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March 2012 DPBRN E-Update
Thursday, March 01, 2012
Each month we highlight a recent
publication that may be of interest to DPBRN members, recent study
results, or other important DPBRN information. Please click here to view the pdf version. If you would like to be added to the mailing list, please contact our Director of Communications.
DPBRN presents at the University of Florida's Clinical and Translational Science Institute Seminar Series
Monday, February 06, 2012
DPBRN Orlando Practitioner-Investigator,
Dr. Stanley Asensio II, was a guest speaker at the University of
Florida's Clinical and Translational Science Institute Seminar Series on
1/25/2012. The presentation, "Learning about Practice-Based Research
Using the Dental PBRN Model", given by Dr. Valeria Gordan, along with
Dr. Asensio and Deborah McEdward, provided an overview of the Dental
Practice-Based Research Network from the perspective of the Principal
Investigator, Practitioner-Investigator, and the Regional Coordinator.
Dr. Asensio’s perspective proved to be a vital connection between
private practice and academic research efforts, which is one of the
visions of the DPBRN.
Click on the thumbnails to view the photos.
Study summary results for DPBRN studies are now available
Thursday, February 02, 2012
Summary results, overall and by region, for
DPBRN studies "Reasons for replacement or repair of dental
restorations", "Patient satisfaction with dental
restorations",“Prevalence of questionable occlusal caries lesions”,
“Blood sugar testing in dental practice”, “Peri-operative pain and root
canal therapy”, “Persistent pain and root canal therapy”,"Impact of
dental practice-based research networks on patient care", and
“Infrastructure Update Survey” are now available for viewing. Please
click here to view them under each study heading.
February 2012 DPBRN E-Update
Wednesday, February 01, 2012
Each month we highlight a recent
publication that may be of interest to DPBRN members, recent study
results, or other important DPBRN information. Please click here to view the pdf version. If you would like to be added to the mailing list, please contact our Director of Communications.
Online video tutorials explain statistics used in systematic reviews
Friday, January 13, 2012
A new series of online video tutorials
helps dental professionals and students become more discriminating
readers of research articles and how they can be applied in the dental
practice. The videos were developed by the ADA Center for Evidence-Based
Dentistry (EBD).
The first three tutorials focus on statistics and provide an
understanding of the statistics-related concepts clinicians will
encounter in evidence-based research and systematic reviews.
•“Why Do We Need Statistics?” describes three situations that can be
quantified using statistics and identifies what the authors of a
systematic review are trying to quantify.
•“What are the Different Types of Data?” explains the differences
between nominal, ordinal and quantitative data and identifies the type
of data being presented in a systematic review.
•In “What is a Null Hypothesis?” viewers develop a null hypothesis and identify the null hypotheses in systematic reviews.
For more advanced training in EBD principles, attend the next ADA EBD
Champions Conference in Chicago on March 8-10, 2012. To view the videos,
click here.
Nixdorf presents DPBRN Study 17 feasibility results in Master of Science in Clinical Research defense
Tuesday, January 10, 2012
DPBRN Study 17 Principal Investigator Don
Nixdorf, DDS, MS completed the oral defense of his Master of Science in
Clinical Research at the University of Minnesota School of Dentistry.
Dr. Nixdorf presented data from DPBRN Study 17: “Peri-Operative Pain and
Root Canal Therapy.” Practitioners involved in the study, Alan Law,
DDS, PhD, Deb Knaup, DDS, MS and Dennis Tucker, DDS attended the public
presentation.
“From a researcher’s perspective,” says Dr. Nixdorf, “large prospective
endodontic studies have not had high levels of patient follow-up. In
that context, this study was a big success.” With patient follow-up
response rates of more than 90%, the DPBRN achieved meaningful
participation of both practitioners and their patients.
The study involved both endodontists and general dentists across the US,
as well as general dentists in Denmark and endodontists in Sweden.
Endodontists in the audience agreed that the results represent the
population of patients typically seen in practice. “This too is
important with regards to the contribution of these studies,” says
Nixdorf. “It is a tribute to the excellent enrollment capabilities of
practitioners engaged in the DPBRN. These daily efforts really add up
and result in the diversity of patients and providers we’re looking to
represent.”
