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Director: Dr. Rosemary Craen
PROGRAM:
Neurosurgery and Interventional Neuroradiology, encompassing all types of elective and emergency cases, are performed at two sites - University Hospital (adult) and Victoria Hospital (pediatric). There is a core group of anesthesiologists with neuroanesthesia fellowship training. The academic program, established under previous chair, Dr. Adrian Gelb, has national and international recognition.
Clinical Neuroanesthesia
Cerebrovascular Surgery and Endovascular Treatment
We are a national referral centre for the management of patients with cerebral aneurysms and arteriovenous malformations.
Surgery for Intractable Epilepsy
While we have been doing this type of surgery for more than two decades, it is only recently that neurologists and neurosurgeons worldwide have come to realize the therapeutic potential of such surgery and this has resulted in epilepsy surgery becoming one of the “fastest growth areas” in neurosurgery. We are one of Canada’s two major national referral centres. Patients are treated while awake but sedated so that their speech and motor areas of the brain can be mapped prior to surgical excision.
Stereotactic Surgery
This is used for diagnostic biopsies, management of chronic pain and movement disorders, and the management of intractable epilepsy. Each of these requires different anesthetic approaches.
In addition to the above “special areas”, fellows will be exposed to a wide variety of the more usual neurosurgical procedures including endoscopic neurosurgery, craniotomies for tumors and hemifascial spasm, carotid endarterectomy, spinal instrumentation.
Monitoring/Diagnostic Skills
Fellows will have the opportunity to learn how to use Transcranial Doppler, oximetry, Evoked Potential and EEG monitoring during surgery.
Non-Anesthesia Experience
Fellows will spend a brief period on the Epilepsy Service to have a better understanding of the total management of patients with epilepsy and to learn (much) more about the reading, use and potential of EEG monitoring.
As well, a similar brief period will be offered in the Neuroradiology Department to learn more about the indications and uses of diagnostic and interventional neuroradiology and to become much more facile with the interpretation of CT scans, MRI scans, etc.
Research/Academic Activities
The Department offers a variety of clinical research opportunities.
It is our expectation that each fellow will complete at least one research project taking it from conception through to completion. In addition, each fellow is expected to write at least one review article/book chapter. Further participation in research and writing activities is always welcome and encouraged.
Under supervision, fellows will also review manuscripts submitted to a variety of anesthesia journals, abstracts submitted to anesthesia scientific meetings and grant applications. These activities together with the research activities outlined above will provide fellows with an excellent insider’s view of the entire research process.
For fellows interested in medical education, we encourage them to take the 2-day or the 5-day course in “Teaching at the University Level” offered by the University of Western Ontario. For those who anticipate that teaching will be a major component of their career, we advise our 30-week teaching course for medical educators.
EDUCATION:
| Anesthesia Residents |
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Objectives |
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Introductory - St. Joseph's Health Care
Introductory - University Hospital
Introductory - Victoria Hospital |
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Neuroanesthesia Rotation Objectives |
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Two separate one-month rotations in neuroanesthesia will provide the Resident with a theoretical basis and clinical experience in the anesthetic management of adults undergoing surgical treatment of diseases of the CNS and Spine. This clinical experience is supplemented by a formal series of seminars in neuroanesthesia in the core curriculum and informal lectures within the O.R. setting and Interdisciplinary Neurodiscussion Rounds. Guided independent study is also encouraged with the provision of a Manual of Neuroanesthesia and compilation of SNACC-recommended neurodiscussion peer-reviewed articles located in the Anesthesia Library at London Health Sciences Centre, University Campus.
Upon completion of the neuroanesthesia rotation, Residents should have demonstrated proficiency in caring for patients with neurologic disease in a compassionate manner. This includes the preoperative evaluation, intraoperative management, and postoperative care utilizing the most current medical/anesthetic knowledge pertinent to each case using online medical information; communicating with patients and working effectively with patient care team; demonstrating ethical practices and practice cost-effective yet quality health care. The clinical experience will provide exposure to a variety of basic and complex procedures in patients with neurologic disease, with graded independence and responsibility.
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At the completion of the neuroanesthesia rotation, the Resident should exhibit the following knowledge, skills and attitudes:
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General Requirements |
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• Demonstrate diagnostic and therapeutic skills for ethical and effective patient care.
