Pat Crumrine: Advancements in Treating Children with Epilepsy

Welcome to Disability Matters with your host Joyce Bender. All comments, views, and opinions expressed on the show are solely those of the host, guest, and callers. Now the host of Disability Matters, here's Joyce Bender.

Hi everyone, welcome to the show, to everyone in the United States and around the world. And hey, around the world, special shout out to my friend from the State Department Richard Roberts, who is in Brazil. I just love him. He'll be visiting me. Oh, will that be great, in December. And we'll be having Brazil at some point on the radio. So he's just fabulous. So hello to Richard. Gang-young in South Korea, how are you? Special greetings. Cheryl Harris at the U.S. State Department. Hi, Cheryl, miss you. And to Venyamin, Venyamin in Kazakhstan, a special greeting to all of you. And they're all with the State Department. They're all diplomats around the world, and the countries around the world listening to the show are Italy, Ireland, Germany, Korea, France, United Kingdom, Australia, South Africa, Japan, Russia, Canada, China, New Zealand, and Taiwan have had listeners even this last week, last show. Now, some countries only have one person, one, but even if you're one person Wherever you are, you can make a difference. Tell other people about this show. Talk to other people, English-speaking, about this show, because you can be the person that makes a difference right in your country, the way my great friend Yoshiko Dart makes a difference. Hello, Yoshiko. I hope you're having a great day. And Yoshiko, is the wife of the late, great Justin Dart, who we think so highly of, and I just want you all to remember him. And that's why for the past years I always mention Yoshiko, and I know right now Yoshiko is listening saying, "Hello, Joyce." So Yoshiko, I feel you even though you're there in Washington, D.C. And I always have to thank my great sponsor, Highmark. Lead sponsor, such a great company. Thank you, Highmark, for continuing on supporting me and supporting this show. I just so much appreciate it. Well, this is National Epilepsy Awareness Month. And as you all know, I live with epilepsy and I'm the chair of the board in Western Pennsylvania and Central Pennsylvania of the Epilepsy Association of Western and Central PA, which I'm so honored to be in that role. And we have such a great board of directors, and one of them who I think so highly of and who I have been a friend of for years is Dr. Pat Crumrine, Professor of Pediatrics, the University of Pittsburgh School of Medicine, and In addition, the attending child neurologist epileptologist at Children's Hospital of Pittsburgh, UPMC. So you can see she has a lot going on. And Dr. Crumrine, welcome to the show.

Thank you, Joyce Bender. It's a pleasure to be here, particularly during the month of November.

Yes, yes, it's great to have you this month with your work as an epileptologist. Dr. Crumrine, as you heard, we have people listening around the world to the show in addition to all the people in the United States. So they know a little bit about you. What made you decide to become a doctor and what made you decide to specialize in pediatric medicine and then as a neurologist and working in epilepsy?

Well, the decision to become a doctor began somewhere around the time I was in junior high school. I really enjoyed biology. I enjoyed working with children. I did a lot of my money earning as a babysitter when I was growing up. And I chose a college that had a very good pre-med program when I went away to college and moved on into doing some research that stimulated further my interest in biology and medicine. And went from my undergraduate program in— from Marietta, Ohio, on to medical school in Philadelphia. And during medical school, although I really enjoyed surgery, in that time period it probably was not the best field for a woman, and I also enjoyed pediatrics and had an elective that took me to Boston where I spent some time with a pediatric neurologist who did neuromuscular work. And I think that further enhanced my interest in pediatric medicine and particularly began my thoughts about pediatric neurology. When I graduated from medical school, I came back to Ohio and did a pediatric internship. And there was a very well-known neurology program at the hospital where I did my residency, and in particular, there was a very important man in my career, Dr. Robert Iban, who ran the neurology program in pediatrics there. And from there, I had the opportunity to meet other child neurologists and when I finished my pediatrics, I was encouraged to go to New York where I did further training, 3 years of training in child neurology. So that was sort of my road to child neurology. And subsequently, I ended up in Pittsburgh after completing my child neurology training and they had a busy epilepsy clinic and I was assigned to take charge of that epilepsy clinic and the rest is really history.

Wow. What a career. How did you get to UPMC then?

One of the child neurologists that was a year ahead of me in training at in New York, had done his pediatrics here. And I— when I finished my training in New York, I did a year in general child neurology in a multi-specialty clinic in Wisconsin and got a call from him one day that they were in need of an additional child neurologist. And would I be interested in looking at the program. I came, liked the city, and I liked the hospital, and here I came and here I've stayed.

