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As antimicrobial therapies become less effective, more people are at risk for infections that can progress to sepsis.

Sepsis and Antimicrobial Resistance Awareness Gain Ground, But Action Must Continue

Along with a 1 reported case in Massachusetts, the

New Hampshire Department of Health and Human Services (DHHS) has confirmed a person infected with eastern equine encephalitis (EEE) has died. The public health agency said the person was hospitalized due to severe central nervous system disease. The last reported human EEEV infection in New Hampshire was in 2014, when DHHS identified 3 human infections, including 2 fatalities. In the same statement, DHHS mentions there has been 1 confirmed case in Vermont this summer.

On August 16, the Massachusetts Department of Public Health (MDPH) released a statement discussing the confirmation of the first human case of EEE in the state this year. The confirmed case was discovered in an 80 year old man who was exposed to the vector borne disease in Worcester County. As a result, the risk level in the local communities of Douglas, Oxford, Sutton, and Webster has been raised to critical, and in Dudley, Northbridge, and Uxbridge the risk is increased to high.

Additionally, the neighboring communities of Auburn, Charlton, Grafton, Leicester, Mendon, Millbury, Millville, Southbridge, and Upton are now considered at moderate risk according to MDPH.

“This is the first time we have seen a person infected with EEE in Massachusetts since 2020,” Public Health Commissioner Robbie Goldstein, MD, PhD, said in a statement. “EEE is a rare but serious disease and a public health concern. We want to remind residents of the need to protect themselves from mosquito bites, especially in areas of the state where we are seeing EEE activity.

Though very rare, EEE is serious and a potentially fatal disease that can affect people of all ages. EEE is generally spread to humans through the bite of an infected mosquito. There were 12 human cases of EEE in Massachusetts in 2019 with 6 deaths, and 5 human cases with 1 death in 2020. There were no human cases of EEE in Massachusetts in 2021, 2022, or 2023.

EEE has a fatality rate of 33% to 70%, with most deaths occurring 2–10 days after the onset of symptoms.

In addition to a high mortality rate, long-term physical and mental complications, including permanent neurological deficits have been identified in many people who survive EEE.

Plymouth is approximately 40 miles south of Boston along the coast, and Worcester County is in the middle of the state, so the 2 areas are not in close proximity, but due to the elevated risk locally, the town of Plymouth decided to take action in response to outdoor parks. As of last Friday, all town public parks and fields are close daily from dusk until dawn.

“As Mass DPH has now elevated Plymouth’s EEE risk status to high, it is important to take extra precautions when outdoors and follow state and local health guidelines to avoid unnecessary risk to exposure to EEE. The health and safety of our community, residents, and visitors remain our priority,” Plymouth’s Commissioner of Health and Human Services, Michelle Bratti, said in a statement.

According to the Centers for Disease Control and Prevention (CDC) most people who are infected with the virus do not develop symptoms; however, for those that do, the date from the bite to the onset of the illness is 4 to 10 days. EEE can also result in fever or neurologic disease. The type of illness will depend on the age of the person and other factors. Those who are infected can develop meningitis.

There are no FDA-approved treatments for EEE and for patients who develop severe cases, they can be hospitalized to receive supportive treatment.

Over the weekend, MDPH detailed plans of spraying for mosquitos including aerially in areas of Plymouth County, and truck-mounted spraying in parts of Worcester County. As of Saturday, 10 communities in Massachusetts were raised to high or critical risk for EEE virus.

“The risk from EEE is high in parts of Plymouth County and critical in parts of Worcester County,” State Epidemiologist Catherine M. Brown, DVM, said in a statement. “In addition to recommending that people use mosquito repellent with an EPA-registered active ingredient and clothing to reduce exposed skin, we also recommend that evening outdoor events be rescheduled to avoid the hours between dusk and dawn. The mosquitoes most likely to spread EEE are most active during the dusk to dawn hours.”

There are preventative strategies to avoid EEE, and the MDPH has listed such measures 

For those who live in Massachusetts and want more information on EEE, it can be found 

 or by calling the DPH Division of Epidemiology at 617-983-6800.