• Access and apply relevant information to clinical practice.
• Demonstrate effective referral/consultation skills
• Recognize limitations of expertise and summon assistance when required.
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Specific Requirements |
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• Demonstrate knowledge of basic sciences as applicable to neuroanesthesia, including neuroanatomy, neurophysiology and neuropharmacology.
• Demonstrate knowledge of medicine with particular reference to the neurologic system.
• Demonstrate knowledge of basic legal matters encountered in anesthetic practice including informed consent and patient confidentiality.
• Demonstrate Basic Understanding of the commonly performed neurosurgical procedures impact on anesthetic management.
• Demonstrate clinical knowledge and skills necessary for the \practice of neuroanesthesia including:
• Preoperative neuro-assessment (using Glasgow Coma Scale, Hunt-Hess Classification for SAH and basic neurological exam).
• Intraoperative support including:
• Special Positioning (sitting, prone, park-bench, lateral and knee-chest).
• Understanding basic principles of neurophysiologic monitoring
• EEG, Evoked potential (SSEP, BAEP), transcranial Doppler, cerebral oximetry, and intracranial pressure monitoring methods available.
• Specific interventions – systemic arterial hypotension/hypertension, CSF drainage, ICP management, hypothermia and precordial Doppler monitoring for air embolus.
• Management of specific perioperative complications such as seizures, cerebral ischemia, intracranial hypertension, intraoperative aneurysm rupture, air embolism, cranial nerve dysfunction and neuroendocrine disturbance (DI, SIADH).
• Postoperative management of neuro patients in PACU, ICU and the Neuro-Observation Unit.
• Demonstrate competence in all technical procedures commonly employed in neuroanesthetic practice – including airway management (basic and difficult), cardiovascular and neuro-resuscitation, invasive monitoring (arterial line, central line and LP Drain placement).
• Develop and implement a rational anesthetic plan of management for each of the following neurosurgical procedures:
• Craniotomy for mass lesions (tumor, abscess, hematoma)
• Cerebrovascular procedures (aneurysm, AVM, carotid vascular disease)
• CSF shunting procedures
• Transphenoidal surgery
• Stereotactic procedures
• Awake craniotomy
• Neuroradiologic procedures (embolization, thrombolytic and MRI)
• Spine surgery
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| Communicator: |
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General Requirements |
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• Establish a therapeutic relationship with patients and their families in the limited time available.
• Obtain and collate relevant history from patients and families.
• Listen effectively.
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| Collaborator: |
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Manager: |
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• Demonstrate empathy, consideration and compassion in communicating with patients and families.
• Communicate effectively with medical/surgical colleagues, nurses, and paramedical personnel regarding the anesthetic management of the patient.
• Demonstrate appropriate written communication skills through accurate, legible, and complete documentation of the anesthetic record, patient chart and in consultation.
• Ensure adequate information has been provided to the patient prior to implementing the anesthetic plan and invasive procedures.
• Residents should demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their families and professional associates.
• Demonstrate ability to function in the clinical environment using the full abilities of all team members (surgical, nursing, ICU, etc.).
• Residents will develop their anesthetic plan for their patients in consultation and in concert with surgery, nursing and ICU (if necessary) for more complicated neurosurgical patients.
•When time permits, Residents are encouraged to attend multidisciplinary Neurosciences and Epilepsy Rounds. These experiences should permit the Resident to:
• Understand and value the skills of other specialists and health care professionals.
• Understand the limits of their knowledge and skills.
• Be able to understand, accept and respect the opinions of others on the neuro team.
• Residents will function in the O.R. as a member of the neuro team and work in a positive, constructive manner.
• Residents will demonstrate the ability to manage their operating room:
• Ensuring necessary equipment, monitoring, and medications are available for each case.
• Making preparations to deal with anticipated complications.
• All these activities should be conducted in an effective and efficient timely manner in order to avoid O.R. delays.
• Residents will begin to adopt a leadership role in the postoperative care of their patients by anticipating and arranging for either PACU, ICU or Neuro-Observation Unit care.
• Utilize personal resources effectively in order to balance patient care, continuing education and personal activities.
• Utilize information technology to optimize patient care and life long learning.
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| Health Advocate: |
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Scholar:
Professional: |
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• Residents will begin to recognize the opportunities for anesthesiologist to advocate for resources for neurosurgical patients, emerging medical techs, and new health care practices.