Wow. And a great asset, may I say, to not only UPMC but children living with epilepsy I just so appreciate everything you've done, Dr. Crumrine. You really are making a difference. And at UPMC, you are the pediatric epileptologist at the center. How many doctors are there at the center that specializes as epileptologists?

On the children's side, We currently have 8 of our child neurologists who have undergone additional training in epilepsy and are trained as pediatric epileptologists. And we have a total of 24 child neurologists and of those 24, a third of us are— spend our time in epilepsy.

And do you see a lot of children coming in with epilepsy?

We do. Or other spells that are suspect for epilepsy and that we have to spend some time with some various studies to determine whether there is epilepsy or not.

For one minute, Dr. Crumrine, as you know, my epilepsy was misdiagnosed. And the reason, one of the reasons is because I would fall but not have a convulsion. And I think that most of our listeners right now think when they hear epilepsy, that's what they think of. They think of a person having a tonic-clonic seizure, better known to them as a grand mal seizure. But there are many types of seizures. I wonder, you know, just so they'll understand that, if you could, you know, go through a few of them so they'll understand what I mean that you can be having a seizure and not have a convulsion.

You're absolutely right. What can be manifested as a seizure is quite variable. From one person to the next. In child— in children, we see seizures in which a child may just stop what they're doing. They may stare straight ahead or their eyes may deviate upward. They might have some brief blinking for just a few seconds and then immediately return back to normal and do what they were doing right before all this took place. And this type of seizure used to be called petit mal seizures. We now refer to them as absence seizures. And they can occur 100 times a day so that if a child were in a classroom, there could be lots of information that they would not pick up. There are seizures where people— and particularly I'm going to talk about infants right now, but these can occur in older children— where they may just suddenly fall down just briefly and then immediately pick themselves up, where their body sort of loses our sort of upright position or tone, as we call them., and we refer to those seizures as atonic seizures, but they can result in self-injury. We have myoclonic seizures where someone may have a brief, quick jerk or they may have a cluster of brief jerks, and those can occur in infancy They can also occur in teenagers. We have what you refer to as a tonic-clonic seizure or used to be called a grand mal seizure. We have seizures where people can just all of a sudden just sort of stop what they're doing and they may or may not be aware of what's going on, sometimes yes and sometimes no. We can have people, and again, more commonly seen in young children where laughter is the main manifestation of a seizure and that's called gelastic seizures, but the laughter is not usually the typical laughter for the child or the person. An unusual laughter. We can have seizures that involve a rhythmic jerking of an arm, a leg, an arm and a leg, a portion of the face, and those are referred to as clonic seizures where the movement is a rhythmic sort of brief jerking movement. That occurs. And some of these seizures can start out on one side of the body and then spread to the other side of the body, or they may remain just on one side. We can have seizures where there's emotional symptoms that occurred. And like crying or, you know, I've mentioned the unusual laughter. So these seizures can occur with just the manifestations I described, or some of them can spread to the other side and go on to be a generalized seizure. There's the So sometimes a seizure can involve jerking movements and the patient may remain totally aware of what's happening. The current terminology for that is focal aware seizure. And the terminology I think is something that I think is confusing to a lot of people because it seems to be an evolving terminology. And the best way I think for people to become aware of some of the terminology is to look at the terminology that is listed in the— on the website of the International League Against Epilepsy. They have a very nice description of the newer classification, the types of seizures, and they relate it to some of the prior terminology that we have used for these seizure types. I don't know if that answers all of the questions.

Oh yeah, I hope the listeners— as you can see, there are so many types— of seizures. I'll give that one example, absence seizure. Someone can look as if they're staring for just a few seconds and they're having a seizure. And then people at school, the teacher may think they're not paying attention. Any of these things— you want to know my suggestion? Go to an epileptologist, a neurologist that has specialty in epilepsy. Do not go to the family doctor. Because most family doctors are not going to understand this, which is what happened to me. And subsequently, you know, I fell at the movie theater and fractured my skull and had life-saving brain surgery. Why? Because the family doctor did not think falling down, even though I told him my husband found me and thought I was having a heart attack because my— the way my eyes were. And a bluish color. That's epilepsy. So I'm really glad you did that, Dr. Crumrine, because I want people to understand if their child has any of these symptoms, or an adult listening, that, you know, they have to get on it. And children, sometimes these seizures aren't noticed by a parent because they— well, they just don't understand. I've had people call me honestly and asking me, do you think this is normal? And I'll say, no, it isn't normal, but go to the doctor because medication can help. And other things, Dr. Crumrine, there are children that have brain surgery. I mean, it's hard to believe that half a brain could be removed, but could you talk about the different types of surgery and implants?

