Get Healthy: January, February, March 2010

8/14/2019 Get Healthy: January, February, March 2010

1/12

Featured in this issue ...

Family planning

after 40See page 4.

a publication of Norton Healthcare

GETHealthy

nHow the thyroid affects your health

nA new way of relieving hip pain

nSisters share rare spinal cord condition

nColonoscopy: Overcoming the fear

nMind, body, spirit care for older adults

See pullout calendar

for screenings and

special events

January/February/March 2010


2/12

general health care

G e t H e a l t h y 2

On the cover: Rhonda Casey conquered the challenges of getting pregnantlater in life. See page 4.

Nick

Bonura

photos

The thyroid is a gland in the neck

that produces hormones that

control many of the bodys functions.

When not working properly, thissmall gland can cause major changes

in the body and you might not

even realize its to blame.

Carla Marshall of Louisville

UNDERACTIVE THYROIDTo blame or getting a bad rap?

Carla Marshall didnt realize it. She

began gaining weight and noticed

hoarseness in her voice but thought

it was just a part of aging. Duringa routine visit, her gynecologist

happened to notice her thyroid was

enlarged. After some testing, Marshall

was diagnosed with Hashimotos

disease.

Hashimotos disease is the most

common cause of an underactive

thyroid, also called hypothyroidism,

said Angelino Yson, M.D.,

endocrinology. The bodys immunesystem attacks the thyroid gland,

causing it to become inamed and

stop functioning properly.

Hypothyroidism usually progresses

slowly over time but can cause a

host of symptoms, from fatigue,

constipation and menstrual

irregularities, to dry skin, hoarse

voice, elevated cholesterol

level, weight gain and

infertility, according to

Dr. Yson.

Hypothyroidism

is more common in

women, especially

those over age 50,

and increases with

age, Dr. Yson said,

although anyone can

develop it.

Left untreated, thethyroid can grow into a

goiter, which is the name

for an enlarged thyroid,

Dr. Yson said. A goiter

can cause a cough or

make it difcult to

swallow or breathe.

An improperly functioning thyroid

also can increase the risk for heart

disease, depression, infertility and

birth defects.I had surgery to remove half of

my thyroid, which had attached to

my vocal chords, Marshall said. At

the time I was diagnosed it was more

common to remove the gland for fear

it could be cancerous.

Diagnosis and treatment are

relatively simple. A blood test

can diagnose the disease, and

treatment usually is daily thyroidhormone replacement medication.

Not all patients diagnosed with

hypothyroidism need surgical

removal.

I take a thyroid replacement

medication, Marshall said. Im back

to normal now and feel ne.

Though it may be a relief to think

weight gain can be cured with a

thyroid pill, more often than not the

thyroid is not to blame for weight

gain alone. If youve gained weight

along with experiencing unexplained

tiredness, hoarseness in your voice

and changes in the dryness and

paleness of your skin, then its time

to talk with your physician about

checking your thyroid.

Jennifer Reynolds

Want to know more?Attend a seminar, Thyroid: Is It to

Blame for Weight, Energy or Mood

Changes? at the Marshall Womens

Health & Education Center at

Norton Suburban Hospital on

Thursday, Jan. 14, 2010, from

6 to 8 p.m. To register, call

(502) 629-1234.


3/12

heart care

N o r t o n H e a l t h c a r e . c o m 5 0 2 - 6 2 9 - 1 2 3 4 3

Debra Walton of Louisville

We all know the drill: Eat right. Exercise more.

Get regular physicals and health screenings. Intodays busy world, its easy to put good health habits

off till tomorrow when they need attention today and

every day.

Debra Walton, 54, knows that all too well. After

leaving a job with good health coverage, keeping up with

physicals and screenings became even more difcult. But

nding quick, easy and inexpensive health screenings

helped her avoid a major health issue.

I received a mailing for a convenient and affordable

heart health risk assessment at Norton Womens HeartCenter, Walton said. I found the screenings helpful both

economically and in quality of health services.

Luckily, Waltons heart was given a clean bill of health,

but she learned her glucose level was high.

It was quite surprising, Walton said. I knew diabetes

ran in my family, but I didnt think I had symptoms.

Adults with diabetes have heart disease death rates that

are two to four times those of adults without diabetes,

said Theresa Byrd, R.N., Norton Womens Heart Center.

