DOCSLIB.ORG

Let's Get Clinical

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Let's Get Clinical 10/21/19 1 Let’s Get Clinical: Addressing Metabolic Disease Functionally Melody L. Hartzler, PharmD, BCACP, BC-ADM Clinical Pharmacist, Western Medicine Family Physicians CEO, PharmToTable, LLC Associate Professor of Pharmacy Practice, Cedarville University School of Pharmacy 2 1 10/21/19 Disclosure There are no relevant financial relationshiPs with ACCME- defined commercial interests for anyone who was in control of the content of the activity. 3 Pharmacist and Pharmacy Technician Learning Objectives • Summarize the relationshiP between gut health and metabolic disease • Outline imPortant suPPlements for consideration in diabetic and Pre-diabetic populations • Identify the role of stress in diabetes and adrenal dysregulation 4 2 10/21/19 THIS SESSION WILL BE UTILIZING AUDIENCE POLLING SOFTWARE Please go to MEET.PS/CLINICAL to answer poll questions 5 Case: Mary • Mary is a 55 year old Caucasian female Presenting to your Pharmacist-run metabolic syndrome clinic • Here today to discuss her “diagnosis” of Prediabetes • Past medical history • SePsis 12 months ago (hospitalized for 2 weeks) • HTN • born via C-section • bottle fed with formula • frequent infections as a child 6 3 10/21/19 Case: Mary • Current History of Present Illness • Fatigue • Frequent yeast infections • Sedentary Lifestyle (works 8-10 hour days at a desk) • High stress job • TyPically follows a moderate intake of carbohydrate diet due to family history of diabetes • ConstiPation/Flatulence/Periodic Abdominal Pain 7 Case: Mary • Discuss with the Person next to you what your apProach for Mary would be today. 8 4 10/21/19 WHAT IS FUNCTIONAL MEDICINE? 9 Functional Medicine •Functional Medicine is a personalized, systems- oriented model that emPowers Patients and practitioners to achieve the highest expression of health by working in collaboration to address the underlying causes of disease. Jones D, Quinn S. Introduction to FM. 2014 10 5 10/21/19 7 Core Principles of FM • Acknowledging the biochemical individuality of each human being, based on concePts of genetic and environmental uniqueness • IncorPorating a Patient-centered aPProach to treatment • Seeking a dynamic balance among the internal and external factors in a patient’s body, mind, and spirit • Addressing the web-like interconnections of internal Physiological factors Jones D, Quinn S. Introduction to FM. 2014 11 7 Core Principles of FM • Identifying health as a Positive vitality—not merely the absence of disease—and emphasizing those factors that encourage a vigorous physiology • Promoting organ reserve as a means of enhancing the health span • Functional Medicine is a science-using profession Jones D, Quinn S. Introduction to FM. 2014 12 6 10/21/19 Nutrition Sedentary Aging Population Lifestyles Chronic Indoor Living Chronic Stress (Vitamin D) Disease Epidemic Fragmented Families & Poverty Communities Environmental Toxicity AdaPted from Jones D, Quinn S. Introduction to FM. 2014 13 One Condition Many Imbalances Inflammation Hormones Genetics and Epigenetics Diet and Exercise Mood Disorders Obesity AdaPted from Jones D, Quinn S. Introduction to FM. 2014 14 7 10/21/19 One Imbalance Heart Disease Many Conditions Diabetes Depression Inflammation Cancer Arthritis AdaPted from Jones D, Quinn S. Introduction to FM. 2014 15 Functional Strategies for Improving Cardiometabolic Resilience • Decrease central adiPosity • ImProve periPheral insulin sensitivity • Reduce inflammatory signaling • Reduce circulating free fatty acids • ImProve aPProPriate incretin signaling • Modulate inaPProPriate HPA-axis regulation & cortisol burden • Maintain/imProve kidney metabolic caPacity • Maintain circadian alignment Guilliams, T. Cardiometabolic Risk Management: A Functional and Lifestyle APProach. The Standard Road Map Series. Pointe Institute 2018. 16 8 10/21/19 Functional Strategies for Improving Cardiometabolic Resilience • Protect/imProve Pancreatic beta cell function • Reduce Post-prandial hyperinsulinemia (reduce meal impact) • Reduce liPoProtein atherogenicity • ImProve endothelial function • Reduce glycation and formation of accumulation AGEs • Modulate/balance coagulation caPacity • ImProve mitochondrial efficiency • Reduce oxidative burden • Restore metabolically-favorable gut microbiota Guilliams, T. Cardiometabolic Risk Management: A Functional and Lifestyle APProach. The Standard Road Map Series. Pointe Institute 2018. 