1.NH DHHS Identifies Person Infected with Eastern Equine Encephalitis Virus in New Hampshire.The New Hampshire Department of Health and Human Services. August 27, 2024. Accessed August 28, 2024.
https://www.dhhs.nh.gov/news-and-media/nh-dhhs-identifies-person-infected-eastern-equine-encephalitis-virus-new-hampshire
2. State health officials announce season’s first human case of Eastern Equine Encephalitis in Massachusetts. MDPH. August 16, 2024. Accessed August 27, 2024.
https://www.mass.gov/news/state-health-officials-announce-seasons-first-human-case-of-eastern-equine-encephalitis-in-massachusetts
3.Plymouth to Close all Public Parks and Fields from Dusk to Dawn. Town of Plymouth. August 23, 2024. Accessed August 27, 2024. PDF.
4. Eastern Equine Encephalitis: Symptoms, Diagnosis, and Treatment. CDC. May 15, 2024. Accessed August 27, 2024.
https://www.cdc.gov/eastern-equine-encephalitis/symptoms-diagnosis-treatment/index.html
5. State officials announce plans to spray for mosquitoes in sections of Worcester and Plymouth counties due to EEE. MDPH. August 24, 2024. Accessed August 27, 2024. 
https://www.mass.gov/news/state-officials-announce-plans-to-spray-for-mosquitoes-in-sections-of-worcester-and-plymouth-counties-due-to-eee



The town of Plymouth decided to prohibit people from using the parks from dusk to dawn due to concerns over eastern equine encephalitis after a man contracted the rare disease in the state.

Concerns Over Mosquito-Borne Illness Causes Massachusetts Town to Create Curfew for Parks, Spraying in Counties

MeMed CEO Eran Eden, PhD, discusses the MeMed BV test and how it can help make the distinction between the types of infections, 

From Pathogen to Infectious Disease Diagnosis: 

One of the ongoing treatment challenges for providers is the ability to determine whether infections are bacterial or viral. Their presentation can be similar, and traditional testing can be time-consuming. Of course, clinicians want to be sure patients are receiving some type of intervention, so broad-spectrum antibiotics can often be prescribed in these cases.

“It [the MeMed BV test] tries to solve the following seemingly simple problem: A patient, a kid or adult, comes to urgent care or to an ED [emergency department] with a suspected acute infection. Broadly, we're trying to discern the etiologies of a bacterial or viral infection. Do we treat or not treat with antibiotics?” said MeMed's cofounder and CEO, Eran Eden, PhD.

Eden’s company developed a novel assay, the MeMed BV test, that can distinguish between bacterial and viral infections in 15 minutes. The test received a US Food and Drug Administration 510(k) clearance in 2023 and also has the European CE mark.



Eden says the test itself is a blood test that measures 3 proteins and integrates them into a score. “They are measured and then computationally integrated into a score between 0 and 100; the higher the score, the higher the likelihood of a bacterial infection.” 

MeMed shared results of 3 studies of the MeMed BV test, which demonstrated the following:

63% reduction in unnecessary antibiotic prescriptions (real-world study of 3920 patients)

70% of previously missed bacterial infections correctly identified, leading to significantly fewer hospitalizations (7.8% vs 30.3%)

Outperformance of standard biomarkers such as procalcitonin in distinguishing bacterial vs viral infections

Lower health care costs, especially in managing community-acquired pneumonia


Eden mentions the multiple challenges of pathogen testing. “The first is that even if you use a multiplex PCR [polymerase chain reaction], you're only going to put your hands on a microorganism in 30 to 40% of the cases; [in] 60% of the cases, there is no microorganism, and you still have to treat, so that's one gap we're trying to solve,” Eden said. “The second thing is inaccessible infections. So you can apply, say, a SARS-CoV-2 or strep [

test in cases of pharyngitis. But what about otitis, bronchitis, and pneumonia? The immune system circulates throughout the entire body, so it allows you to identify these infections or the source of infection in these inaccessible infection sites. Third is the issue of colonization. So let's say you identify a virus or bacteria. Some of them have very high prevalence, especially in kids, so mere detection does not apply causality, which is confusing, leading to overuse and underuse of antibiotics. Another element here is the element of superinfections. So you identify an influenza. There's about 10% to 20% probability of bacterial superinfection on top of that. So all these elements and obviously time—you want to get results fast—it's taking this simple problem and making it really hard to discern in real time.” 