For most people, diabetes is largely preventable through

diet and exercise.

Waltons glucose level was caught just in time, when

its still considered pre-diabetes and can be controlled

through diet and exercise.

It is so important for women to have regular health

screenings to assess for cardiovascular disease risk

factors, Byrd said. Becoming aware, educated and

An ounce of prevention

Regular screenings are animportant part of healthy living

motivated will help women to reduce their risk factors

and lead a healthy lifestyle.

Now I am one of Norton Womens Heart Centers

biggest advocates! Walton said.

Jennifer Reynolds

Celebrate Heart Month!Take part in some of these fun events in celebration of Heart Month.Also see the pullout calendar for Healthy Heart Expos at area malls and heart disease screenings around town.Dance for your Heart

Free dance lessons, including Latin, belly and line

dancing to get your heart moving and grooving.

All ages welcome.

Thursday, Feb. 4 6 to 8 p.m.

Norton Suburban Hospital

Cooking Healthy with Chocolate

Learn how to enjoy your favorite foods in a heart-healthy way, including free advice from a physician

who specializes in womens hearts!


Norton Audubon Hospital

Cooking Class and Wine Tasting

Learn heart-healthy cooking tips, sample tantalizing

appetizers and taste some great wines.


Whole Foods Market

4944 Shelbyville Road

Get cookin!

Share a heart-healthy meal withyour family. For a free cookbook

full of delicious recipes and

health tips, call (502) 629-1234.


4/124

womens care

G e t H e a l t h y

With 40 being touted as the

new 30, theres been a trend

toward starting families later in life.

While careers and nances may

be more certain by 40, becoming

pregnant may be less certain.

Fertility decreases with age,particularly after age 35 and

dramatically after the age of 40, due

to the natural aging process of the

ovaries and eggs, said Robert Homm,

M.D., reproductive endocrinology/

infertility. The quantity and quality

of eggs drop signicantly for reasons

not totally understood. For women

over age 40, spontaneous or natural

conception becomes less likely and,

if it occurs, is much more likely to

result in miscarriage.

In fact, the risk of miscarriage after

age 40 can be as high as 40 percent.

Even women who live healthy

lifestyles cannot avoid the

natural, age-related decline

in fertility. Gynecologic

conditions that

advance with age,

such as ovulationdysfunction,

broids and

endometriosis,

also affect

fertility,

according to

Dr. Homm.

Starting afamily

Rhonda and Joe Casey

of Louisville

after 40What are the risks?Are there benefts?


5/125

womens care

Rhonda, 40, and Joe Casey, 42,

knew they wanted to start a family

right away after recently getting

married. They also knew the odds

were beginning to stack against them.

We both underwent fertility

testing right away because we hadsome health issues, which can

sometimes affect fertility, Rhonda

said.

Tests indicated the Caseys best

chance of getting pregnant would

be via in vitro fertilization (IVF), in

which eggs are harvested from the

woman, implanted with sperm, then

transferred back into the womans

uterus.

I started getting two injections

a day to induce ovulation, Rhonda

said. Then after weeks of other

medications, 11 viable eggs were

retrieved.

The eggs were fertilized and

allowed to grow in a controlled

chamber for three days. The

outcome was seven viable embryos

(fertilized eggs).

We were so excited! Rhondasaid. We then had to decide how

many to transfer to my uterus, which

was difcult knowing some may not

progress or all could progress and

wed have multiples. We decided to

implant three embryos.

The couple and the treating

physician make this decision together

once the health of the embryos is

known, Dr. Homm said. The goalis to have a healthy pregnancy and

reduce the risk of multiple babies.

Although IVF results in pregnancy

30 to 50 percent of the time per try,

this rate may be signicantly lower in

women over 40 and those with other

health conditions.

After implantation, it takes two

weeks before a pregnancy test will

detect if the embryos successfully

implant. Although embryos are

placed directly into the uterus, it

doesnt mean they always implant.

It was the longest two weeks of

our lives! Rhonda said. When I took

the pregnancy test, it was positive!

Then we had to wait another two

weeks for an ultrasound to nd out

how many babies we were having.

The Caseys learned one embryosuccessfully implanted. Now beyond

the pivotal rst trimester, their hard-

earned bundle of joy is due in early

summer!

Good nutrition, exercise and

stress reduction have all been shown

to improve fertility, Dr. Homm said.