17 Functional medicine approaches to address the underlying causes of metabolic disease • Address gut dysfunction • Improve insulin sensitivity • SuPPlements • Exercise (Enhances uPtake of glucose by Dr. Hartzler’s Peripheral tissues, DPP Trial) DM Protocol! • Diet • Address stress • Consider anti-inflammatory/cardiac risk reduction suPPlementation 18 9 10/21/19 Toxicities Related to Diabetes •Mercury exPosure1 •Persistent organic Pollutants2 1. He K, et al. Diabetes Care. 2013 Jun;36(6):1584-9 2. Lee D, et al. Diabetes Care. 2006;29(7):1638-1644 19 Egregious Eleven: defects present in diabetes and prediabetes AGI, alPha glucosidase inhibitor; GLP-1, glucagon-like PePtide 1; QR, quick release; TZDs, thiazolidinediones © 2016 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. Schwartz SS, Epstein S, Corkey BE, et al. The Time Is Right for a New Classification System for Diabetes: Rationale and Implications of the β-Cell–Centric Classification Schema. Diabetes Care Feb 2016, 39 (2) 179-186; DOI: 10.2337/dc15- 1585 20 10 10/21/19 Case: Mary • Mary is a 55 year old Caucasian female presenting to your Pharmacist-run metabolic syndrome clinic • She is here today to discuss her “diagnosis” of prediabetes • Past medical history • sePsis 12 months ago (hospitalized for 2 weeks) • HTN • born via C-section • bottle fed with formula • frequent infections as a child 21 Case: Mary • Current HPI • Fatigue • Frequent yeast infections • Sedentary Lifestyle (works 8-10 hour days at a desk) • High stress job • TyPically follows a moderate intake of carbohydrate diet due to family history of diabetes • ConstiPation/Flatulence/Periodic Abdominal Pain 22 11 10/21/19 Please go to MEET.PS/CLINICAL to answer Poll questions! 23 24 12 10/21/19 "All Disease Begins In The Gut." -Hippocrates METABOLIC DISEASE & THE GUT 26 Metabolic Syndrome • Metabolic syndrome is 3 of the following: • Increased waist circumference (>40 inches men, 35 women) • Elevated TG (>150 mg/dL) • Elevated BP (>130/80) • Elevated glucose • Low HDL-C (<40 mg/dL in men, <50 mg/dL in women) NCEP IV 2018 J Am Coll Cardiol. Nov 2018; DOI: 10.1016/j.jacc.2018.11.003 27 13 10/21/19 Metabolic Continuum & Type 2 Diabetes RePrinted with Permission: Figure 25. Guilliams, T. Cardiometabolic Risk Management: A Functional and Lifestyle Approach. The Standard Road Map Series. Pointe Institute 2018. 28 Insulin Resistance & CVD RePrinted with Permission: Figure 4. Guilliams, T. Cardiometabolic Risk Management: A Functional and Lifestyle Approach. The Standard Road Map Series. Pointe Institute 2018. 29 14 10/21/19 GIT Microbiome… an endocrine organ? Roles: Food - Carbohydrate digestion Intake - Hormone synthesis - Neurotransmitter production - Vitamin synthesis - Immune response modulation - Inflammatory response modulation Metabolism Energy GUT-BRAIN Homeostasis AXIS Galland L. J Med Food. 2014;17(12):1261-1272 Brown JM, et al. Annu Rev Med. 2015;66:343–359. 30 Metabolic Disease and the Gut- SCFAs • Short-chain fatty acids (SCFAs) are Produced by the fermentation of bacteria, when the bacteria in the colon metabolize Proteins and complex carbohydrates. • These SCFAs may decrease the risk of develoPing metabolic disorders due to the increasing demand of cholesterol for de novo synthesis of bile acids • SCFA Provide a direct energy source for colonocytes and as signaling molecules that influence ePigenetics Yoo JY et al. Nutrients. 2016 Mar; 8(3): 173. 31 15 10/21/19 Metabolic Disease and the Gut- SCFAs • SCFAs also are signaling molecules that Produce metabolic and satiety signaling comPounds such as: • Glucogon-like-pePtide-1 (GLP-1) • PePtide YY • SCFA can modulate insulin-signaling in adiPose tissue, Preventing fat accumulation. 1. Samuel BS et al. Pro Natl Acad Sci USA. 2008 Oct 28;105(43):16767-72. 2. Bolognini D, et al. Mol Pharmacol. 2016 Mar;89(3):388-98. 3. KimuraI et al. Nat Commun. 2013; 4:1829. 32 Metabolic Disease and the Gut- Microbiome Composition • Many persons with diabetes may be deficient in a sPecific gut microbe, bifidobacteria.1 • Having an imbalance of gut microbes can increase gut permeability and allow for infiltration of inflammatory signals which can cause damage to the Pancreas and contribute to the development of diabetes. 1. Gomes A, Bueno A, de Souza R, Mota J. Gut microbiota, Probiotics and diabetes. Nutr J. 2014;13:60. doi: 10.1186/1475-2891-13-60 33 16 10/21/19 Metabolic Disease and the Gut Microbiome & Immune Activation • LiPopolysaccharide (LPS) • Highly studied comPonent of gram-negative bacteria • Stimulates immunological responses • Stimulates Production of numerous inflammatory mediators • Leads to intestinal Permeability & chronic inflammation Creely SJ, et al. Am J Physiol Endrocrinol Metab. 2007 Mar; 292(3):E740-7. 34 Metabolic Disease and the Gut Microbiome & Immune Activation • This deficiency of bifidobacteria has been shown to result in increased translocation of bacterial liPopolysaccharide (LPS)9 which is thought to be a contributor to develoPment of insulin resistance.1 • SuPPlementation with
