available in Australia where the family lives, so he sent Sophia’s records to six proton therapy centers around world to get their opinion on whether they would accept her for treatment and estimates for the cost of treatment. Sophia’s radiation oncologists recommended that he include UF Health Proton Therapy Institute and Dr. Daniel J. Indelicato in the review. The physicians were comfortable with Dr. Danny and the program at the Institute – the treatment and the facility.

At the same time, he wrote to the Health Minister and other elected officials to petition support of expediting review of Sophia’s case by the health agency that could approve funding for proton therapy abroad. Time was critical since the window to begin radiation following chemo was limited.

According to her parents Linda Fleming (Gall) and Mark Gall, their daughter spent seven months in hospital for 22 rounds of chemotherapy that took a significant toll. Prior to her illness, Sophia was physically active, playing soccer and swimming competitively. She was involved in the theatre arts dancing and acting. The chemotherapy left her very weak and she either walked with support or was transported by wheelchair. She was on a feeding tube for six months and bedridden for four months. Her weight dropped to 87 pounds, which for her height of 5’10” was quite low.

Things started to turn for the better in early October after Sophia began a new steroid medication to control the persistent nausea and her pain medication was better managed. She started gaining weight, regaining her strength and feeling more like her usual self. Even more reason for optimism, scans confirmed that the tumor was responding to the chemo.

She flew from her home in Australia on January 18 to the United States for proton therapy in Jacksonville, Fla., at UF Health Proton Therapy Institute.

“If someone with cancer was coming here, I would tell them don’t worry about anything,” said Sophia. “Everyone is so amazing. You make friends for life. It’s almost like when you come here, everyone has been through the same thing. People get it.”

Her mom Linda added “There’s just no stress. You don’t have to worry about anything.”

While in Jacksonville, Sophia enjoyed shopping at the St. Augustine Premium Outlets, the St. Johns Town Center, the Avenues Mall and the shops in San Marco, which was within walking distance of the apartment they rented. Sophia remarked that she enjoyed being outdoors and even walked to her appointments at Nemours Children’s Specialty Care.

Ten weeks after arriving in Jacksonville, Sophia headed back home on March 27, looking forward to seeing her brother, friends and school. She is especially anticipating the eight-week school trip to Chiang Mai, Thailand, that they have been planning since she was five years old. Her mom Linda said, “The school principal told us even if he had to carry Sophia on his back, Sophia would go.” Indeed, Sophia’s positive attitude is taking her far.

Large-scale proton therapy study confirms long-term survival, quality of life for prostate cancer patients

UF Health Proton Therapy Institute reports excellent tumor control rates, low incidence of gastrointestinal or urologic toxicity

By Theresa Edwards Makrush

prostate_research_300x300.jpgA large-scale study of men treated with proton therapy for prostate cancer confirms proton therapy is a highly effective treatment for low-, intermediate-, and high-risk prostate cancer. The cohort of 1,327 men was treated at the University of Florida Health Proton Therapy Institute between 2006 and 2010 with median follow-up of five-and-a-half years.

Researchers report that 99 percent, 94 percent and 74 percent of men with low-, intermediate-, and high-risk prostate cancer, respectively, have no signs of cancer recurrence after five years of follow-up. Less than one percent (0.6 percent) in the cohort experienced serious gastrointestinal side effects and approximately three percent (2.9 percent) experienced serious urologic side effects.

“This study is the largest published series to date documenting the efficacy of dose-escalated proton therapy for localized prostate cancer with prospectively collected patient-reported quality of life and toxicity data,” reported lead researcher Curtis Bryant, M.D., M.P.H., UF Health Proton Therapy Institute radiation oncologist, in the article Five-Year Biochemical Results, Toxicity, and Patient-Reported Quality of Life Following Delivery of Dose-Escalated Image-Guided Proton Therapy for Prostate Cancer.1  The study is published in the International Journal of Radiation Oncology Biology Physics (IJROBP), the main journal of the American Society of Radiation Oncology (ASTRO).

The primary goal of the study was to find out if the results from three benchmark clinical trials2 with prospectively reported data by UF Health Proton Therapy Institute could be replicated in a larger population of unselected consecutive patients treated in a similar fashion. The researchers also wanted to identify factors that could predict either disease recurrence or urologic toxicity.

Proton therapy is a form of external beam radiation therapy that uses the positive-charged particles of atoms, protons, to deliver targeted treatment in cancerous tumors.