Yes, absolutely. I mean, I'll sort of preface it by saying that the initial treatment that we will try for the majority of people that have seizures would be an anti-seizure medication. And if that is not working and someone has tried generally a couple of appropriately selected seizure medications, then we would look at— to try to determine where the seizure's coming from and if the source of that seizure is something that could be safely surgically removed without creating further medical or neurological problems. And if so, then the typical surgery would be additional monitoring of the source of the seizure as well as making certain that the source of the seizure does not involve other significant areas of the brain such as language or motor function and that these would not be in any way impaired after a surgical removal of the seizure focus. Other possibilities for treating seizures besides the medications and surgical removals are stimulation procedures. We have stimulation that are called vagal nerve stimulators where a device can be implanted on the vagus nerve outside of the brain, but the vagus nerve communicates with many areas of the brain and thus stimulating that nerve may have impact on the source of the seizures. There's stimulation where we can actually implant small electrodes into the brain itself, and that is another potential treatment option for certain types of seizures. Surgery can involve removal of just a small source of where that seizure's coming from, or I mean not a small source, but a small area of brain tissue. And without harming language or harming motor function, we can actually do larger surgical resections where if someone has very debilitating seizures and the brain is genetically— has developed abnormally, that we can remove larger portions of the brain And although this may create permanent weakness on one side of the body, it may resolve seizures enough that that person can be functioning in other ways. And then there are surgical procedures where we can separate the right and left side of the brain. From one another and by sort of disconnecting prevent seizures from spreading from one side of the brain to the other side of the brain. So there are a number of different types of surgical procedures and the type of surgical procedure depends again on the type of surgery and where the source of that seizure arises.

Wow. Amazing today how many different options there are for children, you know, having seizures. It's just unbelievable. Although, as you said, a great majority of the seizures are controlled with anti-seizure medication, like I'm one of them. Although if I didn't take this medicine, I would have a seizure because I also have scar tissue, you know, when I had that accident. But I always tell employers, remember, the majority, over 60% of people living with epilepsy have the seizures controlled through medication because right away, Dr. Crumrine, people are often nervous to hire a person with epilepsy and the main reason they're nervous is they don't understand it. Do you feel that's true? Like when you talk to people, do you feel—

I think that's very true. And I think there's the fear of someone having a seizure, not knowing what to do, and they've never had basic information and first aid information provided on what to do if someone should have a seizure. And I think generally most— the majority of people are scared of what we used to term the grand mal seizure or a generalized tonic-clonic seizure.

Yes, and when they see that, they are afraid. And just as you said, they think, oh my God, how are we going to do this? Or, you know, how is the person going to function? But trust me, I can, I do, and so do many, many people I know who live with epilepsy. Everyone deserves the right to work. Disability rights are civil rights. And remember, the author of the Americans with Disabilities Act, Tony Coelho, lives with epilepsy. And to me, that just really says it all. And I'll bet, Dr. Crumrine, you've seen it all because I'll bet from when you started to right now, things are so different. For people living with epilepsy and children?

Amazingly different. At a time that I started my career in neurology, we were working with primarily 3 anti-seizure medications and one that had been used since probably the late 1850s, 1850s, which were bromides. And during my career, the three that I had access to were phenobarbital, Dilantin, and Mysoline. And during my early part of my neurology training, we had access to Tegretol or carbamazepine, and then the next one was valproate or Depakote. I did leave out Zorontin, which we did have access to to treat the absence seizures.

Yes, I was for a long time using Dilantin, and then, you know, our good friend Dr. Brian Smith and Valeriano were talking to me one day about how that can impact the calcium. And so then I moved on to Lamictal, and everything has been great, but Listen to me. Anti-seizure medication can control the seizure and work. And that's what it's all about. Employment. Getting a chance to work. Because without employment, you are never free in this country. Can't buy a car. Can't buy a house. You can't live the American dream until you have employment. Disability rights are civil rights. And with that, I can't think of a better time for our news break than right now with Perri Jude Radesik. Perri, uh, good afternoon. How are you?

Joyce, I'm great.