Prenatal vitamins and folic acid

supplements help reduce the risk of

birth defects and are recommended

for all patients trying to conceive

regardless of age.

If a woman is over 35 and has been

trying to conceive for more than six

months, the couple should discuss

evaluation and begin treatment with

their OB/GYN or a reproductive

endocrinologist, according to

Dr. Homm. In addition to IVF,

there are other methods available to

increase fertility. Dr. Homms advice:Dont wait!

I always joked I wouldnt have

kids until I was 40, Rhonda said. I

guess it was a self-fullling prophecy!

Jennifer Reynolds

Want to know more?Are you having trouble getting

pregnant? Come to the Marshall

Womens Health & Education Center

at Norton Suburban Hospital for a

seminar, Conception Perception:

Fertility Options for Those Having

Trouble Conceiving, Thursday,

March 18, 6 to 8 p.m. Call

(502) 629-1234 to register.

So youre expecting!Many women who get pregnant

after age 40 are considered high

risk. Norton Maternal-Fetal Medicine

Specialists cares for these women

along with others experiencing

multiple gestation, premature labor,

maternal hypertension, diabetes and

other pregnancy-related conditions.

Specialists also provide diagnosis and

counseling for fetal abnormalities

and inherited conditions. Maternal-

fetal medicine specialists have special

expertise in caring for complicated

pregnancies. These physicians

provide care or consultation for both

mother and unborn baby, education

and research concerning the most

advanced approaches to caring forcomplicated pregnancies.

Maternal-fetal medicine specialists

work with obstetricians, family

physicians and patients considered

high risk from preconception through

pregnancy, labor and delivery. Ask

your obstetrician about Norton

Maternal-Fetal Medicine Specialists if

youve been diagnosed with a high-

risk pregnancy.

Thomas Tabb, M.D., maternal-fetal

medicine, with patient Soo Emerson

of Elizabethtown, Ky.


6/126

orthopaedic care

G e t H e a l t h y

Living with hip pain for years, David Ditto didnt

expect hed be pain-free and competing at the 2009

National Senior Games in California this past summer.I was experiencing pain in my inner thigh. I thought I

had just pulled a muscle, but it wasnt getting any better,

Ditto said. An X-ray conrmed my hip was worn out.

With a diagnosis of osteoarthritis, Ditto, an active

58-year-old with a busy optometry practice, persevered to

nd a treatment that would allow him to continue to play

sports and participate in other activities he loved.

Ditto visited two surgeons near his hometown of

Nicholasville, Ky., who advised him to give up sports.

But Ditto wasnt ready to accept that. Finally, he traveledto Louisville to meet with Jonathan Yerasimides, M.D., one

of few orthoapedic surgeons in the country who performs

anterior-approach hip resurfacing.

Hip resurfacing involves placing a metal cap over

the femoral head (the end of the thigh bone) instead of

replacing the femoral head, as in total hip replacement

surgery, Dr. Yerasimides said. It preserves more of the

femoral bone, and has a low dislocation and wear rate.

After hip resurfacing, many patients have a more

natural gait and faster walking rate compared to those

who have hip replacement. Best of all, patients have no

restrictions and are allowed to return to normal activities,

including sports.

When Dr. Yerasimides told me about hip resurfacing,

I was sold, Ditto said.

While many surgeons perform hip resurfacing, only

a handful in the United States perform it through the

anterior approach, which offers the advantage of less soft

tissue and muscle being cut and a smaller incision,

Dr. Yerasimides said. I am a rm believer in preservation

of the soft tissue and muscle envelope around the hip.

Olympic-size successNew hip surgery technique offers return to active lifestyle

Orthopaedic care at Norton

Brownsboro HospitalThe rst new hospital to serve the northeastern Jefferson

County community features a patient- and family-centered

model of care and an enhanced environmental and health

principles model. Find out the latest trends in orthopaedic

care, including surgery, available at the new hospital,

and take a virtual tour of the state-of-the-art facility atNortonBrownsboroHospital.com.

Anterior-approach hip resurfacing is performed

with the assistance of X-rays in the operating room.

This ensures the cap is centered precisely on the femurand the cup is positioned correctly in the pelvis. The

longevity and success of hip resurfacing has been shown

to be directly related to implant position, so this is a

considerable advantage

of performing the surgery

through the anterior

approach, according to

Dr. Yerasimides.