Load more

Recommended publications
  • Personal Protective Equipment ______
    Personal Protective Equipment __________________________________________________________________ Page Introduction Purpose ………. 2 Background ………. 2 Who’s Covered? …….... 3 Explanation of Key Terms ………. 3 How It Works Hazard Assessment ………. 4 Hazard Control ………. 5 Training ………. 5 Documentation ………. 6 Appendix A – Hazard Assessment/Training Certification Form ………. 7 B – Personal Protective Equipment (PPE) Guidelines ………. 8 University of Arizona Risk Management & Safety Health and Safety Instruction April 2007 ________________________________ Page 2 Health and Safety Instruction ______________________________________________________________________ INTRODUCTION Purpose The purpose of this Health and Safety Instruction (HSI) is to protect employees from hazards in the workplace by using personal protective equipment to supplement other primary hazard controls. Background Hazards exist in every workplace in many different forms: sharp edges, falling objects, flying sparks, chemicals, noise and a myriad of other potentially dangerous situations. Controlling hazards with engineering and administrative controls is the best way to protect employees When these controls are not feasible or do not provide sufficient protection, personal protective equipment (PPE) must be use. In line with this rational for controlling or eliminating workplace hazards, the Occupational Safety and Health Administration (OSHA) issued the Personal Protective Equipment standard, also know as "The PPE Standard." Under this standard, the University is required to: • Conduct hazard assessments to determine if PPE is necessary to protect employees and certify in writing that assessments have been performed. • Select appropriate PPE, where necessary. • Provide employees training on proper care, use and limitations of the selected PPE. • Ensure the PPE is properly used. This HSI, developed by Risk Management & Safety outlines the minimum requirements to protect employees from hazards in the workplace by using personal protective equipment to supplement other primary hazard controls.
    [Show full text]
  • Risk Management for a Small Business Participant Guide
    Risk Management for a Small Business Participant Guide Table of Contents Welcome ................................................................................................................................................................................. 3 What Do You Know? Risk Management for a Small Business ........................................................................................ 4 Pre-Test .................................................................................................................................................................................. 5 Risk Management ................................................................................................................................................................. 6 Discussion Point #1: Risks from Positive Situations .......................................................................................................... 6 Internal Risks ........................................................................................................................................................................ 6 Discussion Point #2: Internal Risks ..................................................................................................................................... 8 External Risks ....................................................................................................................................................................... 8 Discussion Point #3: External Risks ...................................................................................................................................