Uh, it's a great show.

Thank you. Well, Perri, what news you have for us today?

Well, the House, the United States House and the U.S. Senate are back, and so there are hearings happening on Capitol Hill tomorrow. That's Wednesday, November 30th. The U.S. Senate Committee on Health, Education, Labor, and Pensions. Senator Casey, our own Bob Casey from Pennsylvania, chairs the Subcommittee on Children and Families, and they're holding an important hearing on mental health. The title of the hearing is Caring for Our Kids: Supporting Mental Health in the Transition from High School to College. Now, if you remember, and those who've been involved in the education for students with disabilities, transitioning from high school to college is not always easy because you will not have an IEP in college or a Section 504 plan. So it's really the student's responsibility to seek an accommodation and it's even more important to do so for mental health. So Senator Bob Casey, who's chair of the subcommittee, is holding a hearing on that transition between high school to college. There are 4 witnesses tomorrow. The hearing starts at 10 o'clock. Now, one of the witnesses is from Allegheny County, Baldwin High School. And her name is Brooklyn Williams from Baldwin. And Ms. Williams started a club at Baldwin High School called the Chill Club with support from the Allegheny Health Network. Now if you want to read more about Ms. Baldwin and why she started the Chill Club at Baldwin High School, you can do so by going to disabilityrightspa.org and clicking on an article from the Pittsburgh City Paper that covered this, this club that Brooklyn Williams started, and she'll be testifying tomorrow at the subcommittee. There was a survey done by the American College Health Association in 2021 that found— of 100,000 students were surveyed, 100,000 students— 16% of college men and 33% of college women had been diagnosed with anxiety. The study also found that 14% of college men and 25% of college women were diagnosed with depression. So Joyce Bender, this transition between high school to college is very important for many reasons, including making sure that students understand their responsibility to seek an accommodation for mental illness. Advocacy matters. We hope your listeners tune in to the Senate hearing tomorrow to learn more about that transition from high school to college, and we really encourage everyone to go to disabilityrightspa.org for links to the hearing and all of the information we mentioned on today's segment.

Right. Now I want to ask you a question again. What percentage did you say live with anxiety?

So 16% of college men and 33% of college women. 33% had been diagnosed with anxiety. That's just of 100,000 students surveyed.

Wow. And what is, what is Senator Casey saying he's going to do about all this?

Well, uh, I think what they need to do is have a hearing, and then usually Senator Casey will introduce legislation once there's been some documentation of the need for legislation.

And would this be focused mainly on helping schools with this, or would this be focusing on employment, that transition part?

No, the transition is only about how we can or how Congress can or what are the recommendations to support mental health in that transition from high school to college. I don't think they're limiting it to just making sure you seek an accommodation. It could be related to anything, Joyce.

Wow, that is so great. Uh, one other question: is it possible to see this, to livestream this, or not?

Uh, there is a livestream. It's happening by the subcommittee, and we have a link to the livestream for tomorrow. It's— if you go to disabilityrightspa.org, you can click on the link we have to the subcommittee hearing and join the hearing live.

Oh, that is awesome. That is great. Well, thank you so much, Perry, for keeping us up to date, and we'll look forward to talking to you again next week.

Thanks, Joyce.

Take care. All right. So interesting, isn't it, Dr. Crumrine?

That's fascinating. And, and I actually have read something recently in the New York Times about these higher percentages of anxiety and depression in teenagers. They've associated some of this increase to COVID and the lack of contact that many of these teenagers have had with their peers. But even still, it seems to me that we see a much higher percent even in our neurology clinics than we had when I was first starting in neurology.

Wow. Yeah, that truly is amazing. When Perry went over that, I thought, well— and wait a minute, there is a comorbidity of depression or mental health with epilepsy, right?

Correct. Very much so.

Or mood disorders. Yeah, that is something that is important to know. Well, Dr. Crumrine, remember when I was asking you how far we've come in pediatric? Peggy Beam, the CEO of the Epilepsy Association of Western and Central PA, was telling me there was a time you had to send brown envelopes without any name on it such as Epilepsy Association to homes because the family did not even want the mailman to know.

No, and there are still occasionally families that I run into that have teenagers that are either ready to graduate or have graduated where they have never told anyone that they have epilepsy and that they have been very hesitant to talk about it in any way. And I think that that's a shame.