With just a 5-inch

incision compared to12-16 inches in a total hip

replacement, Ditto was up

and walking the evening of

his surgery and discharged

from the hospital the next day; plus he didnt need

physical therapy.

I used a crutch for three days and did the stretches

and exercises Dr. Yerasimides told me to do, Ditto said.

I was walking three miles in just weeks. In four months I

was back playing basketball, mountain biking and hiking

and pain-free!

Proving nothing was going to slow him down, just

a year after surgery Ditto competed in basketball at the

National Senior Games.

Jennifer Reynolds

Want to know more?Is hip pain slowing you down? Find out if anterior-

approach hip resurfacing could be right for you by calling

Norton Orthopaedic Specialists at (502) 394-6341.

Jonathan Yerasimides, M.D.


7/12

orthopaedic care

7

David Ditto of Nicholasville, Ky.


8/12

neuro/spine care

8 G e t H e a l t h y

M

adeline and Camille Davis

share sweet personalities,long straight hair and a love of

American Girl dolls. They also share

a condition called tethered cord

syndrome.

Tethered cord syndrome is a

neurological disorder that results from

a birth defect, according to Thomas

Moriarty, M.D., Ph.D., pediatric

neurosurgery. The lowest part of the

spinal cord develops abnormally and

causes several signs and symptoms

that show up as a child grows.

For Madeline, 8, and Camille, 6,

the disorder caused bladder and

bowel problems, pain, tingling in

their legs and feet, and affected their

basic motor skills, which made them

appear a bit clumsy. They both also

walked on their toes.

We began to notice something was

wrong when Madeline was about2 years old. When I would tell her

to walk at-footed she would tell me

that she couldnt because it hurt, said

Lori Davis, the girls mom. Later we

saw some of the same problems with

Camille. They just couldnt do the

things that other children their ages

were doing.

Both girls were seeing multiple

specialists for their symptoms, but achance encounter during a visit with

a friend at Kosair Childrens Hospital

A tale of two sisterssaved the day. The Davis family met

Dr. Moriarty, who later reviewed anMRI scan for Madeline and saw the

tethered cord that had previously

gone undetected. Madeline was then

scheduled for surgery. During the

procedure, Dr. Moriarty released the

connected part of the spinal cord by

clipping it.

As Lori was answering questions

before Madelines surgery, she realized

that many of the answers applied

to symptoms that Camille was

experiencing as well. An MRI revealed

the same condition in Camille, who

had surgery just three months after

Madeline.

The girls are now avid swimmers,

active in gymnastics and love to ride

bikes all things they either couldnt

do or couldnt do well before surgery.

In 2008 our daughters had more

than 200 doctor appointments as wetried to deal with the symptoms they

were experiencing, Lori said. Last

year was a totally different year for us.

Our lives were changed by knowing

what were dealing with and having it

corrected.Keri Shain

Pediatric

neurosurgeon joinsNorton NeuroscienceInstitute

Norton Healthcare welcomes

Charles Stevenson, M.D.,

pediatric neurosurgery, who joins

Thomas Moriarty, M.D., Ph.D.,

chief of pediatric neurosurgery

at Kosair Childrens Hospital.

Dr. Stevenson also is a part of

Norton Neuroscience Institute.He has advanced training in pediatric

neurosurgery and the study and

treatment of brain tumors.

Dr. Stevenson brings a wealth of

skills and expertise to the community,

where there is a great need for

neurosurgeons specializing in the

care of children.

Charles Stevenson, M.D.

Madeline and Camille Davis

of Louisville


9/12

cancer care

N o r t o n H e a l t h c a r e . c o m 5 0 2 - 6 2 9 - 1 2 3 4 9

Scott Moore, 53, an avid bicyclist, considered himself a health-conscious

individual. So in January 2009, he was shocked to learn he had colon cancer.

Ive always been relatively healthy and active, Moore said. Ive been prettygood about going to the doctor for regular checkups. I never imagined I would be

diagnosed with colon cancer.

According to the American Cancer Society, some 148,000 people are diagnosed

with colon cancer each year, resulting in more than 55,000 deaths making it the

No. 2 cancer killer in the United States. Despite staggering statistics, colon cancer,

unlike other cancers, is nearly 90 percent treatable if detected early.