Each DPBRN study sheds light on new challenges and ways for the network
to grow and improve. “In these studies, the challenging part—and the
practitioners will tell you this— was the consecutive logging of
eligible patients,” stated Dr. Nixdorf. “We’ve learned how to address
robust data collection in the environment of a busy dental practice.
Practitioners in the network demonstrated a great deal of skill in this
regard. We are very grateful. It leads to results that contribute
meaningfully to the body of knowledge in this area.”
Main outcomes of the studies are pending publication. Stay tuned for future DPBRN news releases.
Click on the thumbnails to view the photos.
January 2012 DPBRN E-Update
Sunday, January 01, 2012
Each month we highlight a recent
publication that may be of interest to DPBRN members, recent study
results, or other important DPBRN information. Please click here to view the pdf version. If you would like to be added to the mailing list, please contact our Director of Communications.
December 2011 DPBRN E-Update
Thursday, December 01, 2011
Each month we highlight a recent
publication that may be of interest to DPBRN members, recent study
results, or other important DPBRN information. Please click here to view the pdf version. If you would like to be added to the mailing list, please contact our Director of Communications.
November 2011 DPBRN E-Update
Tuesday, November 01, 2011
Each month we highlight a recent
publication that may be of interest to DPBRN members, recent study
results, or other important DPBRN information. Please click here to view the pdf version. If you would like to be added to the mailing list, please contact our Director of Communications.
Fall 2011 DPBRN Newsletter
Monday, October 10, 2011
The Fall 2011 DPBRN Newsletter is now available. Please click here
to view the pdf version. If you would like to be added to the mailing
list to receive the electronic version, please contact our Director of Communications.
October 2011 DPBRN E-Update
Saturday, October 01, 2011
Each month we highlight a recent
publication that may be of interest to DPBRN members, recent study
results, or other important DPBRN information. Please click here to view the pdf version. If you would like to be added to the mailing list, please contact our Director of Communications.
Practitioner-investigator in the Minnesota region, Dr. Mike Bauer, discusses how DPBRN participation has improved his practice
Friday, September 02, 2011
I have been involved as a co-author on
three manuscripts that have reported results from certain DPBRN studies.
When contemplating the results and contributing to the discussion, I
start to take inventory of my current practice patterns.
Recently I was involved in a manuscript that will report on the use of
rubber dam by DPBRN dentists during root canal treatment. My practice
pattern was to use it for all posterior teeth, but not all anterior
teeth. I have changed that pattern as a result of my involvement. I
met with my dental assistants to inform them of this change in my
clinical practice. I also discussed these results with the other
dentists in our clinic. One dentist, a 2008 graduate of the University
of Minnesota, reported that she was taught that if you cannot place a
rubber dam, the patient should be referred to an endodontist or an
extraction should be considered. I can report that our clinic has used
results from this DPBRN study and made changes that will improve the
quality and safety of the care that we deliver to our patients. I can
attest to the fact that DPBRN participation has changed the way that I
practice, and my patients benefit from this!
September 2011 DPBRN E-Update
Thursday, September 01, 2011
Each month we highlight a recent
publication that may be of interest to DPBRN members, recent study
results, or other important DPBRN information. Please click here to view the pdf version. If you would like to be added to the mailing list, please contact our Director of Communications.
Dental hygiene educator in the MN Region dedicates
sabbatical to increasing engagement of the dental team in practice-based
research
Friday, August 26, 2011
Debra Sidd, RDH, RF, MEd has been a dental
hygiene educator for more than 30 years. Recent engagement with The
Dental Practice-Based Research Network (DPBRN) has further energized her
already-accomplished career. Awarded a one-year sabbatical from
teaching, she will use the time to promote involvement of the entire
dental team in practice-based research activities. Her rationale:
evidence-based improvements in care can only be achieved when the entire
team is engaged in the process. She sees involvement in practice-based
research as a way to support that engagement.
Teaching her dental hygiene bachelor’s degree students about
evidence-based practice in 2008 led Sidd to meet DPBRN Minnesota
Regional Primary Investigator, Brad Rindal, DDS and then Regional
Coordinator, Merry Jo Thoele, RDH, MPH. She states, “Being fairly new to
research myself, their insights and expertise inspired me and informed
my course design.” Sidd invited them to participate as guest speakers
and developed a better understanding of DPBRN activities when Dr. Rindal
addressed the network with her students. “As chair of the dental
hygiene program at Normandale Community College from 2008-2010, I saw
the need to sequence evidence-based decision making (EBDM) throughout
our dental hygiene curriculum.”