Yeah, that's so sad. And you know, when I was in Asia where there's pervasive shame, they didn't even want me to say the word, which of course, you know me, I didn't listen. I did say the word. Uh, but you know, they have these weird names like cerebral electric disorder, and I thought, why would you want to say that? That sounds scarier to me than epilepsy. But when they hear the word epilepsy, they think demonic or witchcraft or, or mental health. They think something. And we, thank goodness, don't have that. But even in the South you know, there's this feeling of demonic, especially like in Louisiana, or witchcraft or something. But I know you're right that many people that I've met do not want anyone to know they have this. And that is my question. Why do you think there's so much stigma toward epilepsy?

I think Part of it is fear on the part of the observer or the family member of not understanding what it is, not understanding that it is a medical illness like heart disease, pneumonia, and that there are medications that can control it. That people can live a fairly normal life, or even— I shouldn't say fairly normal, you know, I would say a very normal life, you know, taking a medication such as we would take insulin for diabetes or, you know, an allergy medicine. It's part of our makeup. And we adjust to it and can be normal functioning human beings. But I think it has had such a negative history throughout our human lives that it takes a long time to overcome that history. You know, the people from early on in ancient days were ostracized with epilepsy. And I think it still is a pervasive fear that people have of seizures.

Yeah, I think so too, Dr. Crumrine. And here's an example. For years, even, you know, when I was the chair of the National Epilepsy Foundation, if you go way back before I became chair and was just on the board, do you know I almost never heard about SUDEP? People didn't talk about it, which it is a horrible thing. But I wanted to ask you if you could tell everyone what that is and then what advice do you have? Because people have even asked me and I have no idea. What should they be looking for in their children in prevention of SUDEP, or can you even do that?

I mean, you can certainly— I'll come back in just a second, but to answer your last question, I mean, there are some things that certainly diminish that risk. First of all, it is— it involves someone having a seizure very frequently, and I'll say most of the time while sleeping. It tends to— when that occurs, can result in death, and it's not related, let's say, to a heart condition or any other medical or traumatic situation. There has been a lot of study, and there is ongoing study of the causes and looking at ways of preventing this. It is uncommon in children, although it can occur. It is more likely to occur in people that have uncontrolled epilepsy. And some of the genetic disorders that result in very difficult to control epilepsy in early childhood, those are situations in which there could be higher risk of SUDEP. And I'll just define that it's sudden unexplained death in epilepsy. And it tends to be an entity that occurs more frequently in adult populations. Prevention of it involves fairly regular or very regular maintenance of prescribed anti-seizure medication. And I think for parents that are concerned about having their children sleep alone, there are available many devices nowadays that can— such as bed mattresses and things like that, where you can monitor movement, bed movement and such. There are sound-operated recorders, such as baby monitors that people put in rooms. These are not absolutely foolproof. But I think they do help parents relax a little bit about this concern. There are other things like watches that now are available that can pick up heart rates and changes in heart rate and indicate alarms, but the— probably the One of the best ways of decreasing the risk of that is regular medication, regular sleep habits, and maintenance and good seizure control. Yeah. I don't know if there are other— questions that you have concerning that, Joyce, or not?

I just wondered, you know, let's say you have a child with uncontrolled seizures, or a teenager, or young adult, whatever it is, but let's say you're a parent. If the child— if you're in that room with them, how would you know, uh-oh, it's time, we better call 911? How would they know that?

Well, I mean, it would be— the child could have a seizure and suddenly have cessation of heartbeat, and certainly any color change or anything of that nature probably would be of concern. People with generalized tonic-clonic seizures can have color change. They will sometimes have some color change around their lips during a more prolonged tonic-clonic or grand mal seizure. But it would probably oftentimes is a fairly— they describe it as a fairly silent event where Parents have not been aware that the child has had a seizure. So—

That's so terrible. Well, I think education is, you know, good because I know I would want to know what can I do. And one thing I would never do is if in the past my child had been having seizures, go along with them not taking medication. I mean, do not do that. You know, don't do that because you're putting yourself that child immediately at risk. And I know of people this has happened where, you know, the child did not live and that same child had stopped taking their medication. So, you know what Dr. Krumme-Rhein said, medication, maintaining, getting enough sleep, all of those things.

Yeah, and I think it, it be I think, and I will say this for myself, it has been a hard subject to introduce to families and particularly to teenagers. And yet, I've come to realize that the teenagers need to hear about it, particularly if there's a tendency that they have for not taking their medication. I think it's important that they understand why we emphasize that so much. Mm-hmm.