On average, it takes ve to 15 years for cancer to form from colon polyps in the

intestine, said Martin Mark, M.D., gastroenterology. Because colon cancer often

doesnt present any symptoms, regular screenings, typically every 10 years starting

at age 50, are the most effective way to prevent colon cancer.During a colonoscopy, a specialist examines the large intestine using a thin,

exible tube equipped with a ber optic camera to inspect for polyps, or

growths, that can develop into cancer. If a polyp is detected, it typically can be

removed during the colonoscopy. The procedure is relatively quick and usually

is conducted on an outpatient basis.

For most people, the hardest part of the procedure is the prep required

the day before, Dr. Mark said. They must take uid to help empty their

intestines. While not pleasant, it typically isnt painful. The procedure is

usually completed in less than 30 minutes and conscious sedation is used,

so most patients report feeling no to very little discomfort during the

colonoscopy and return to normal activities later that day.

Despite the effectiveness of colonoscopy for prevention and

early detection of colon cancer, the majority of Kentuckians

arent screened as recommended, because many put off

colonoscopies out of fear or the stigma associated with the

procedure.

When I turned 50, I knew it was time to get a

colonoscopy, but I just kept avoiding it, Moore said. It

wasnt until I started having symptoms that I decided to

take action.

In February, Moore underwent surgery to remove his colon.Looking back, knowing what I know now, I most denitely

would have had a colonoscopy when I turned 50, he said.

The colonoscopy was nothing compared to my surgery

and recovery.Steven Jenkins

Want to know more?March is Colon Cancer Awareness Month! Come to a colon cancer

education and screening event at area malls, pick up a home

screening kit and learn how you can win a $50 mall gift card.

See the enclosed pullout calendar for locations, dates and times.

Conquering colonoscopy

Overcoming the fear could help save

your life

Scott Moore of Louisville


10/12

geriatric care

G e t H e a l t h y 0

An elderly neighbor who

regularly walks her dog, drives

to the grocery store and takes a yoga

class ends up in the hospital with

pneumonia. She may recover quickly

and be back to her gardening before

the rst weed appears; or, like manyaging adults, she could experience

distress, disorientation and even

depression, leading to further decline.

During times of hospitalization,

it is common for older patients to

have some setbacks due to a change

in environment, inactivity and

lack of mental stimulation, said

William R. Bradford, M.D., medical

director, Norton Audubon Hospital.

ACEing a hospital stay

New inpatient units focus on older adults unique needs

Nick

Bonura

photo

A growing number of hospitals

nationwide are addressing this issue

by creating specialty units designed to

promote healing by keeping elderly

patients safe, active and mentally alert

during a short-term stay.

Just as pediatricians care forthe special needs of children, in

these specialty units for the elderly

(usually called ACE acute care for

elders units), a geriatric-trained

team of caregivers creates and carries

out a personalized plan of care for

each patient. The team promotes

caring and coping, safe medication

management, mobility, healthy

nutrition, cognition and dischargeplanning/care transition.

The pharmacist, for example, talks

with patients about their medications

to ensure treating one conditiondoesnt affect another. The nutritionist

may create a meal plan to address

such issues as anemia or diabetes.

The music therapist may use a

number of instruments or guided

relaxation techniques to ease a

patients anxiety before or during a

diagnostic test.

Unless a patients physician has

ordered bed rest, the care team assistspatients with activities of daily living

like getting out of bed, dressing

for meals, walking the hallways or

playing a game with a volunteer

or family member to help keep

them active, restore their condence

and help them regain strength and

stamina.

Research has shown that

older adults treated in ACE units

nationwide tend to have shorter

hospital stays and fewer incidences

of being discharged to long-term care

facilities, according to Dr. Bradford.

ACE unit patients have the

desire to return to the same level of

independence they had before they

were admitted to the hospital,

Dr. Bradford said. We help them

do that.

Tammy Warren

Want to know more?Norton Audubon Hospital is the

rst facility in the Louisville area to

create an acute care for elders (ACE)

unit. For more information, visit

NortonHealthcare.com/ACE.