• Provide direction to hospital administrators regarding compliance with national/international practice guidelines and equipment for the management of neurosurgical patients.
• Responsible for developing, implementing and regularly re- evaluating a personal continuing education strategy.
• Required to synthesize medical/anesthetic literature and critically appraise it using the principles of evidence-based medicine.
• Contribute to the development of new knowledge through facilitation/participation in ongoing departmental research activities. - Required to prepare in advance for the O.R. cases scheduled through additional reading, patient chart review/assessment.
• Demonstrate a commitment to executing, professional responsibilities with integrity, honesty and compassion.
• Demonstrate appropriate personal and interpersonal professional behaviors and boundaries.
• Residents should regularly review personal and professional performance.
• Recognize limits of personal skill and knowledge by appropriately consulting other physicians when caring for the patient.
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Recommended Lectures |
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General |
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1. Voorhees JR, Cohen-Gadol AA, Laws ER et al.
Battling blood loss in neurosurgery: Harvey Cushing's embrace of
electrosurgery. J Neurosurg. 2005 Apr;102(4):745-52.
2. Patel PP. Neuroanesthesia for the occasional neuroanesthesiologist Refresher course lecture, CJA annual meeting supplement June 2005
3. Pasternak JJ, Lanier WL. Neuroanesthesiology review J Neurosurg Anesthesiol. 2005 Jan;17(1):2-8. Review.
4. Lukins MB, Manninen PH. Hyperglycemia in patients administered dexamethasone for craniotomy. Anesth Analg. 2005 Apr;100(4):1129-33
5. Hans P, Bonhomme V. Muscle relaxants in neurosurgical anaesthesia: a critical appraisal. Eur J Anaesthesiol. 2003 Aug;20(8):600-5. Review.
6. Smith M, Hirsch NP. Pituitary disease and anaesthesia. Br J Anaesth. 2000 Jul;85(1):3-14. Review. No abstract available.
7. Gale T, Leslie K. Anaesthesia for neurosurgery in the sitting position. J Clin Neurosci. 2004 Sep;11(7):693-6.
8. Ravussin P, Wilder-Smith O. General anaesthesia for supratentorial neurosurgery. CNS Drugs. 2001;15(7):527-35. Review.
9. Kathirvel S, Dash HH, Bhatia A, et al Effect of prophylactic ondansetron on postoperative nausea and vomiting after elective craniotomy. J Neurosurg Anesthesiol. 2001 Jul;13(3):207-12.
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Monitoring |
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1. Soriano SG, McCann ME, Laussen PC. Neuroanesthesia. Innovative techniques and monitoring. Anesthesiol Clin North America. 2002 Mar;20(1):137 51. Review.
2. Zhong J, Dujovny M, Park HK et al. Advances in ICP monitoring techniques. Neurol Res. 2003 Jun;25(4):339-50. Review.
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NeuroRadiology |
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1. Osborn IP. Anesthetic considerations for interventional neuroradiology.
Int Anesthesiol Clin. 2003 Spring;41(2):69-77. Review.
2. Hashimoto T, Gupta DK, Young WL. Interventional neuroradiology--anesthetic considerations. Anesthesiol Clin North America. 2002 Jun;20(2):347-59, Review.
3. Quader K, Manninen PH, Lai JK. Pulmonary edema in the neuroradiology suite: a diagnostic dilemma. Can J Anaesth. 2001 Mar;48(3):308-12.
4. Castagnini HE, van Eijs F, Salevsky FC et al. Sevoflurane for interventional neuroradiology procedures is associated with more rapid early recovery than propofol. Can J Anaesth. 2004 May;51(5):486-91.
5. Schmitz B, Nimsky C, Wendel G et al. Anesthesia during high-field intraoperative magnetic resonance imaging experience with 80 consecutive cases. J Neurosurg Anesthesiol. 2003 Jul;15(3):255-62.
6. Birkholz T, Schmid M, Nimsky C et al. ECG artifacts during intraoperative high-field MRI scanning. J Neurosurg Anesthesiol. 2004 Oct;16(4):271-6.
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Cerebral Aneurysms |
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1. Todd MM, Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST)Investigators. Mild intraoperative hypothermia during surgery for intracranial aneurysm. N Engl J Med. 2005 Jan 13;352(2):135-45.