Seeing the importance of EBDM in the educational setting, Sidd is now
inspired to engage providers already in practice. With input from Dr.
Rindal and Regional Coordinators Emily Durand, RDH, RF and Sarah Basile
RDH, MPH, Sidd is organizing a symposium for the entire dental team with
the following two strategic priorities: (1) to effectively increase the
participation of the dental team in dental practice-based research
network activities; (2) to actively engage an effective team approach to
evidence-based improvements in patient care.
The event will be highly collaborative, engaging a range of stakeholders
in the planning process. Sidd states, “I am grateful to have this
opportunity and hope our efforts encourage effective partnerships which
truly impact the quality of dental care.” The symposium will take place
Friday, May 11th, 2012 at Normandale Community College in Bloomington,
MN (details to follow). Contact:
Emily Durand.
DPBRN Blood Glucose Study featured in NNOHA Newsletter
Thursday, August 18, 2011
The National Network for Oral Health Access
(NNOHA) featured a story on DPBRN practitioner-investigator Dr. Gary
Lease and his staff from the South Lake Community Health Center Dental
Clinic in Groveland, Florida in its Summer 2011 quarterly newsletter.
Dr. Lease participated in DPBRN Study 15 entitled ‘Blood Glucose Testing
in Dental Practice'. The story highlights a patient who, because of
enrolling in the study, was diagnosed with diabetes and is now under
medical care. Please click here to view the newsletter (see page 3 for the story).
DPBRN HealthPartners Principal Investigator awarded a
grant from NIDCR to examine the question: Does Participation in a
Dental Practice-Based Research Network Impact Treatment?
Wednesday, August 10, 2011
Dr. Brad Rindal, Director of the DPBRN
Minnesota region and Principal Investigator at the HealthPartners
Research Foundation, was recently awarded a grant from NIDCR
(R03-DE-022089) to examine the question: Does Participation in a Dental
Practice-Based Research Network Impact Treatment?
The study addresses this important question by examining actual
care-delivery patterns of dentists. Dr. Rindal and his investigative
team will utilize electronic clinical data from the HealthPartners
Dental Group (HPDG), including diagnosis codes, caries depths and
treatment data to determine if dentists with a high level of DPBRN
participation are quicker to assimilate DPBRN research into their
practices. HPDG has a thorough dental record that is easily married with
HealthPartners administrative data. Patient diagnosis and treatment
data aggregated by provider will be examined in 2005, prior to the
implementation of the DPBRN. They will then examine the dental practice
patterns again in calendar year 2009 and will evaluate the personal
characteristics of dentists in calendar year 2005 among dentists who
later went on to participate in DPBRN. The dentists will be stratified
into three categories based on level of involvement in the DPBRN: not
enrolled, enrolled but minimally involved, enrolled and involved.
Congratulations to Dr. Rindal and his colleagues at the HealthPartners Research Foundation!
August 2011 DPBRN E-Update
Monday, August 01, 2011
Each month we highlight a recent
publication that may be of interest to DPBRN members, recent study
results, or other important DPBRN information. Please click here to view the pdf version. If you would like to be added to the mailing list, please contact our Director of Communications.
First DPBRN Japan study has started
Monday, August 01, 2011
The Dental PBRN Japan has begun its first
study entitled “Assessment of Caries Diagnosis and Caries Treatment”,
led by Dr. Naoki Kakudate of the Kyoto University School of Medicine and
Public Health. Data collection is currently underway. Please click here
to view the Japanese version of the questionnaire. This study is
modeled after DPBRN Study 3 of the same name. DPBRN has been
collaborating with this new network in Japan as it builds its
infrastructure and research capabilities.
Summer 2011 DPBRN Newsletter
Monday, July 18, 2011
The DPBRN Summer 2011 Newsletter is now available. Please click here
to view the pdf version. If you would like to be added to the mailing
list to receive the electronic version, please contact our Director of Communications.
July 2011 DPBRN E-update
Friday, July 01, 2011
Each month we highlight a recent
publication that may be of interest to DPBRN members, recent study
results, or other important DPBRN information. Please click here to view the pdf version. If you would like to be added to the mailing list, please contact our Director of Communications.
