Welcome to the North American Thrombosis Forum
Register for the Patient Education Seminar – May 12:
Brigham and Women’s Hospital Anticoagulation Management Service and NATF are hosting the 2nd Annual Patient Seminar on Saturday, May 12 from 7:30 am – 2:00 pm. This free program was designed to educate patients and their families on cardiovascular and thrombotic conditions, and to promote an overall heart-healthy lifestyle.
Lecture topics will include Basics of Atrial Fibrillation, Venous Thromboembolism, and Mechanical Heart Valves; New Research in Anticoagulation; Nutrition and Exercise; and INR self-testing and self-dosing.
Click here to view the full schedule and topics.
NATF Thrombosis Summit Date Announcement:
Save the date for our 6th annual Thrombosis Summit: Saturday, September 8, 2012.
Click here to view the preliminary Thrombosis Summit 2013 agenda.
2012 NATF Atrial Fibrillation Management in 2012 – A New State-of-the-Art:
The 2012 North American Thrombosis Summit was held Thursday, April 12, 2012, at the Holiday Inn in Brookline, MA hosting physicians, nurses, physician assistants, pharmacists, hospitalists, hospital administrators, patients and family members interested in atrial fibrillation treatment and stroke prevention. The presentations at this event are available on our YouTube Channel. Below is a playlist of the lectures.
Video Presentations available here
NATF Contributions
NATF Board Member, Jeanine Walenga, shares presentations from Grand Rounds at Loyola University Health Systems Department of Neurology and Department of Pathology. Click below for these presentations.
Dabigatran and other New Oral Anticoagulants
Clinical Laboratory Monitoring of Conventional and New Anticoagulants
Jeanine M. Walenga, PhD
Professor, Thoracic-CV Surgery and Pathology
Co-Director, Hemostasis and Thrombosis
Research Laboratories
Loyola University Chicago
NATF Patient Advocate Rajan Laddu visits Boston:
Rajan Laddu and his family stop by BWH on his college tours to have lunch with Dr. Goldhaber and the NATF staff.
May 2012: NATF President’s Letter
he NATF Educational Dinner Symposium on Stroke Prevention in Atrial Fibrillation was a resounding success. On April 12, more than 200 participated in this multidisciplinary teaching event, which featured physicians, nurses, pharmacists, patients, and interested members of the public. I reviewed the public health threat of atrial fibrillation and its status as the #1 cause of preventable stroke. Christian T. Ruff, MD discussed landmark randomized trials testing novel oral anticoagulants against warfarin. Gregory Pizza, MD, Chair of the NATF Education Committee, discussed issues related to rate versus rhythm control of atrial fibrillation. And Julie Shea, RNCS, discussed patient education and issues related to living with atrial fibrillation. What next followed was an interactive panel discussion with the faculty and with a patient who has atrial fibrillation. The course has drawn rave reviews.
We are now in the final planning stages for another educational symposium that will be entirely focused on patients taking anticoagulant medication. NATF will host this program on Saturday, May 12, at the Holiday Inn Brookline, in conjunction with the Brigham and Women’s Hospital Anticoagulation Management Service. Breakfast and lunch will be included. This program will provide patients and their families and friends with the necessary information to improve anticoagulation management, improve patient satisfaction, and increase patient advocacy and empowerment. Dr. Piazza and I, along with the rest of the NATF leadership and staff, hope you’ll be able to join us. You can register on this Home Page of our website.
–Samuel Z. Goldhaber, MD
President, NATF
Latest NATF Article Contribution:
Venous thromboembolism: a collaborative quality improvement model for practitioners, hospitals, and insurers
J Thromb Thrombolysis
Authored By: Geoffrey D. Barnes a,⁎, Nancy Birkmeyer b, Scott A. Flanders c, James B. Froehlich a, Mark Hemmila b, Peter K. Henke a, Richard L. Prager a, Tom Leyden d, David Share d
a Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
b Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
c Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
d Blue Cross Blue Shield of Michigan, Detroit, MI, USA
a b s t r a c t
Venous thromboembolism (VTE) carries significant morbidity and mortality and affects a large portion of hospitalized patients. VTE prophylaxis is rated by the Agency for Healthcare Research and Quality as the most effective of 79 patient safety practices it assessed in 2001. Since 1997, Blue Cross Blue Shield of Michigan/Blue Care Network (BCBSM/BCN) have partnered with Michigan hospitals and providers in statewide registry-based collaborative quality improvement initiatives (CQI) aimed at improving the safety and quality of surgical and medical care; many of these collaborative have a particular focus on VTE prevention. The CQIs are uniquely structured to catalyze hospitals and practitioners to become self-optimizing. In this review, we describe the model BCBSM/BCN and participating Michigan hospitals have developed to improve the prevention and diagnosis of VTE for patients in the state of Michigan.