He says these factors lead to uncertainty about the nature of the infection and that they are trying to reduce that with the use of this newer generation of screening tools. He says screening can greatly aid in antibiotic stewardship and address the global issue of antimicrobial resistance.

“When you talk about reduction of overuse, I would like to maybe broaden the discussion to say it's both…depending on the overprescribed or nonbacterial infection for which it does not provide any benefit,” Eden said. “But there's also an element of underuse where you should prescribe and you're not prescribing…. The BV test has started to show utility in reducing this uncertainty, reducing overuse of antibiotics but at the same time doing it in a safe manner [and] also reducing cases where there are missed bacterial infections.”



References
1. MeMed BV test demonstrates antibiotic overuse reduction in first US interventional trial. News release. MeMed. September 30, 2024. Accessed September 30, 2024. 

https://www.prnewswire.com/news-releases/memed-bv-test-demonstrates-antibiotic-overuse-reduction-in-first-us-interventional-trial-302260001.html


2. MeMed BV proven to optimize antibiotic use, outperform standard care, and cut costs in new studies. News release. MeMed. February 27, 2025. Accessed April 11, 2025.
https://www.me-med.com/press_release/memed-bv-proven-to-optimize-antibiotic-use-outperform-standard-care-and-cut-costs-in-new-studies/



MeMed CEO Eran Eden, PhD, discusses the MeMed BV test and how it can help make the distinction between the types of infections, aid in patient management, and reduce antimicrobial resistance.

From Pathogen to Infectious Disease Diagnosis: Test Determines Between Bacterial and Viral Infections in 15 Minutes

In our latest From Pathogen to Infectious Disease Diagnosis podcast, bioMérieux Chief Medical Officer Chuck Cooper, MD, discusses the burden of resistance, and insights on the company’s novel Vitek Compact Pro ID/AST system.

Can Diagnostics Aid in Alleviating Antimicrobial Resistance and Sepsis? 

Antimicrobial resistance (AMR) continues to be an increasingly significant public health issue, leading to higher mortality rates. Findings from one study estimated that bacterial AMR was directly responsible for 1.27 million global deaths in 2019 and contributed to 4.95 million deaths.

Untreated or undertreated bacterial infections are a major cause of sepsis, a serious complication that places a significant burden on hospitalized patients. The Centers for Disease Control and Prevention estimates that 1.7 million adults in the US develop sepsis each year. In terms of mortality, the agency reports that at least 350,000 adults who develop sepsis die during hospitalization or are discharged to hospice. Additionally, 1 in 3 people who die in the hospital had sepsis.

Chuck Cooper, MD, chief medical officer at bioMérieux, highlights the urgency of timely diagnosis and treatment.

“Every hour of delay in getting patients on effective therapy dramatically increases their mortality,” Cooper said.

“The challenge with antimicrobial resistance is that it compromises our ability to treat sepsis effectively, because it limits the options from an antimicrobial therapeutic perspective and it makes it more difficult to get patients on the right therapy as quickly as possible,” Cooper said. “So it's critically important for clinicians to receive accurate, rapid information about the antimicrobials that will work for an infection so that they can treat patients with the effective therapy as soon as possible.”

To address resistance—and by extension, sepsis—bioMérieux has developed a diagnostic platform designed to efficiently and quickly identify infectious diseases. Earlier this year, the US Food and Drug Administration cleared bioMérieux’s Vitek Compact Pro ID/AST system for microorganism identification (ID) and antibiotic susceptibility testing (AST). This system is intended to support clinical laboratories in identifying infectious diseases and combating AMR and for use in industrial laboratories to identify contaminants and ensure consumer safety.

“The Vitek Compact Pro provides both microorganism identification and antibiotic susceptibility testing results. This is essential for helping laboratories diagnose infectious diseases and combat resistance,” Cooper said.

The Vitek Compact Pro ID/AST system combines new diagnostic technology with features from its predecessor, the Vitek 2 Compact. With an ergonomically advanced design and simplified workflow, it enhances the user experience and boosts efficiency, reducing the time laboratory technicians need to spend on sample loading and processing.

“It has a very intuitive user interface with guided workflow steps. This leads to a faster, more streamlined hands-on process before loading cassettes into the instrument, significantly reducing hands-on time,” Cooper added.

For industrial applications, the system will be used for the routine identification of pathogens to help ensure the quality and safety of food, pharmaceutical, and cosmetic products.