2. Bendo AA. Intracranial vascular surgery. Anesthesiol Clin North America. 2002 Jun;20(2):377-88. Review.
3. Veyna RS, Seyfried D, Burke DG, et al Magnesium sulfate therapy after aneurysmal subarachnoid hemorrhage. J Neurosurg. 2002 Mar;96(3):510-4.
4. Lai YC, Manninen PH. Anesthesia for cerebral aneurysms: a comparison between interventional neuroradiology and surgery. Can J Anaesth. 2001 Apr;48(4):391-5.
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Traumatic Brain Injury |
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1. Chee VW, Lew TW. Acute intraoperative cerebral oedema: are current therapies evidence based? Anaesth Intensive Care. 2003 Jun;31(3):309-15. Review.
2. Edwards P, Arango M, Balica L, et al CRASH trial collaborators. Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury-outcomes at 6 months. Lancet. 2005 Jun 21;365(9475):1957-9.
3. Roberts I, Yates D, Sandercock P, et al CRASH trial collaborators.
Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet. 2004 Oct 9;364(9442):1321-8.
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Brain Protection |
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1. Hans P, Bonhomme V. The rationale for perioperative brain protection.
Eur J Anaesthesiol. 2004 Jan;21(1):1-5. Review.
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Brain Tumors |
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1. Duffy CM, Matta BF. Sevoflurane and anesthesia for neurosurgery: a review.
J Neurosurg Anesthesiol. 2000 Apr;12(2):128-40. Review.
2. Gelb AW, Salevsky F, Chung F, et al Remifentanil with morphine transitional analgesia shortens neurological recovery compared to fentanyl for supratentorial craniotomy. Can J Anaesth. 2003 Nov;50(9):946-52.
3. Gerlach K, Uhlig T, Huppe M, et al Remifentanil-propofol versus sufentanil-propofol anaesthesia for supratentorial craniotomy: a randomized trial.
Eur J Anaesthesiol. 2003 Oct;20(10):813-20.
4. Rasmussen M, Bundgaard H, Cold GE. Craniotomy for supratentorial brain tumors: risk factors for brain swelling after opening the dura mater.
J Neurosurg. 2004 Oct;101(4):621-6.
5. Haure P, Cold GE, Hansen TM et al. The ICP-lowering effect of 10 degrees reverse Trendelenburg position during craniotomy is stable during a 10-minute period. J Neurosurg Anesthesiol. 2003 Oct;15(4):297-301.
6. Petersen KD, Landsfeldt U, Cold GE et al. Intracranial pressure and cerebral hemodynamic in patients with cerebral tumors: a randomized prospective study of patients subjected to craniotomy in propofol-fentanyl, isoflurane-fentanyl, or sevoflurane fentanyl anesthesia. Anesthesiology. 2003 Feb;98(2):329-36.
7. Tankisi A, Rolighed Larsen J, Rasmussen M et al. The effects of 10 degrees reverse trendelenburg position on ICP and CPP in prone positioned patients subjected to craniotomy for occipital or cerebellar tumours. Acta Neurochir (Wien). 2002 Jul;144(7):665-70.
8. Petersen KD, Landsfeldt U, Cold GE et al. ICP is lower during propofol anaesthesia compared to isoflurane and sevoflurane. Acta Neurochir Suppl. 2002;81:89-91.
9. Balki M, Manninen PH. Craniotomy for suprasellar meningioma in a 28-week pregnant woman without fetal heart rate monitoring. Can J Anaesth. 2004 Jun-Jul;51(6):573-6.
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Awake Craniotomy & Epilepsy |
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1. Sahjpaul RL. Awake craniotomy: controversies, indications and techniques in the surgical treatment of temporal lobe epilepsy. Can J Neurol Sci. 2000 May;27 Suppl 1:S55-63; discussion S92-6. Review.
2. Sarang A, Dinsmore J. Anaesthesia for awake craniotomy--evolution of a technique that facilitates awake neurological testing. Br J Anaesth. 2003 Feb;90(2):161-5.
3. McGuire G, El-Beheiry H, Manninen P et al. Activation of electrocorticographic activity with remifentanil and alfentanil during neurosurgical excision of epileptogenic focus. Br J Anaesth. 2003 Nov;91(5):651-5.