Keywords
Venous thromboembolism, Thromboprophylaxis, Managed care, Warfarin , Low molecular weight heparin
Dr. Ofosu speaks to NATF about his article published in the Journal of Thrombosis and Haemostasis.
A review of the two major regulatory pathways for non-proprietary
low-molecular-weight heparins
Journal of Thrombosis and Haemostasis
Authored By: Frederick A. Ofosu
Department of Pathology Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
a b s t r a c t
With the expiry or pending expiry of originator low-molecular-weight heparin (LMWH) patents, pharmaceutical companies have invested in developing non-proprietary versions of LMWHs. LMWHs are manufactured by depolymerising highly purified unfractionated heparin. In contrast to traditional synthetic drugs with well-defined chemical structures, LMWHs contain complex oligosaccharide mixtures and the different manufacturing processes for LMWHs add to the heterogeneity in their physicochemical properties such that the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA) consider existing originator LMWHs to be distinct medicinal entities that are not clinically interchangeable. The FDA views LMWHs as drugs and has approved two non-proprietary (generic) LMWHs, using the Abbreviated New Drug Application pathway. In contrast, the World Health Organization and the EMA view LMWHs as biological medicines. Therefore, the EMA and also the Scientific and Standardization Subcommittee on Anticoagulation of the International Society on Thrombosis and Hae- mostasis and the South Asian Society of Atherosclerosis and Thrombo- sis have all published specific guidelines for assessing non-proprietary (biosimilar) LMWHs. This manuscript reviews why there are two distinct pathways for approving non-proprietary LMWHs. Available literature on non-proprietary LMWHs approved in some jurisdictions is also re- viewed in order to assess whether they satisfy the requirements for LMWHs in the three guidance documents. The review also highlights some of the significant difficulties the two pathways pose for manufacturers and an urgent need to develop a consensus governing the manufacture and regulation of non-proprietary LMWHs to make them more widely available.
Keywords
Low-molecular-weight heparins, biosimilars, biologics, patents, venous thromboembolism
Latest NATF Corner Article:
Obesity and pulmonary embolism:
The mounting evidence of risk and the mortality paradox
Authored By: Paul D. Stein a,b,⁎, Fadi Matta a,b, Jose Goldman c
a Department of Research, St. Mary Mercy Hospital, Livonia, Michigan
b Department of Internal Medicine, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan
c Department of Internal Medicine, Michigan State University, East Lansing, Michigan
a b s t r a c t
Purpose: To determine the prevalence of pulmonary embolism in obese patients according to age, gender and comorbid conditions and explore the relation of obesity to mortality. Methods: The number of patients discharged from short-stay hospitals throughout the United States from 1998–2008 with pulmonary embolism who were obese or not obese, and in-hospital all-cause mortality were determined from the Nationwide Inpatient Sample.
Results: From 1998–2008, 203,500 of 17,979,200 (1.1%) obese patients were diagnosed with pulmonary embolism compared with 2,034,100 of 346,049,800 (0.6%) non-obese patients [relative risk (RR) =2.03]. Relative risk for pulmonary embolism was highest among obese patients aged 11–20 years (RR=5.80) and was higher in obese women (RR=2.08) than in obese men (RR=1.74). Mortality was 4.3% in obese patients with pulmonary embolism compared with 9.5% in non-obese patients (RR=0.45). Obesity had…
New Stroke-Prevention Drugs Spur A-Fib Guides
Family Practice News:
Dr. Samuel Z. Goldhaber on Stroke Prevention in Atrial Fibrillation
The effort, spearheaded by the ACP Foundation’s Initiative on Atrial Fibrillation and Stroke Prevention, shores up the role of primary care in atrial fibrillation management at a time when newly approved alternatives to warfarin have dramatically expanded treatment options. “You don’t need to be a specialist to prevent a stroke from atrial fibrillation,” said Dr. Goldhaber, a member the initiative’s panel.