The commercial launch of the Vitek Compact Pro is planned in select countries, with a global rollout beginning this quarter.

1. Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. 

. 2022;399(10325):629-655.
2. About sepsis. Centers for Disease Control and Prevention. March 8, 2024. Accessed May 16, 2025. https://www.cdc.gov/sepsis/about/index.html
3. bioMérieux receives FDA 510(k) clearance for its Vitek Compact Pro, a new ID/AST system to fight against antimicrobial resistance. Press release. bioMérieux. March 18, 2025. Accessed May 16, 2025. 

https://www.biomerieux.com/corp/en/journalists/press-releases/vitek-compact-pro-fda-clearance-antimicrobial-resistance.html

In our latest From Pathogen to Infectious Disease Diagnosis podcast, bioMérieux Chief Medical Officer Chuck Cooper, MD, discusses the burden of resistance and insights on the company’s novel Vitek Compact Pro ID/AST system, which looks to identify infectious disease in a timely manner and aid clinicians in diagnosing patients, streamlining antimicrobial treatment, and avoiding severe complications such as sepsis. 

In our latest podcast, Tim Gauthier, PharmD, BCPS, BCIDP, discusses his passion for all things pathogens and antibiotics.  He also details the opportunities for antimicrobial stewardship when it combines diagnostics and treatment duration. 

A Passion for Infectious Disease Education and Communication

Tim Gauthier, PharmD, BCPS, BCIDP, began his career in academia, and although he has transitioned to working in a health system, he has never left behind his passion for education about pathogens, antibiotics, and stewardship. He has 2 websites, 

, on these topics, and it has allowed him to continue communicating and educating people globally on these infectious disease subjects.

“I love this stuff so much, genuinely. I have a website called ID Stewardship, and many people are familiar with my work and my reach through that avenue, where it's been supercool to connect with people from all over the world and help people learn about antibiotics,” Gauthier said.

This website has reached millions of people since he first launched it in 2016, and he says it has allowed him to talk about his experiences in the field.

“It's really geared toward practical, real-life experience and suggestions about how to go about navigating something. It could be anything in the field of clinical pharmacy or infectious diseases, antimicrobial stewardship, or pharmacy education. And the goal is to provide quick information that is useful and practical for the reader,” Gauthier explained.

He reminds people that everyone learns differently and that having resources such as websites can be helpful for young learners as they begin to digest the voluminous amounts of educational materials they need to commit to memory.

For years, Gauthier has been communicating with the masses through social media, especially using X, formerly known as Twitter, and building a large audience through it. “I think it's been pretty neat to provide education in that forum too,” Gauthier said.

He sees the changes in social media today, and as many people in the infectious disease community have steered away from the X platform, Gauthier still uses it and acknowledges how it has evolved.

“I've been a content creator for infectious diseases education material for almost a decade, and it just changes,” Gauthier said. “So Instagram becomes more popular as Facebook pages become less popular, or TikTok gains traction and then TikTok loses traction. It's always changing, and it's always evolving. You always have to—in my mind at least—go back to, why am I here? What is my purpose? What am I doing? And if what you're engaging in aligns with what your purpose is, then you're probably fine…. I don't feel great about X. I go on my profile, and I just see content that I'm not interested in. It's supertoxic, and I don't feel good about being part of that community right now. I’m keeping an eye on it and trying to maybe have a voice to some degree, because if we don't have a voice, someone will be happy to speak for us.” 

He also mentions the importance of staying professional on these platforms, and he values the importance of taking the time to reach out, whether it is remotely through digital means or connecting in person with professionals in the infectious disease field or other fields at institutions, including the laboratory.

“Respect for all individuals is something that we need to keep front of mind as we go through these very turbulent times and consider using social media or not,” Gauthier said. “That's one of my biggest things…as I'm looking around. The other thing is, we can get a lot of happiness out of working together. I really do believe that, and we should not hesitate to reach out and make connections with each other. If you haven't talked to your ID [infectious diseases] pharmacist or if you haven't spoken to your microbiology laboratory folks, just go visit them.” 