4. Balki M, Manninen PH, McGuire GP et al. Venous air embolism during awake craniotomy in a supine patient. Can J Anaesth. 2003 Oct;50(8):835-8.
5. Maltete D, Navarro S, Welter ML et al. Subthalamic stimulation in Parkinson disease: with or without anesthesia? Arch Neurol. 2004 Mar;61(3):390-2.
6. Ali II, Pirzada NA, Kanjwal Y et al. Complete heart block with ventricular asystole during left vagus nerve stimulation for epilepsy. Epilepsy Behav. 2004 Oct;5(5):768-71.
7. Bernard EJ, Passannante AN, Mann B et al. Insertion of vagal nerve stimulator using local and regional anesthesia. Surg Neurol. 2002 Feb;57(2):94-8.
8. Murphy JV, Patil A. Stimulation of the nervous system for the management of seizures: current and future developments. CNS Drugs. 2003;17(2):101-15. Review.
9. Deogaonkar A, Avitsian R, Henderson JM, Schubert A. Venous air embolism during deep brain stimulation surgery in an awake supine patient. Stereotact Funct Neurosurg. 2005;83(1):32-5. Epub 2005 Apr 8.
10. Costello TG, Cormack JR, Mather LE, LaFerlita B, Murphy MA, Harris K.
Plasma levobupivacaine concentrations following scalp block in patients undergoing awake craniotomy. Br J Anaesth. 2005 Jun;94(6):848-51. Epub 2005 Apr 7.
11. Costello TG, Cormack JR, Hoy C, Wyss A, Braniff V, Martin K, Murphy M. Plasma ropivacaine levels following scalp block for awake craniotomy. J Neurosurg Anesthesiol. 2004 Apr;16(2):147-50.
12. Costello TG, Cormack JR. Anaesthesia for awake craniotomy: a modern approach. J Clin Neurosci. 2004 Jan;11(1):16-9.
13. Ard JL Jr, Bekker AY, Doyle WK. Dexmedetomidine in awake craniotomy: a technical note. Surg Neurol. 2005 Feb;63(2):114-6; discussion 116-7.
14. Mack PF, Perrine K, Kobylarz E, Schwartz TH, Lien CA. Dexmedetomidine and neurocognitive testing in awake craniotomy. J Neurosurg Anesthesiol. 2004 Jan;16(1):20-5.
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NeuroEndoscopy |
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1. Kalmar AF, Van Aken J, Caemaert J et al. Value of Cushing reflex as warning sign for brain ischaemia during neuroendoscopy. Br J Anaesth. 2005 Jun;94(6):791-9. Epub 2005 Apr 1.
2. Van Aken J, Struys M, Verplancke T et al. Cardiovascular changes during endoscopic third ventriculostomy. Minim Invasive Neurosurg. 2003 Aug;46(4):198-201.
3. El-Dawlatly AA, Murshid WR, Elshimy A et al. The incidence of bradycardia during endoscopic third ventriculostomy. Anesth Analg. 2000 Nov;91(5):1142-4.
4. Fabregas N, Craen RA. Anaesthesia for minimally invasive neurosurgery. Best Pract Res Clin Anaesthesiol. 2002 Mar;16(1):81-93. Review.
5. Fabregas N, Valero R, Carrero E et al. Episodic high irrigation pressure during surgical neuroendoscopy may cause intermittent intracranial circulatory insufficiency. J Neurosurg Anesthesiol. 2001 Apr;13(2):152-7.
6. Fabregas N, Lopez A, Valero R et al. Anesthetic management of surgical neuroendoscopies: usefulness of monitoring the pressure inside the neuroendoscope. J Neurosurg Anesthesiol. 2000 Jan;12(1):21-8.
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Carotid Endarterectomy |
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1. Findlay JM, Marchak BE, Pelz DM et al. Carotid endarterectomy: a review.
Can J Neurol Sci. 2004 Feb;31(1):22-36. Review.
2. Kostopanagiotou G, Markantonis SL, Polydorou M et al. Recovery and cognitive function after fentanyl or remifentanil administration for carotid endarterectomy. J Clin Anesth. 2005 Feb;17(1):16-20.
3. Stoneham MD, Martin T. Increased oxygen administration during awake carotid surgery can reverse neurological deficit following carotid cross-clamping.