Yeah, and I tell people, well, if your child has a heart problem and you're not, you're not watching that, or your child's doing things they shouldn't be doing that the doctor told them, it's the same thing. So you've got to follow this.

Uh, you know, I'm glad you said that about teenagers because of the alcohol, and alcohol and epilepsy, lower sleep, seizure medication, and then you have somebody that's overdone it the first few times they've used alcohol and they forget their medications, they go to sleep. That puts that person at a very high risk for, you know, a situation like Sudep.

Yeah, so I'm glad you're telling people. Uh, well, Dr. Crumrine, you know, as I hear, you're so brilliant. And if you know her, I mean, she's just the kindest, nicest person. Uh, therefore, someone must have had an impact on you. So, Dr. Crumrine, who was your role model?

Well, I mentioned, I, earlier this Dr. Iben, who was a pediatric neurologist at the Cleveland Metropolitan Hospital when I was doing my pediatric residency, and he was one of the kindest people that I have ever known, but he had had a— congenital heart problem and had undergone major surgery as a young adult at the Mayo Clinic. And he ran the child neurology ward, and at that time it was a— had been a big polio ward, and we still saw young patients coming in to be in iron lungs there when I was doing my residency. So, he kind of fostered my interest. I was a pediatric resident then and fostered my interest in child neurology. And there was another person there, Dr. Schaefer, and he knew someone at Columbia by the name of Arnold Gold. Joyce Bender, who is the person that implemented the white coat ceremony in medicine, where incoming medical students are given the white coat on their first day in medical school. And he—

No kidding. Do they still do that?

They still do that. Oh, it's done throughout the country. And he, he was wonderful with patients and children. He knew just how to connect with them. And the other person at Columbia that really had a big impact on me ran the department and had come from Boston, Dr. Sidney Carter. And so these were several people who really, I think, influenced me significantly in my career.

Wow. You know what? They would be so proud. So proud of what has happened. Really proud of you and all your accomplishments. Speaking of that, Dr. Crumrine, at this time of your life, as you look you know, on everything you've done, what would you say is your greatest accomplishment?

Well, I don't know that I would say accomplishment. I think I have had the very, very good fortune of meeting people who have been very encouraging to me in my career. I'm very supportive of the things I've wanted to do. My family, my parents, my sister, but also, you know, people and physicians like Dr. Iban, Dr. Schaefer, Dr. Carter, Dr. Gold. These have been— and the patients themselves. It has just been a joy to work with the patients and their families and, and to see the growth in both groups of people over the years that I have taken care of them, from some of them from the time they were infants to watching them grow into their 20s.

Well, you, as far as I'm concerned, your whole life, what you've been doing is a great, great— so many great accomplishments. But see how you are? You're so modest. This is what I mean about Dr. Pat Crumrine, pediatric professor of pediatrics at the University of Pittsburgh School of Medicine, attending child neurologist, epileptologist, at Children's Hospital of Pittsburgh, UPMC. What a gift they have with you there. What a treasure, Dr. Crumrine.

Thank you, Joyce.

I so much appreciate you being on the show today as we celebrate National Epilepsy Awareness Month.

It's a great opportunity and it's wonderful To be able to see the breadth of epilepsy in this time period and the various organizations supporting it and the camps for children and I think the expansion of information into the school systems and things like that.

It is, it is wonderful. Well, before we close the show today, I want to remind you that today is, yes, Giving Tuesday. Giving Tuesday. And there are many associations where you can contribute and I hope you will. One, of course, the Epilepsy Association of Western and Central PA, who we support. Epilepsy Association of Western and Central PA, which is E-A-W-C-P dot org. And the other is, of course, the Bender Leadership Academy, BenderLeadership.org. Take time to go, take time to make a contribution, take time to give. And I will end this show with a quote from a great person in history. That certainly impacted lives. Since it is Giving Tuesday, no one has ever become poor by giving. Epilepsy Association of Western and Central PA, Bender Leadership Academy, make a donation today. No one has ever become poor by giving, said and Frank. This is Joyce Bender, America's Voice, where disability matters, at voiceamerica.com. Talk to you all next week, and in the words of Mary Brooker, choose joy.

Voice America would like to thank you for tuning in. Please join us next Tuesday at 11 AM Pacific time and 2 PM Eastern time for another installment of Disability Matters right here on the Voice America variety channel. We are the leader in live internet talk radio. VoiceAmerica.com.