Occupational therapist Karla Ferguson and patient Marie Gardner in the ACE unit at

Norton Audubon Hospital


11/12

Want to know more?Bookmark KosairChildrens.com on your computer! This kid-friendly health information, part of the Kohls

Just for Kids C.A.R.E. (Child Advocacy Regional Education) Program, is made possible by generous support

from Kohls Department Stores in partnership with the Childrens Hospital Foundation.

pediatric care

11N o r t o n H e a l t h c a r e . c o m 5 0 2 - 6 2 9 - 1 2 3 4

Web offers trusted information for whole family

In an age when information is available

at the stroke of a key, it can be difcult

to know what is legitimate and what may

be hype. To help take the guesswork out of

health and safety information for kids, teens

and families, Kosair Childrens Hospitaladded a comprehensive health information

library to KosairChildrens.com. The site

features medically reviewed articles, videos,

features and news written to be age-

appropriate for parents, children and teens.

We understand how important it is to

educate not only parents, but children and

teens, about health and wellness, said

Thomas D. Kmetz, president,

Kosair Childrens Hospital and PediatricServices. As families look to the Web for

information about disease and wellness, we

want to ensure they are receiving factual,

relevant, medically accurate information.

Thats why were offering health information

written just for kids and teens.

The site features information in both English

and Spanish presented in fun ways, including

topics on parenting, general health, medical

conditions, child development, behavior,

nutrition, tness, rst aid, safety and more.

Other unique features include: Cooking and Recipes Recipes for

kids and teens with diabetes, lactose

intolerance and other health conditions

Childrens Health News The latest

medical research and news written for

parents in easy-to-understand language

The Game Closet Fun and interactive

experiments, mini-health movies and

games to make learning fun for kids

Word! Medical terms with denitionschildren can understand; a great

homework helper

BMI Calculator Easy-to-understand

information about weight (including

ideal weight ranges) and the ability to

track a childs body mass index over time

Keri Shain

Christina and Mike Efngerwith son Matt of

Louisville

More on the physicians

in this issue of

Get Healthy

William R. Bradford, M.D.medical directorNorton Audubon Hospital1 Audubon Plaza DriveLouisville, KY 40217(502) 636-7679

Robert Homm, M.D. reproductive endocrinology/infertility

Fertility and Endocrine AssociatesNorton Medical Plaza III SuburbanSuite 4144121 Dutchmans LaneLouisville, KY 40207(502) 897-2144

Martin Mark, M.D.gastroenterologyGastroenterology Consultants

of Louisville4001 Dutchmans Lane, Suite 7BLouisville, KY 40207(502) 896-4711

Thomas M. Moriarty, M.D., Ph.D.pediatric neurosurgerychief of pediatric neurosurgery,

Kosair Childrens HospitalNorton Neuroscience Institute210 E. Gray St., Suite 1105Louisville, KY 40202(502) 583-1697

Charles Stevenson, M.D.pediatric neurosurgeryNorton Neuroscience Institute210 E. Gray St., Suite 1105Louisville, KY 40202(502) 583-1697

Thomas N. Tabb, M.D.perinatologyNorton Maternal-Fetal Medicine

SpecialistsChildrens Hospital Foundation BuildingSuite 700

601 S. Floyd St.Louisville, KY 40202(502) 629-7181

Jonathan Yerasimides, M.D.orthopaedics/hip & pelvis reconstructionNorton Orthopaedic SpecialistsNorton Medical Plaza BrownsboroSuite 3034950 Norton Healthcare Blvd.Louisville, KY 40241(502) 394-6341

Angelino Yson, M.D.endocrinology & internal medicineNorton Medical Associates

Endocrinology & Internal MedicineNorton Medical Plaza West AudubonSuite 305

2355 Poplar Level RoadLouisville, KY 40217

(502) 636-5532

Physicians quoted in Get Healthyare

on the medical staff of one or more

Norton Healthcare hospitals.


12/12

Envisioning the future

of neuroscience.

Seeing the hope it will bring.

Here, we specialize in both.

Christopher Shields, M.D.

Neurosurgeon

Dr. Christopher Shields is more than one o the regions fnest neurosurgeons.

Hes also a trusted mentor to many younger colleagues who share his passion or

healing and restoring lives. And hes just one o the more than 10,600 employees

and physicians o Norton Healthcare living lives just like you. Every day, at over

85 locations, we are real people dedicated to providing remarkable care.

Real people. Remarkable care.

Norton Healthcare Inc.

P.O. Box 35070

Louisville, KY 40232-5070

NONPROFIT ORG

U.S. POSTAGE

PAID

LEBANON JCT., KY

PERMIT NO. 677

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