    [Show full text]
  • Hot Work Permit Program
    Hot Work Permit Program Risk Management 1 Hot Work Permit Program Risk Management July 2019 Table of Contents I. Program Goals and Objectives ...................................................................................................................3 II. Scope and Application ................................................................................................................................3 III. Definitions ..................................................................................................................................................3 IV. Responsibilities ...........................................................................................................................................4 V. Record Keeping ..........................................................................................................................................4 VI. Procedures .................................................................................................................................................5 VII. Hot Work Permit Form ...............................................................................................................................8 VIII. Regulatory Authority and Related Information .........................................................................................9 IX. Contact .......................................................................................................................................................9 2 Hot Work Permit Program Risk Management
    [Show full text]
  • Guide Six Steps to Risk Management
    Guide Six step to risk management www.worksafe.nt.gov.au Disclaimer This publication contains information regarding work health and safety. It includes some of your obligations under the Work Health and Safety (National Uniform Legislation) Act – the WHS Act – that NT WorkSafe administers. The information provided is a guide only and must be read in conjunction with the appropriate legislation to ensure you understand and comply with your legal obligations. Acknowledgement This guide is based on material produced by WorkSafe ACT at www.worksafe.act.gov.au Version: 1.2 Publish date: September 2018 Contents Introduction ..............................................................................................................................4 Good management practice.....................................................................................................4 Defining Hazard and Risk.....................................................................................................5 Systematic approach to the management of Hazards and associated Risks ......................5 Step 1: Hazard identification ....................................................................................................6 Examples of Hazards ...........................................................................................................6 Step 2: Risk identification.........................................................................................................7 Examples of risk identification ..............................................................................................7
    [Show full text]
  • Permit to Work Systems
    Loss prevention standards Permit to Work Systems High risk work can become even more hazardous due to unsafe conditions and human error. Formal controls, such as a permit to work system, must be followed by everyone and enforced properly to be effective. Aviva: Public Permit to Work Systems Introduction The aim of a permit to work system is to remove both unsafe conditions and human error from a high-risk process, by imposing a formal system detailing exactly what work is to be done and when and how to undertake the job safely. Permit to work systems are used where the potential hazards are significant and a formal documented system is required to control the work and minimise the risk of personal injury, loss or damage. Operation of the Permit to Work System Examples of work in which a permit to work system should be used include: • Entry into confined spaces • Work involving the splitting or breaking into of pressurised pipelines • Work on high voltage electrical systems above 3,000 volts • Hot work, e.g. welding, brazing, soldering, etc. • Work in isolated situations or where access is difficult • Work at height • Work near to, or requiring the use of highly flammable/explosive/toxic substances • Fumigation operations using gases • High-risk operations involving contractors, such as excavation works, or demolition works Designing the Permit to Work System Permit to work systems demand robust, formal and effective controls in place to prevent danger, as well as good standards of organisation to ensure compliance. - include fire extinguishers being available for hot work, or harnesses and resuscitation equipment available when entering confined spaces.
    [Show full text]
  • Personal Protective Equipment
    2019 Personal Protective Equipment Program INJURY ILLNESS PREVENTION PROGRAM CAL MARITIME| 200 Maritime Academy Vallejo, CA 94590 Personal Protective Equipment Program (PPE) This sheet should be completed each time the Personal Protective Equipment Program is reviewed and/or modified. The Director of Safety and Risk Management is responsible for the review and update this document annually or more frequently as determined or needed per CSU Chancellor’s Executive Order 1039 Occupational Health and Safety Policy, 1069 Risk Management as well as Cal Maritime A&F Policy 09-004 IIPP. Version Date Approved Author Revision Notes: Marianne Spotorno, CSP 1.0 04/01/2018 New Program Document Dir. Safety & Risk Management Marianne Spotorno, CSP 08/01/2019 • Campus Emergency Response update. 2.0 Dir. Safety & Risk Management • TSGB component update Electronically Controlled. Latest revision is in the Document Management System. A printed copy is uncontrolled and may be outdated unless it bears a red ink “controlled copy” stamp. Cal Maritime Document # 09-04023 Injury Illness Prevention Program Page 1 of 57 Department of Safety & Risk Management Revision: 002 Personal Protective Equipment Program (PPE) Table of Contents 1.0 Purpose & Scope .................................................................................................................................................................................... 4 1.1 Regulatory Standards Reference ...................................................................................................................................................