Announcement:
NATF’s DVT/PE Risk Assessment Tool won the Silver Award from the Web Health Awards!
The goal of the Web Health Awards is to recognize high-quality digital health resources for consumers and health professionals. The National Health Information Awards program is organized by the Health Information Resource Center (HIRC), an 18 year old national clearinghouse for professionals who work in consumer health fields.
Announcement:
A new series of AHA and TCT programs on cardiovascular medicine and thrombosis are available on our Online Programs page. Take the opportunity to register.
“Bridging” anticoagulation may not be necessary in vast majority of patients
American Heart Association:
To bridge or not to bridge? Pros and cons of this approach
November 13, 2011 – by Lisa Nainggolan
theHeart.org coverage of Dr. Goldhaber’s talk on bridging at
the American Heart Association 2011 Scientific Session in Orlando, FL was the most read article on theheart.org.
Speaking to a packed room at the American Heart Association 2011 Scientific Sessions this morning, with his talk being broadcast outside to those who could not get in, Dr Samuel Z Goldhaber (Brigham and Women’s Hospital, Boston, MA) did a quick poll of his audience and discovered that 90% had “bridged” patients. “But there is a lack of evidence. There are no randomized clinical trials to say that bridging is the way to go,” he observed.
Click here to read the entire article.
NATF President and Founder, Dr. Samuel Goldhaber (Brigham and Women’s Hospital, Boston, MA) and Dr. Manesh Patel (Duke Clinical Research Institute, Durham, NC) discuss results of the Apixaban Dosing to Optimize Protection from Thrombosis (ADOPT) Trial on extended anticoagulant prophylaxis in initially hospitalized medically ill patients - Filmed at AHA 2011. The abstract, news release, audio, and presentation and discussant slides for Dr. Goldhaber’s full lecture on the ADOPT Trial are available here.
Nationalizing PE Patient Support Groups
Dr. Caprini and his assistant, Nancy Lala, hosted their first PE Support Group last week at NorthShore University HealthSystem in Illinois. The Support Group was a success with nearly 20 attendees. The next Support Group in Illinois is not yet scheduled, but is expected to be in January. If you are in the area, or interested in joining the Support Group, please contact Nancy Lala at NLala@northshore.org with any questions.
Here at NATF, Ruth Morrison and Kathryn Mikkelsen are continuing their efforts in nationalizing PE Patient Support Groups. For questions regarding hosting a PE Support Group in your area, please email Kathryn Mikkelsen at kzmikkelsen@partners.org.
Latest News:
NATF Member Starts Support Group
Click here to read a recent article featuring NATF Advocacy Committee member Brenda Blackburn and her efforts to form patient support groups for survivors of deep vein thrombosis (DVT) and pulmonary embolism (PE).
Samuel Z. Goldhaber, MD, and Christopher Kabhrel, MD, publish new paper
Our director, Samuel Z. Goldhaber, MD, has coauthored a new paper in BMJ Magazine concerning sedantary lifestyles and its relation to pulmonary embolism. Co-author Christopher Kabhrel MD has been interviewed by our staff, and here are his thoughts:
Click here to watch on youtube.
NATF Spotlight: Apixaban vs. Warfarin
Dr. Piazza discusses recently released outcomes of the drug trial entitled “Apixaban for the Prevention of Stroke in Subjects with Atrial Fibrillation” (ARISTOTLE).
For additional information on this trial, click here.
NATF Fellow Launches Website
2009 NATF Traveling Fellow, Sara Vazquez, PharmD, BCPS, CACP has successfully completed her Fellowship project! A website dedicated to post-thrombotic syndrome (PTS) awareness and education is live!