Tumor control data

The new study confirms similar results as the benchmark study for rate of tumor control in low-risk (both 99 percent) and high-risk prostate cancer (74 percent in the new study vs. 76 percent in the benchmark study). Intermediate-risk prostate cancer tumor control was slightly lower in the new study – 94 percent vs. 99 percent in the benchmark study. The reason for the difference in patient outcomes in intermediate-risk is unclear, researchers say, though may be related to a larger, broader sample of patients in the larger study. Overall, the presence of more than one intermediate-risk or high-risk factor may predict whether the disease will recur following treatment.

Toxicity data

Toxicities were graded using the Common Terminology Criteria for Adverse Events version 4.0 (CTCAEv4). Incidence of serious urologic toxicity in the larger series study is 2.9 percent vs. 1 percent in the benchmark study. Incidence of serious gastrointestinal toxicity in the larger series study is consistent with the benchmark study, 0.6 percent and 0.5 percent, respectively.

The risk of developing a serious urologic toxicity  appears to be higher in men who have one or more of the following predictive factors: a large prostate volume, pretreatment use of alpha blockers, pretreatment prostate reductive (TURP) procedures, diabetes, or a higher volume of bladder tissue receiving a dose of 30 Gy (RBE).

Quality of life data

Patient-reported quality of life scores following proton therapy for prostate cancer were good for urinary and bowel function, but significant decreases were seen in sexual function. Comparing pretreatment scores with scores at five years after treatment, the median baseline International Prostate Symptom Score remained unchanged. Similarly, the median and mean EPIC summary scores for bowel, urinary irritative/obstructive, and urinary incontinence domains remained relatively stable. The only significant change reported was in sexual function scores. Between baseline and 5 years, mean scores in patients not receiving hormone therapy declined from 67 to 53 and median sexual summary scores fell from 75 to 55.

Comparative effectiveness

Currently there are no published prospective clinical trials comparing proton therapy with other forms of external beam radiotherapy that use X-rays to treat prostate cancer, intensity modulated radiotherapy (IMRT) and 3-dimensional conformal photon radiation (3DCRT). A few retrospective studies comparing proton therapy and IMRT have been published in recent years, however, the reliability of the study conclusions is limited since the studies had short follow-up, lacked treatment-related information (e.g., radiation dose, field size), lacked toxicity grading and reporting, or lacked quality-of-life patient-reported outcomes. “Prospective comparative studies are needed for definitive comparison of proton therapy with IMRT,” concluded Bryant.

About prospective clinical trials

Prospective studies have an advantage over retrospective studies because they are prospectively designed to answer a specific study question. In addition, participants must meet specific criteria for inclusion and exclusion in order to reduce the chance that results will be confused by confounding variables. Finally, specific times and methods of collecting the information on cancer control and problems related to treatment are defined. These factors improve the quality of the data and potential reliability of the conclusions associated with these studies.

About proton therapy

Proton therapy is a type of radiation treatment that uses particles of an atom, protons, to deliver radiation. Protons have the potential to improve the therapeutic ratio in patients: delivering more curative dose in the tumor while delivering little or no dose to surrounding healthy tissue, thereby increasing the chance for cure and reducing the risk of side effects. Until recently, only a handful of academic medical centers in the U.S. were equipped with proton therapy. Today, 23 facilities offer proton therapy in the U.S, but access remains limited. Approximately one million people are treated with some form of radiation annually in the United States.3   Proton therapy accounts for an estimated one percent of those treated.

1. Bryant C, Smith TL, Henderson RH, Hoppe BS, Mendenhall WM, Nichols RC, Morris CG, Williams CR, Su Z, Li Z, Lee D, Mendenhall NP. Five-Year Biochemical Results, Toxicity, and Patient-Reported Quality of Life Following Delivery of Dose-Escalated Image-Guided Proton Therapy for Prostate Cancer. International Journal of Radiation, Oncology, Biology, Physics. 2016; 2016;95(1):435-43.

2. Mendenhall NP, Hoppe BS, Nichols RC, Mendenhall WM, Morris CG, Li Z, Su Z, Williams CR, Costa J, Henderson RH. Five-year outcomes from 3 prospective trials of image-guided proton therapy for prostate cancer. International Journal of Radiation, Oncology, Biology, Physics. 2014;88:596-602.

3. Statistics About Radiation Therapy. Last modified June 13, 2013. Accessed April 18, 2016.


About This Newsletter

The Precision Newsletter is an electronic-only publication that is distributed by email. Each issue is sent monthly to patients, alumni patients and friends of the University of Florida Health Proton Therapy Institute. As the official newsletter of the Institute, the content is compiled and prepared by our communications representative and approved by the editor Stuart Klein, executive director of UF Health Proton Therapy Institute. Special bulletin newsletters may occasionally be prepared when timely topics and new developments in proton therapy occur. If you would like to send a Letter to the Editor, please click here.


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