    [Show full text]
  • Lockout/Tagout Compliance Guide and Checklist
    Lockout/Tagout Compliance Guide and Checklist Scope: The OSHA Control of Hazardous Energy (Lockout/Tagout) standard (29 CFR 1910.147) covers the servicing and maintenance of machines and equipment in which the unexpected energization or start up of the machines or equipment or release of stored energy could cause injury to employees. Energy sources may include: electrical, mechanical, hydraulic, pneumatic, chemical, nuclear, thermal or other energy. Application: This standard applies to the control of energy during servicing and/or maintenance of machines or equipment. Normal production operations are not covered by this standard. Servicing and/or maintenance which takes place during normal production operations is covered by this standard if: 1. An employee is required to remove or bypass a guard or other safety device; or 2. An employee is required to place any part of his or her body into an area on a machine or piece of equipment where work is actually performed upon the material being processed (point of operation) or where an associated danger zone exists during a machine operating cycle. Applications not covered: Minor tool changes and adjustments which take place during normal production operations are not covered by the standard if they are routine, repetitive and integral to the use of the equipment for production, provided that the work is performed using alternative measure which provide effective protection. D Cord and plug connected electrical equipment when the employee performing the service or maintenance controls energization by unplugging the equipment from the energy source. D Hot tap operations involving transmission systems from substances such as gas, steam, water or petroleum, when they are performed on pressurized pipelines.
    [Show full text]
  • Personal Protective Equipment Program
    Personal Protective Equipment Program Risk Management Services Table of Contents I. Program Goals and Objectives .............................................................................................................. 2 II. Scope and Application........................................................................................................................... 2 III. Responsibilities ..................................................................................................................................... 2 IV. Procedures ............................................................................................................................................ 3 V. Training ................................................................................................................................................. 5 VI. Regulatory Authority and Related Information .................................................................................... 5 VII. Contact .................................................................................................................................................. 5 1 Personal Protective Equipment Program Risk Management January 2016 I. Program Goals and Objectives Northwestern University requires all employees to use appropriate personal protective equipment (including eye, face, foot, hand and head protection) when deemed necessary. Departments shall determine and document required personal protective equipment (PPE) through the completion of a PPE Hazard Assessment.
    [Show full text]
  • Risk Management Checklist
    Risk Management United States Department of Agriculture Risk Management Agency Checklist Print out this checklist. Answer yes or no to the following questions. Review your answers with your family and/or your business team and employees. You may identify some risk exposure. On the other hand, you may find that you are protected against risk enough so that you have the resources to explore some new venture. If you do not know all the dates in the “Deadlines” section, you should contact your crop insurance agent for help. If you need assistance locating an agent, go to the agent locator at tool .html rma.usda.gov/ s/agent . Production ______ 1. Have you recently evaluated your risk in the event of the loss of your crops? ______ 2. Have you recently evaluated your risk in the event of the loss of your animals? ______ 3. Have you investigated other alternative production methods and their consequences? ______ 4. Do you have the necessary knowledge to consider an additional or alternative enterprise? ______ 5. Is your crop insurance protection adequate to cover a severe crop loss? ______ 6. Have you reviewed all of your crop insurance options with your agent? ______ 7. Have you conducted a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis for your operation? ______ 8. Are you in an area capable of supporting irrigation? Marketing ______ 1. Do you have a current, written marketing plan? ______ 2. Have you coordinated your marketing plan with your goals and objectives and your financial and production plans? 3. Managing marketing risks: ______ a) Are you comfortable with your knowledge of marketing opportunities? ______ b) Have you reviewed your marketing options within the past 6 months? ______ c) Do you understand how crop insurance revenue guarantees can enhance marketing opportunities? Financial ______ 1.