Highlights for healthcare providers include:
· 60-minute webcast with overview of PTS
· Three 20-minute online modules (PTS Risk Factors, PTS Prevention, and PTS Diagnosis and Treatment)
· Total of 2 hours of free CE/CME credit available with completion of webcast and all online modules
· Downloadable tools:
o Worksheet for assessing PTS risk factors
o Step-by-step instructions for how to prescribe compression stockings
o Villalta scale PTS diagnosis worksheet
o Compression stocking handout for patients
· Videos:
o Susan Kahn, MD conducting patient interview and demonstrating PTS assessment
o Demo of proper leg elevation technique
Patients can find helpful resources, tools, and videos as well!
Deep Vein Thrombosis: I Thought It Was Just a Sprained Ankle
Source: http://www.health.com/health/article/0,,20489056,00.html
Injuring your ankle shouldn’t be a big deal, right? I was 35 and otherwise in perfect health. But three weeks after I sprained and broke mine by tripping on a stair, I was being rushed to a hospital, weak, gasping for air, literally minutes from death.
What happened? It turned out that a large blood clot—a serious condition known as deep vein thrombosis (DVT)—formed in my leg as I tried to recuperate. The clot broke off and traveled to my lungs (what’s known as a pulmonary embolism), where it blocked blood flow—and threatened my life. You may recall that in 2003 NBC correspondent David Bloom died from a pulmonary embolism after being dehydrated and sleeping curled up in a tank for weeks while reporting in Iraq. And recently, tennis champion Serena Williams made headlines when she was hospitalized and treated for a pulmonary embolism and related complications (see “Behind Serena’s Scare,” below).
To read the entire article, Click Here
Actress and Plus-Size Model Mia Amber Rose dies from unknown causes, speculated to be from a blood clot
May 12, 2011
To read the entire article, Click Here
Tall, obese men at higher risk for blood clots
April 29, 2011 – By Marrisa Cevallos, HealthKey
Tall and obese men appear more likely to develop venous thromboemoblism, which can lead to a potentially lethal blood clot in the lungs, according to a study published Thursday.
To read the entire article, Click Here
Interview with Gregory Piazza, MD
Discusses Pulmonary Embolism and the recent report that U.S. Women’s Tennis Player, Serena Williams, has been diagnosed with Pulmonary Embolism (PE)
Serena Williams Treated for Blood Clot in Lung, People Reports
By Eben Novy-Williams and Elizabeth Lopatto
March 2 (Bloomberg) – Serena Williams was treated for a blood clot in her lung, the latest setback after injuries that have kept the 13-time Grand Slam singles winner off the court since last July, People magazine said.
Williams, 29, was treated at Cedars-Sinai Medical Center in Los Angeles for the clot found last week, the magazine quoted the player’s representative Nicole Chabot as saying. The former No. 1-ranked player on the WTA women’s tennis tour also received emergency care two days ago for a bruise sustained as a result of “treatment for a more critical situation,” Chabot told the magazine. Williams, who hasn’t played a competitive match in more than seven months, may miss up to six months as she recovers from the condition, according to Jonathan Orens, associate director and clinical chief of pulmonary care at Johns Hopkins University School of Medicine. Chabot and Jill Smoller, who also represents Williams, didn’t immediately return voicemail messages seeking comment.
Williams last played in July, when she won her fourth Wimbledon title. She cut her foot on a shard of glass in Germany following the victory and had surgery that month. Williams had a second operation in October after re-tearing a tendon in her right foot. Raed Dweik, director of the pulmonary vascular program in the department of pulmonology and critical care medicine at Cleveland Clinic, said Williams’s clot could be a result of the foot injury.
Upcoming Events, Programs, and Webcasts
NATF Thrombosis Summit Date Announcement:
Save the date for our 6th annual Thrombosis Summit: Saturday, September 8, 2012.
Click here to view the preliminary Thrombosis Summit 2013 agenda.
May 12: Patient Education Seminar
Brigham and Women’s Hospital Anticoagulation Management Service and NATF are hosting the 2nd Annual Patient Seminar on Saturday, May 12 from 7:30 am – 2:00 pm.
Click here to view the full schedule and topics.