DPBRN presents posters at PBRN National Research Conference
Tuesday, June 28, 2011
DPBRN presented three posters at the
2011 annual Practice-Based Research Networks National Research
Conference June 22-24, 2011, in Bethesda, Maryland. This is an annual
research conference of PBRNs sponsored by the federal Agency for
Healthcare Research and Quality (AHRQ).
The three DPBRN posters were entitled: (1) “Regional variation in
information use by Dental PBRN practitioners”; (2) “Practice improvement
associated with Dental PBRN participation”; and (3) “Characteristics of
questionable tooth decay lesions: findings from The Dental
Practice-Based Research Network”. In addition to presenting three
posters, DPBRN was discussed as a model for inter-professional research
collaborations during a plenary presentation entitled “Collaboration:
The Experience of Three PBRNs” by Dr. Michael Harrington, Director of
the Alabama Primary Care Research Collaborative.
Mainly in attendance are persons involved in medical primary care PBRNs.
However, a DPBRN representative has attended this annual meeting each
year since 2004. The meeting's web site and agenda can by found by
clicking here (external site).
Click on the thumbnails to view the photos.
June 2011 DPBRN E-update
Wednesday, June 01, 2011
Each month we highlight a recent
publication that may be of interest to DPBRN members, recent study
results, or other important DPBRN information. Please click here to view the pdf version. If you would like to be added to the mailing list, please contact our Director of Communications.
Network-wide results of DPBRN study "Prevalence of questionable occlusal caries lesions” are now available
Thursday, May 26, 2011
The network-wide results for the DPBRN
study, “Prevalence of questionable occlusal caries lesions”, are now
available with individual results to be mailed out to participating
practitioners shortly.
The aims of this study are to (1) quantify the prevalence of
questionable occlusal carious lesions in permanent teeth in the first
100 consecutive eligible patients of DPBRN practitioner-investigators;
(2a) for unopened questionable occlusal carious lesions, to test the
hypothesis that the patient’s baseline caries risk is significantly
associated with lesion description (i.e., perceived caries status); and
(2b) for opened questionable occlusal carious lesions, to test the
hypothesis that the patient’s baseline caries risk is significantly
associated with caries depth. These aims were met by enrolling 82
practitioner-investigators, each of whom recorded information about 100
consecutive patients and 25-50 consecutive questionable early occlusal
caries lesions on a 2-page questionnaire. The study recorded the reason
why these occlusal lesions were questionable, the tools used to diagnose
the lesions, the reason why a certain treatment was rendered, and the
depth of the lesions when treated operatively.
Please click here to to see detailed report, overall and by region. Please click here to see graphical presentation of study findings, also overall and by region.
We hope that you find these results to be interesting. Thank you for your participation!
DPBRN featured in NNOHA Newsletter
Wednesday, May 18, 2011
The National Network for Oral Health Access
(NNOHA) featured a testimonial of DPBRN practitioner-investigator Dr.
Adolphus Jackson, of Birmingham, AL in its Spring 2011 quarterly
newsletter. Please click here to view the article.
Spring 2011 DPBRN Newsletter
Friday, May 06, 2011
The DPBRN Spring 2011 Newsletter is now available. Please click here
to view the pdf version. If you would like to be added to the mailing
list to receive the electronic version, please contact our Director of Communications.
Communication from NIDCR about practitioner-investigators in The National Dental PBRN
Friday, May 06, 2011
NIDCR asked that we forward this message:
NIDCR is strongly committed to engaging a diverse and an expanded body
of dental practitioners in the future National Dental Practice-based
Research Network. Please be assured that practitioners currently
engaged in NIDCR funded practice-based research will have a vital and
essential role in the future National Dental PBRN. NIDCR has provided a
link to important information for PBRN practitioners on the NIDCR
website. To view this information, please click here.
Please do not hesitate to contact your PBRN Director or Don DeNucci at NIDCR if you have any additional questions pertaining to your role in the National Dental PBRN.
May 2011 DPBRN E-update
Sunday, May 01, 2011
Each month we highlight a recent
publication that may be of interest to DPBRN members, recent study
results, or other important DPBRN information. Please click here to view the pdf version. If you would like to be added to the mailing list, please contact our Director of Communications.