    [Show full text]
  • SOP 103 – OHS Hazard and Risk Management
    SOP 103 OHS HAZARD & RISK MANAGEMENT 1. Purpose The purpose of this SOP is to provide a process for the management of workplace hazards and risks to minimise the potential for injury, adverse health effects, loss or damage due to workplace incidents. 2. Approval Managing Director 3. Definitions Dangerous Occurrence means an occurrence as defined in SOP 104, Appendix 2, Section 5B. Hazard means something with the potential to cause injury or illness. Hierarchy of Control means an accepted ranking of measures for controlling risk from elimination of the hazard, substitution, engineering and administrative controls, to the wearing of personal protective equipment. Incident means an event leading to an injury or adverse health effect to an individual, a ‘near miss’, or a dangerous occurrence. Near Miss means an incident that may have led to an injury or adverse health effect to an individual, but did not through the intervention of luck. Risk means the likelihood or probability that a hazard may cause harm. Risk Assessment means a process that seeks to identify hazards; then determine the level of risk by taking into account the likelihood that someone will be injured or something damaged by the hazard, the frequency of contact or exposure to the hazard, the level of exposure (eg number of people, amount/degree/extent of exposure to noise, chemicals, etc), pattern of exposure (eg continuous, intermittent etc) and the adequacy of any existing control measures. Risk Control means the use of measures to control the risk to an acceptable level. 4. Procedure The Hazard Management Process is at Appendix 1.
    [Show full text]
  • Lockout/Tagout
    SOUTH ORANGE COUNTY COMMUNITY COLLEGE DISTRICT OFFICE OF RISK MANAGEMENT FACT SHEET: LOCKOUT/TAGOUT I. What is Lockout/Tagout? Hazardous energy is dangerous and deadly. Failure to lock out equipment is a leading cause of death and injury in the workplace. Cal/OSHA requires Lockout/Tagout (LOTO) procedures for the control of hazardous energy. All machinery and/or equipment capable of movement must be de-energized and locked out during repairs, cleaning, servicing, adjustment, and set-up. A. Applicable Regulation: CA Title 8 General Industry Regulations, Section 3314 Turning off power won’t always keep a machine from starting up. To be sure power stays off to prevent accidental start-up that could cut, crush, hit, or electrocute workers: • LOCK energy controls in the off position • DRAIN stored power • PLACE WARNING TAGS on equipment B. Lockout/Tagout Locks & Tags Locks and tags must be: • Used only for lockout/tagout • Durable enough to stand up to heat, cold, humidity, or other conditions and must be able to withstand 50 lbs. of force • Standardized by color, shape, and size throughout the facility • Sturdy enough to minimize early or accidental removal • Identified with the name of the employee who installs and removes the lock & tag, contact number, date, and reason for locking out C. Who are Authorized and Affected employees? SOCCCD employees should never work on “live” equipment. All equipment must be de- energized before performing maintenance. • Authorized employee = person who has completed a LOTO training course and performs the LOTO procedures on equipment they service or repair. • Affected employee = person whose job requires them to work in the area of the equipment that has been locked and tagged out.
    [Show full text]
  • COSO) Oversight Representative COSO Chair John J
    Enterprise Risk Management — Integrated Framework Executive Summary September 2004 Copyright © 2004 by the Committee of Sponsoring Organizations of the Treadway Commission. All rights reserved. You are hereby authorized to download and distribute unlimited copies of this Executive Summary PDF document, for internal use by you and your firm. You may not remove any copyright or trademark notices, such as the ©, TM, or ® symbols, from the downloaded copy. For any form of commercial exploitation distribution, you must request copyright permission as follows: The current procedure for requesting AICPA permission is to first display our Website homepage on the Internet at www.aicpa.org, then click on the "privacy policies and copyright information" hyperlink at the bottom of the page. Next, click on the resulting copyright menu link to COPYRIGHT PERMISSION REQUEST FORM, fill in all relevant sections of the form online, and click on the SUBMIT button at the bottom of the page. A permission fee will be charged for th e requested reproduction privileges. Committee of Sponsoring Organizations of the Treadway Commission (COSO) Oversight Representative COSO Chair John J. Flaherty American Accounting Association Larry E. Rittenberg American Institute of Certified Public Accountants Alan W. Anderson Financial Executives International John P. Jessup Nicholas S. Cyprus Institute of Management Accountants Frank C. Minter Dennis L. Neider The Institute of Internal Auditors William G. Bishop, III David A. Richards Project Advisory Council to COSO Guidance Tony Maki, Chair James W. DeLoach John P. Jessup Partner Managing Director Vice President and Treasurer Moss Adams LLP Protiviti Inc. E. I. duPont de Nemours and Company Mark S.
    [Show full text]