Program Chair Samuel Z. Goldhaber, MD, of Harvard Medical School, is joined by a Elaine Hylek, MD, of the Boston University Medical Center and Jeffrey Weitz, MD, of McMaster University, in an overview of late-breaking advances in risk stratification and management strategies for stroke prevention in atrial fibrillation (SPAF). Click here to watch the webcast.
Venous thromboembolism: a collaborative quality improvement model for practitioners, hospitals, and insurers
Authored By: Geoffrey D. Barnes a,⁎, Nancy Birkmeyer b, Scott A. Flanders c, James B. Froehlich a, Mark Hemmila b, Peter K. Henke a, Richard L. Prager a, Tom Leyden d, David Share d
a Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA
b Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
c Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
d Blue Cross Blue Shield of Michigan, Detroit, MI, USA
a b s t r a c t
Venous thromboembolism (VTE) carries significant morbidity and mortality and affects a large portion of hospitalized patients. VTE prophylaxis is rated by the Agency for Healthcare Research and Quality as the most effective of 79 patient safety practices it assessed in 2001. Since 1997, Blue Cross Blue Shield of Michigan/Blue Care Network (BCBSM/BCN) have partnered with Michigan hospitals and providers in statewide registry-based collaborative quality improvement initiatives (CQI) aimed at improving the safety and quality of surgical and medical care; many of these collaborative have a particular focus on VTE prevention. The CQIs are uniquely structured to catalyze hospitals and practitioners to become self-optimizing. In this review, we describe the model BCBSM/BCN and participating Michigan hospitals have developed to improve the prevention and diagnosis of VTE for patients in the state of Michigan.
A review of the two major regulatory pathways for non-proprietary low-molecular-weight heparins
Authored By: Frederick A. Ofosu
Department of Pathology Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
a b s t r a c t
With the expiry or pending expiry of originator low-molecular-weight heparin (LMWH) patents, pharmaceutical companies have invested in developing non-proprietary versions of LMWHs. LMWHs are manufactured by depolymerising highly purified unfractionated heparin. In contrast to traditional synthetic drugs with well-defined chemical structures, LMWHs contain complex oligosaccharide mixtures and the different manufacturing processes for LMWHs add to the heterogeneity in their physicochemical properties such that the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA) consider existing originator LMWHs to be distinct medicinal entities that are not clinically interchangeable. The FDA views LMWHs as drugs and has approved two non-proprietary (generic) LMWHs, using the Abbreviated New Drug Application pathway. In contrast, the World Health Organization and the EMA view LMWHs as…
Obesity and pulmonary embolism: The mounting evidence of risk and the
mortality paradox
Authored By: Paul D. Stein a,b,⁎, Fadi Matta a,b, Jose Goldman c
a Department of Research, St. Mary Mercy Hospital, Livonia, Michigan
b Department of Internal Medicine, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan
c Department of Internal Medicine, Michigan State University, East Lansing, Michigan
a b s t r a c t
Purpose: To determine the prevalence of pulmonary embolism in obese patients according to age, gender and comorbid conditions and explore the relation of obesity to mortality.
Methods: The number of patients discharged from short-stay hospitals throughout the United States from 1998–2008 with pulmonary embolism who were obese or not obese, and in-hospital all-cause mortality were determined from the Nationwide Inpatient Sample.
Results: From 1998–2008, 203,500 of 17,979,200 (1.1%) obese patients were diagnosed with pulmonary embolism compared with 2,034,100 of 346,049,800 (0.6%) non-obese patients [relative risk (RR) =2.03]. Relative risk for pulmonary embolism was highest among obese patients aged 11–20 years (RR=5.80) and was higher in obese women (RR=2.08) than in obese men (RR=1.74). Mortality was 4.3% in obese patients with pulmonary embolism compared with 9.5% in non-obese patients (RR=0.45). Obesity had…
New antithrombotics: The impact on global health care
Authored By: Charles E. Mahan a,⁎, John Fanikos b,
a University of New Mexico Health Sciences Center, Albuquerque, New Mexico
b Brigham and Women’s Hospital, Boston, Massachusetts
a b s t r a c t
New and generic forms of widely used medications introduced in the antiplatelet, anticoagulant and fibrinolytic therapeutic classes will have a world-wide impact on prescribing, practice guidelines, and routine patient care. However, several uncertainties regarding these agents will remain even after the publication of their respective pivotal trials or regulatory approval. These questions include dosing in the frail, the elderly, and in those with renal and/or hepatic dysfunction, timing of administration in the peri-operative period, efficacy and safety in subgroup populations such as patients with cancer, the interchangeability of biosimilar products, and outcome differences between new agents in the absence of head-to-head clinical trials. Additionally, new generic forms of widely used agents have recently impacted the United States (US) and Canadian market place and more are under development. Clinicians should be vigilant concerning these agents and be prepared to inform patients and make decisions with their use…
Combination warfarin-ASA therapy: Which patients should receive it, which patients should not, and why?