Application Successfully Submitted in Response to the National Dental PBRN Limited Competition
Friday, April 29, 2011
As follow-up to our news item of December
16, 2010 entitled “New National Dental Practice-Based Research Network
Limited Competition (U19)”, we successfully submitted our grant
application for renewal. Although it was not due until May 3rd, we
submitted our application on April 28th.
Recall that the National Institute of Dental and Craniofacial Research
(NIDCR) funded The Dental PBRN for 2005-2012. NIDCR issued a Funding
Opportunity Announcement (FOA) for a limited competition that invited
applications from the incumbent NIDCR-funded PBRNs to establish a
National Dental Practice-Based Research Network. The Institute will
support one national network.
Dental PBRN Study #14 on Smoking Cessation Yields Results
Thursday, April 14, 2011
Researchers with the Dental PBRN study
entitled “Hygienists’ Internet Tobacco Cessation Study” are helping
dental practices make a difference in the lives of their patients. From
the time the study began, over 700 dental practices nationwide
expressed interest in participating in the study and the enthusiasm has
continued. Ultimately, only 100 practices were randomized into the
study, a limitation required by the study protocol. Hygienists,
dentists, and office staff from 100 dental practices across eight states
are actively participating in the study and reporting success with
using the study’s online tools to educate patients about smoking
cessation.
Recently, one practice reported that one of its patients returned for a
routine office visit and staff noticed that the patient’s demeanor and
appearance were different. When asked about it, the patient reported
that as a result of participating in the study, he had finally succeeded
in quitting smoking. After the hygienist referred the patient to the
study’s website for tobacco control, the patient, who was a long-time
smoker, followed advice provided on the website and took steps to quit.
He explained that although he had made earlier attempts to quit,
hearing the advice and encouragement at the dental office and receiving
advice from the website, was “the straw that broke the camel’s back”.
Other patients have found similar results after using the site, with
comments such as “Thanks for your help. This is the best help I have
ever received” and “I appreciate you being here for me because it wasn’t
easy for me to quit but I'm glad I did. I was just told I'm
cancer-free as of Feb 3rd this year.”
We congratulate these and other patients, as well as the dental offices
participating in the study! DPBRN’s mission is “To improve oral health
by conducting dental practice-based research and by serving dental
professionals and their patients through education and collegiality.”
For this study, we may not only be improving oral health, but general
health as well!
Dental PBRN Blood Glucose Study #15 Has a Major Impact on a Study Participant
Thursday, April 14, 2011
Dr. Gary Lease and his staff from the South
Lake Community Health Center Dental Clinic in Groveland, Florida
participated recently in the DPBRN Study #15 entitled ‘Blood Glucose
Testing in Dental Practice’. The Health Center serves four counties and
draws patients from four additional counties. The population served is
rural, including under-served lower income patients and migrant
workers, as well as full-fee patients. Dr. Lease, also a member of the
National Network for Oral Health Access (www.NNOHA.org), has
participated in several DPBRN studies, and was glad to learn about the
study that sought to determine the feasibility of doing random blood
glucose screening for dental patients at risk for abnormal readings.
Results from the study were recently presented at the International
Association for Dental Research (www.IADR.com) annual meeting in March
2011. Blood glucose screening in dental practice was found to be
feasible and was viewed positively by participating clinics and their
patients. Additionally, the study had a particularly important impact
for one of Dr. Lease’s patients. This patient was being seen for a
routine prophylaxis appointment and agreed to participate in the study.
The initial blood glucose reading was very high (465 mg/dl; normal
random value is 80-120 mg/dl) and stayed high when the test was
repeated. Dr. Lease asked the patient whether he or his family had a
history of diabetes, but the patient was unaware of any problem. At
that point, the study protocol required Dr. Lease to refer the patient
to a physician. Because the dental clinic is associated with a medical
clinic, the dental staff immediately called to see if they could have
the patient seen by a medical provider. Because of the extremely high
reading, the medical clinic advised that the patient should go
immediately to the emergency room.
The patient instead reported very soon after the dental visit to a
medical clinic. At that time, he was diagnosed with diabetes for the
first time and is now under the care of a physician. Although he said
he felt fine at the initial study visit, he realized after the diabetes
diagnosis that he had been having some health problems. The patient is
now on medication for diabetes and he stated that he is being more
careful with his diet, both of which have improved his overall health.
