CT Scans and Cancer Risk: A Mount Sinai Radiologist Explains


You may have seen headlines recently about a link between CT (computed tomography) scans and cancer due to radiation exposure. CT scans project X-rays into the body to produce detailed images and are often necessary in situations where a medical diagnosis needs to be made quickly. While they are generally considered safe, multiple CT scans over time pose a small increase in cancer risk.

To keep you safe, radiologists take steps to reduce your exposure as much as possible.

Bradley Delman, MD, MS

In this Q&A, Bradley Delman, MD, MS, a neuroradiologist and Vice Chair of Quality at Mount Sinai, explains the benefits of CT scans and how radiologists work to reduce the risks.

What is a CT scan, and why is it important for diagnosing health conditions?
CT is a powerful tool that uses carefully focused beams of radiation to generate images inside the body. These scans enable doctors to see structures in three dimensions to diagnose a wide variety of conditions including strokes, bleeding, infections, tumors, and traumatic injuries. Sometimes dye is injected into the veins to improve visualization of blood vessels, tumors, and inflammation. These scans have become invaluable for emergency situations and presurgical planning.

Can CT scans increase my risk of developing cancer from radiation exposure?
CT machines do expose patients to ionizing radiation, which over time can damage DNA. Fortunately, DNA is believed to repair itself in most instances. DNA that does not get repaired can slightly increase your long-term risk for cancer. Cumulative exposure from multiple CT scans over time may cause DNA damage to accumulate, and that is also believed to increase cancer risk.

It’s important to note that we only scan when necessary and that we use the lowest radiation doses necessary for diagnosis. Scanners are getting even more efficient at this. Ultimately, we must compare the risks and the benefits, and it is more essential to diagnose and treat what is wrong with the patient now than to be concerned with the very low potential for cancer years into the future. Our scanners use low radiation doses overall, so the risk is thought to be justified by the value scans provide in patients’ care.

What are the benefits and risks of getting a CT scan?

Benefits:

  • Fast, accurate diagnosis with detailed images
  • Ideal for emergencies and presurgical planning

Risks:

  • A small risk for radiation-induced DNA damage
  • Small potential for increased risk of cancer with multiple scans over time
  • Potential allergic reaction to the contrast dye (if used)

What are the safest alternatives to CT scans for medical imaging?
Low- or no-radiation alternatives to CT scans include X-rays, ultrasounds, and magnetic resonance imaging (MRIs). These do have their role and are used when they can provide comparable or superior information, but CT is fast and reliable, and has become an essential part of diagnosis, especially in the Emergency Department.

How does the number of CT scans I get affect my long-term cancer risk?
If you have many CT scans over a short period, the long-term risk for cancer is thought to be higher than with fewer scans, or with scans spaced apart. But again, we should be concerned about diagnosis and treatment of the ill patient. Scans are offered only when they offer clinical value.

How do radiologists minimize radiation dose from CT scans while ensuring accurate results?

Our responsibility is to keep doses as low as we can. To do that, we follow the “As Low As Reasonably Achievable,” or ALARA, principle:

  • Using low-dose CT scan protocols
  • Scanning only your necessary body parts
  • Limiting the scan coverage to what is necessary
  • Basing scan settings on your age, weight, and scan type
  • Optimizing protocols from the companies that build our advanced CT scanners, which require less radiation than older models

How is my radiation exposure from multiple CT scans tracked to reduce long-term health risks?
Many hospital systems, including Mount Sinai, use digital imaging records and dose tracking systems to monitor patient exposures. We continually use radiation exposure data to refine and optimize our scanning protocols. This tracking does not mitigate radiation risks for individual patients, but it does create transparency for patients to understand their doses over time.

Why Eye Exams Are an Important Part of Care Offered at the Corinne Goldsmith Dickinson Center for Multiple Sclerosis

Eye examinations reveal a lot about a person’s general health. With multiple sclerosis, what is found deep inside an eye may yield an initial diagnosis of the chronic disease, and yearly checkups can help to measure disease progression.