Although Gauthier is excited to see some new antibiotics approved by the US Food and Drug Administration, he does acknowledge they will not likely replace the older, more established “workhorse” antibiotics. Resistance is always a concern, and he is seeing extended-spectrum β-lactamase (ESBL) 

 where he lives. Nonetheless, he sees a stewardship opportunity in these situations that combines shorter courses of antibiotics with help from the laboratory.

“When we look at the latest CDC [Centers for Disease Control and Prevention] report that they had put out, ESBLs are on the upward trend. And locally in the Miami area, many of the hospitals here have considerable rates of ESBL 

,” he explained. “And you know what comes next? You probably use more carbapenems. OK, use more carbapenems. What happens? You get more carbapenem resistance. That is the major issue right now that I'm seeing. I think people need to be aware of managing asymptomatic bacteria appropriately, picking shorter courses of antibiotics, and, when reasonable, de-escalating and narrowing within 48 to 72 hours, utilizing and leveraging the data that are coming out of the laboratory to make those decisions faster and smarter.”

, and much like other areas, Gauthier is seeing this mostly in patients in long-term care with chronic conditions and comorbidities.

“There are definitely more patients with bloodstream infections with 

 than I would have liked to have seen in my life. And of course, the drug resistance that comes with 

 is particularly concerning,” he said. “Although I would say that hospitals that have highly complex patients who have histories of solid organ transplant, for example, or many days and months in the ICU [intensive care unit] are probably going to be battling this much more.”



Disclaimer: The views and opinions expressed represent those of the speaker and do not necessarily reflect the official position or policy of any previous, current, or potential future employer.

In our latest podcast, Tim Gauthier, PharmD, BCPS, BCIDP, discusses all things pathogens and antibiotics. He also details the opportunities presented for antimicrobial stewardship when it combines diagnostics and treatment duration. 

A Passion for Infectious Disease Education and Communication 

In the second part of an interview with Andrea Prinzi, PhD, MPH, SM(ASCP), she talks about the significance of how that foundation played such a significant role against the disease as well as the remain hurdles to its eradication and how polio’s vaccine are a lesson applied to medical science. 

What We Can Learn From Polio

In 1938, President Franklin D. Roosevelt founded the National Foundation for Infantile Paralysis, the name of which he later changed to the March of Dimes Foundation. Roosevelt, himself experiencing paralysis from polio as an adult, became deeply involved in this cause.

 He experienced paralysis in 1921 at the age of 39 years as a result of polio.

With the creation of the foundation, Andrea Prinzi, PhD, MPH, SM(ASCP), field medical director of US medical affairs in clinical and translational science at bioMérieux, says Roosevelt came up with a unique plea that was designed to apply to all Americans. 

“He said every single person in the country, no matter what your status or your wealth, can donate one dime to this cause, and everybody felt like they could relate to that,” Prinzi says. “It reached people who maybe had been excluded from conversations before or people who didn't come from wealth and didn't feel like they could make a donation toward the cause." 

This was a novel way to increase philanthropy that is still being used today, with people giving what they can to causes.

Prinzi says this mobilized the fundraising, and people were sending dimes to the White House. With these monies raised, it helped fund the work of Jonas Salk, MD, who developed his polio vaccine.

“There were a lot of other things that came from this. The power of unifying behind a single cause and getting the public to have a shared responsibility for the wellness of the whole of people. It was also that polio was very, very frightening for people and impacting children heavily. So there's a lot of emotion tied [to] children—a lot more mobilization there. You also had a lot of public figures and celebrities getting behind this cause as well, which was really helpful."

Today, there are only 2 countries in the world where polio is endemic: Pakistan and Afghanistan.

 Although these countries are still dealing with polio, Prinzi says the progress made throughout the rest of the world has come to the point where most countries do not have to think about it and that what has happened in recent years is cases of vaccine-derived polio.

“In some cases, very rarely, but in cases, it can mutate to end up causing paralysis or severe disease in people who come in contact with that, and this is specifically true for the type 2 vaccine–derived polio virus,” Prinzi says. “It's responsible for greater than 90% of cases when this occurs.... Work has been done to develop vaccines that address that type of polio virus…. A vaccine was authorized by [the] World Health Organization that essentially makes the type 2 vaccine–derived polio virus less likely to mutate into something that can cause serious disease.”

She says this is a good example of the evolution of science and making changes to adapt to differing circumstances. This is the reality compared with what some in the public believe, which is that science is supposed to be perfect from the beginning. This can certainly be seen as a good example as it relates to COVID-19 public health policy and the vaccines.