Today, the patient feels lucky that he participated in the study and
said “I am happy I had the testing; if not for the test (study) I would
still not know. I had a problem with my eyesight, my eyes hurt, and
that is better. I am so glad that I was able to be part of the test and
I am very thankful.”
The Community Health Center Dental Clinic at South Lake identified a
number of patients enrolled in the study with elevated readings who also
were unaware of the problem. Dr. Lease sees the “test as a benefit to
the overall health of the patient, treating the whole patient, not just
their oral condition. A poorly controlled diabetic can be expected to
respond differently than a well-controlled one, in terms of healing and
tissue response”. With the clinic serving a population which seems to
have more periodontal disease, Dr. Lease says he is now “more inclined
to suggest medical follow-up if a person comes in with severe
periodontal disease. I ask if they have a family history or have been
tested for diabetes. The blood glucose testing by finger stick is an
efficient and easy tool and I hope in the future our profession is able
to incorporate it into daily clinical practice”.
Click on the thumbnails to view the photos.
DPBRN April 2011 E-update
Friday, April 01, 2011
Each month we highlight a recent
publication that may be of interest to DPBRN members, recent study
results, or other important DPBRN information. Please click here to view the pdf version. If you would like to be added to the mailing list, please contact our Director of Communications.
DPBRN posters and presentations at IADR/AADR meeting in San Diego, CA
Monday, March 28, 2011
DPBRN was well-represented at the 40th
Annual Meeting of the International and American Associations for Dental
Research in San Diego, CA March 16-19, 2011. DPBRN had 14 abstracts,
given as oral presentations or posters, which garnered a lot of interest
in our network. Congratulations to all the presenters for a job well
done! Click here to view the abstract list.
Click on the thumbnails to view the photos.
Japan develops a Dental PBRN
Friday, March 25, 2011
In September 2010, Naoki Kakudate, DDS,
PhD, MPH, a faculty member at the Graduate School of Medicine and Public
Health, Kyoto University, Japan, visited Birmingham, Alabama to learn
about the Dental PBRN Network Chair and Coordinating Center groups.
Then he went on to Portland, Oregon to attend the annual face-to-face
meeting of the DPBRN administrative groups (Executive Committee,
Steering Committee, Regional Coordination Group). See the related news
item about his visit (dated October 10, 2010)
here.
Using the knowledge he gained from his visits helped him establish
“Dental PBRN Japan”, for which he serves as Director. Please click here to visit the website.
We congratulate Dr. Kakudate on his accomplishments. DPBRN and Dental
PBRN Japan hope to collaborate on certain projects in the future.
Article on DPBRN studies featured in HealthPartners Dental Group Weekly Reader
Monday, March 14, 2011
The HealthPartners Dental Group Weekly Reporter
recently featured The DPBRN’s two ONJ reports. “Risk Factors for
Osteonecrosis of the Jaws: a Case-control Study” and “ONJ in Two Dental
Practice-Based Research Network Regions” can be found in February’s Journal of Dental Research. Click here to read the article from HealthPartners.
DPBRN March 2011 E-Update
Tuesday, March 01, 2011
Each month we highlight a recent DPBRN publication, recent study results, or other important DPBRN information. Please click here to view the pdf version. If you would like to be added to the mailing list, please contact our Director of Communications.
Article on DPBRN featured in the University of Florida Post: “Science in the Real World”
Wednesday, February 16, 2011
The University of Florida Post
recently wrote an article entitled “Science in the Real World” which
discusses The DPBRN and the impact it has had in conducting research in
daily clinical practice. Click here to read the article.
DPBRN February 2011 E-update
Tuesday, February 01, 2011
Each month we highlight a recent DPBRN publication, recent study results, or other important DPBRN information. Please click here to view the pdf version. If you would like to be added to the mailing list, please contact our Director of Communications.
Winter 2011 DPBRN Newsletter
Tuesday, January 18, 2011
The DPBRN Winter 2011 Newsletter is now available. Please click here
to view the pdf version. If you would like to be added to the mailing
list to receive the electronic version, please contact our Director of Communications.
January 2011 DPBRN E-Update
Monday, January 03, 2011
Each month we highlight a recent DPBRN publication, recent study results, or other important DPBRN information. Please click here to view the pdf version. If you would like to be added to the mailing list, please contact our Director of Communications.
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