Authored By: James D. Douketis,
Department of Medicine, McMaster University and St Joseph’s Healthcare, Hamilton, ON, Canada
a b s t r a c t
Warfarin and acetylsalicylic acid (ASA) are widely used for the primary and secondary prevention of thromboembolic and atherothrombotic diseases in patients with chronic atrial fibrillation, coronary artery disease, valvular heart disease and venous thromboembolism. Combining these two agents is appealing because of potentially complementary antiplatelet and anticoagulant actions, which may be especially relevant for patients who have concomitant cardiovascular diseases, such as atrial fibrillation and coronary artery disease (CAD). Despite the potential therapeutic advantages of combination warfarin-ASA therapy, when multiple drugs that affect hemostasis are co-administered, this typically increases patients’ risk for serious bleeding…
NATF Shares News, Articles, Studies and Updates:
Announcement:
A new series of AHA and TCT programs on cardiovascular medicine and thrombosis are available on our Online Programs page. Take the opportunity to register.
Meet Behnood Bikdeli, MD : Key Web Content Contributor
Behnood Bikdeli, MD is a physician originally from Tehran, Iran and a Post-doctoral Associate in Cardiovascular Medicine at Yale University School of Medicine and at Yale/ YNHH Center for Outcomes Research and Evaluation (CORE). He has had a longstanding passion for cardiovascular medicine, a fact that is reflected in his consistent publications in the field, and scientific presentations in several countries and continents.
His major research interests include venous and arterial thromboembolism, atherogenesis, and heart failure. He has collaborated with NATF since 2007 and intends to continue his studies in internal medicine and cardiology and to pursue a career in research and clinical cardiology.
Contributed New Studies:
Rivaroxaban for Treatment of Patients with Acute Symptomatic Pulmonary Embolism
EINSTEIN investigators reported the results of a non-inferiority trial for treatment of symptomatic pulmonary embolism with oral rivaroxaban, versus enoxaparin sodium followed by vitamin K antagonists. The primary efficacy endpoint was recurrent symptomatic venous thromboembolism. Treatment with oral rivaroxaban was non-inferior to standard therapy and was suggested to be associated with less bleeding events. These findings, in conjunction with a previous study by EINSTEIN investigators, suggest that rivaroxaban might be a good alternative for treatment of symptomatic VTE.
DASH: A Proposed Risk Score for Prediction of Recurrence in Patients with Unprovoked VTE
Tosetto and colleagues recently proposed the DASH risk score (D-dimer after discontinuation of anticoagulation, Age, hormone therapy, and sex) for prediction of recurrence in patients with unprovoked VTE. The authors suggested that abnormal D-dimer, age <50years, VTE not associated with hormonal therapy in women, and male sex were the major predictors of VTE recurrence. They proposed that lifelong anticoagulation might not be necessary for patients with DASH score ≤ 1. Benefits and harms of such recommendations should be tested in future studies.
New AAOS Guidelines on VTE Prevention after Elective Hip or Knee Arthroplasty.
These guidelines recommend assessment of the risk of bleeding (especially history of hemophilia and active liver disease), as well as previous history of VTE. In brief, the guidelines recommend concomitant use of pharmacological and mechanical prophylaxis or patients undergoing hip or knee arthoplasty if they have a previous history of VTE. In the absence of previous history of VTE, the guidelines suggest “use of pharmacologic agents and/or mechanical compressive devices”.
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2009 Annual Report |  |
NATF Work Plan 2008 – Spring 2011 |