Br J Anaesth. 2005 May;94(5):582-5. Epub 2005 Feb 11.
4. Allain R, Marone LK, Meltzer J, Jeyabalan G. Carotid endarterectomy.
Int Anesthesiol Clin. 2005 Winter;43(1):15-38. Review.
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Spine Surgery |
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1. Ho VT, Newman NJ, Song S et al. Ischemic optic neuropathy following spine surgery. J Neurosurg Anesthesiol. 2005 Jan;17(1):38-44.
2. Urban MK, Jules-Elysee KM, Beckman JB et al. Pulmonary injury in patients undergoing complex spine surgery. Spine J. 2005 May-Jun;5(3):269-76.
3. Raw DA, Beattie JK, Hunter JM. Anaesthesia for spinal surgery in adults.
Br J Anaesth. 2003 Dec;91(6):886-904. Review.
4. Grottke O, Dietrich PJ, Wiegels S et al. Intraoperative wake-up test and postoperative emergence in patients undergoing spinal surgery: a comparison of intravenous and inhaled anesthetic techniques using short-acting anesthetics.
Anesth Analg. 2004 Nov;99(5):1521-7; table of contents.
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Airway |
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1. Wahlen BM, Gercek E. Three-dimensional cervical spine movement during intubation using the Macintosh and Bullard laryngoscopes, the bonfils fibrescope and the intubating laryngeal mask airway. Eur J Anaesthesiol. 2004 Nov;21(11):907-13.
2. Raphael J, Rosenthal-Ganon T, Gozal Y. Emergency airway management with a laryngeal mask airway in a patient placed in the prone position. J Clin Anesth. 2004 Nov;16(7):560-1.
3. Turkstra T, Craen RA, Pelz D, Gelb AW. Cervical Spine Motion: A Fluroscopic Comparison during Intubation with Lighted Stylet, Glidescope and Macintosh Laryngoscope. Anesth Analg 2005;101 910-9154. Hata T, Todd MM. Cervical spine considerations when anesthetizing patients with Down syndrome. Anesthesiology. 2005 Mar;102(3):680-5.
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Hyopthermia |
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1. Lownie SP, Menkis AH, Craen RA, Mezon B, MacDonald J, Steinman DA.
Extracorporeal femoral to carotid artery perfusion in selective brain cooling
for a giant aneurysm. Case report. J Neurosurg. 2004 Feb;100(2):343-7.
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| Anesthesia Fellows |
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Neuroanesthesia Rotation Objectives |
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The aim of the Neuroanesthesia Fellowship Program is to provide advanced training to those individuals who either plan to enter academic anesthesiology with an emphasis in adult neurosurgical anesthesia or those who wish to practice in a setting that has a large number of adult neurosurgical procedures. Trainees gain knowledge not just through case experience, but also through an organized teaching program.
All foreign graduates will undergo 12 weeks of PEAP that is mandated by the Licensing College. During this period the trainee will be closely supervised and their clinical competency evaluated by the staff anesthesiologists. This is essential to ensure that trainees can perform at the level of a junior consultant as they may be administering anesthesia in an OR with minimal supervision. Trainees have to pass the evaluation before they are allowed to continue with the fellowship. |
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Trainees are expected to provide a number of service days, which generates income to support their salary. The rest of the time will be spent in Neuroanesthesia. An average of one day per week will be allocated for the fellow to do clinical research. |
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After-hours call will be approximately seven nights a month - call will be from home as the attending anesthesiologist will be in-house. |
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Trainees are entitled to 4 weeks vacation (20 working days) and 5 days of conference leave per 12 months of fellowship. Conference and vacation are only allowed after 3 months of fellowship to comply with the PEAP period. The rest of the contract, salary and benefit details will be provided by the office of Fellowship Program. |
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Currently we do not offer pediatric neuroanesthesia experience.
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Application Process |
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See our Application Page under Fellowship Program. |
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| Participants |
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Miguel Arango
Kevin Armstrong
Pod Armstrong
Pravin Batohi
Rosemary Craen
Dan Cuillerier
Steve Dain
Achal Dhir |
Ian Herrick
Mary Lampe
Ronit Lavi
Bernie Mezon
Marc St.Amand
Tim Turkstra
Tony Vannelli |
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