“There's likely, very rarely, one single answer to a problem, and the public has to remember that things change and adapt, and we change and adapt and learn with those things, and then hopefully we evolve our science to match that,” Prinzi said. “That's something that I think has gotten a little lost on the public in recent years. We expect science to be perfect all the time and fix the problem right away, and that's just not really how these things work."



In the next installment of this series, we will discuss Roosevelt’s battle with polio and how he did not let the disease prevent him from living his life, including becoming president. 

References
1. Franklin Roosevelt founds March of Dimes. History. Updated May 27, 2025. Accessed July 28, 2025. https://www.history.com/this-day-in-history/january-3/franklin-roosevelt-founds-march-of-dimes
2. Poliomyelitis. World Health Organization. Accessed July 28, 2025.
https://www.who.int/health-topics/poliomyelitis

In the second part of an interview with Andrea Prinzi, PhD, MPH, SM(ASCP), she talks about how the March of Dimes played such a significant role against the disease, how the polio oral vaccine is a singular lesson that can be applied to medical science as a whole, and the understanding of the need to adapt to changing circumstances. 

What We Can Learn From Polio and Its Vaccines

Andrea Prinzi, PhD, MPH, SM(ASCP), provides insights on these areas and in part 1 of a 2 part interview, she discusses how polio cases rose and the severity of it, as well as Jonas Salk’s approach to his vaccine’s development of the debilitating and deadly disease.

Polio: Reviewing its History and the Development of its Vaccine 

Polio is an ancient disease with limited evidence of its existence throughout antiquity. It was not until the late 19th century that the disease became well-documented.

An increase in polio cases coincided with the emergence of the Industrial Age and the transition of people moving from mostly rural, farming environments to cities. This led to more people living closer together and the potential for greater transmission. And paradoxically, the increase of sanitation strategies that came about during this period led to more polio cases, explains Andrea Prinzi, PhD, MPH, SM(ASCP).

“There was this level of protection that was occurring in areas where there weren't the best hygiene or sanitary conditions,” says Prinzi of the agrarian society. “There were areas where there was this level of protection, particularly among parents of young children. They were passing some level of protection to their children by having been exposed to the virus, either through breast milk or carriage of the infant or fetus. There was protection that was happening, and then when everything got really clean, some of that protection was actually lost. Cases started to spike. It's this really strange example of where we saw sanitary improvements contributing to new cases of infection.”

Prinzi is the field medical director of US medical affairs in clinical and translational science at bioMérieux, and she examined this subject in an article she wrote for the American Society for Microbiology in the past year titled “

Polio's Last Stand: The Global Fight for Eradication

.” The article details polio's history as well as the more recent initiatives to rid the world of the disease.

Jonas Salk, MD, is well-known as the creator of one of the polio vaccines. What may not be as well-known is how he was very different in the way he worked and his approach to vaccine development.

In terms of how he worked, Prinzi says he worked with a small team without the backing of the pharmaceutical industry. However, she says he did have some government funding, which ruffled the feathers of a contemporary, Albert Sabin, MD, who was the creator of the oral polio vaccine.

Prinzi says Salk took a divergent path from the existing line of scientific work being done at that time because he looked to develop an inactivated polio vaccine instead of trying to develop a vaccine with a live virus, the attenuated immunization, like Sabin was working on.

“He [Salk] had a lot of reservations around using something that was a live attenuated virus, even though that was what a lot of the research was being focused on at the time,” Prinzi says. "According to the academic and research community, he was going outside the box. He was doing things his own way, being nontraditional, which they didn't really love. And he even said at one point that he just marches to the beat of his own drummer.”

Vaccine Testing, Losing Public Trust, and Vaccine Hesitancy

Both Salk and Sabin’s testing methods for their polio vaccination were questionable. Salk and Sabin tested the vaccines on themselves, their families, and marginalized populations such as children with disabilities and incarcerated individuals. 

“A lot of ethics review material came from the polio saga,” she says.

Andrea Prinzi, PhD, MPH, SM(ASCP), provides insights on how polio cases rose despite sanitation and hygiene improving as well as Jonas Salk’s and Albert Sabin's approaches to their vaccines' development.

Konrad Reinhart, MD

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