With the acquisition of an Optical Coherence Tomography (OCT) machine, vital for neuro-ophthalmologists, the Corinne Goldsmith Dickinson Center for Multiple Sclerosis has expanded its capacity to provide comprehensive care. A generous gift from the Muzio Family Foundation enabled the Center to purchase the OCT machine.

Sylvia Klineova, MD, MS

In this Q&A, Sylvia Klineova, MD, MS, who specializes in multiple sclerosis (MS) eye health, explains why routine exams are essential for MS patients, how an OCT works, and the benefits of offering it at the Center. She is also an Associate Professor of Neurology at the Icahn School of Medicine at Mount Sinai.

“OCT tests are a new part of how we’re assessing our patients and should be incorporated in MS comprehensive care,” she says.

Why are regular eye exams important for multiple sclerosis care?

You can think of eyes as sort of a surrogate for changes in the brain of someone with multiple sclerosis. The “retinal nerve fiber layer” (RNFL) are the nerves in the back of the eye that are the beginning of the pathway for vision into the brain. Loss of thickness in the RNFL has been correlated to the degree of brain atrophy in MS patients, particularly in those with prior optic neuritis, a condition in which the optic nerve, which connects the eye to the brain, becomes swollen or inflamed. An MRI, however, cannot precisely measure the thickness of retinal nerve fiber layer, or accurately determine the effects of lesions in optic nerves. Optic neuritis is one of the most common initial attacks of MS, so a precise diagnosis is important. Even in patients without optic neuritis, we can see the impact of MS on retinal nerve fiber layer thickness.

Why do multiple sclerosis neurologists use an OCT?

The OCT, first introduced in 1991, was predominantly used by ophthalmologists for care in glaucoma, a very common reason for people developing optic neuropathy, or damage to optic nerves. Since the optic nerves are often affected in people who have MS, researchers who focused on eyes concluded that an OCT is more sensitive than an MRI in uncovering optic nerve lesions. The technology can help attain an earlier diagnosis of MS or confirm diagnoses in patients where the use of MRI doesn’t reveal an optic nerve lesion.

An OCT also is used to help to distinguish optic neuritis in MS versus other demyelinating diseases like neuromyelitis optica (NMO). After an MS optic neuritis attack, doctors use OCT to monitor how much optic nerves are damaged. Looking at changes in thickness of the neural layer can help to predict the degree of vision recovery in six months or a year after the attack. In imaging of a patient’s eyes over time, doctors look for any sign of changes of a neural layer in optic nerves and macula, the area with the highest number of cells that form optic nerves.

How does OCT work?

An OCT machine looks a little bit like a big computer. You put your chin on a chin rest and look straight ahead without shifting your eyes. A scanning light, moving across your line of vision, reaches deep inside tissues of the retina, and comes back with pictures of different cell layers. The test lasts about 15 minutes, is painless and non-invasive, and the results are quickly available to the physician.

The OCT will be part of the newest multiple sclerosis diagnostic criteria (the McDonald Criteria), which have been widely discussed at international conferences and will be published in 2025. The older criteria did not specifically single out optic nerves as one of the locations where doctors would look for lesions.

Why did Mount Sinai’s Center get an OCT?

The OCT program began in December 2023 when the Center added an OCT to its onsite equipment. Our Center staff take the images. The only thing needed from a patient is to sit and not move their eyes. With the OCT installed at the Center, patients do not need to go to another facility for a test that is recommended as a part of their comprehensive care. The exams usually are scheduled by providers as part of patients’ regular clinical visits.

Are OCT tests necessary?

Annual OCT exams are recommended for many MS patients. How the nerve layer around the optic nerve and retina looks can tell neurologists something about how MS is affecting the whole nervous system.

OCTs are particularly useful for tracking progression in patients who had optic neuritis. Whether and how much these patients lose vision depends on the extent of damage to the optic nerve as well as the macula, the place of sharpest vision. Evaluating the loss of thickness in optic nerves and macula can help to predict the degree of vision recovery.

For patients without prior optic neuritis, doctors can see how MS affects thickness of the neural layer. They are looking for stability of the thickness over time. And since neuroprotective or remyelinating drugs have not yet been developed, if a significant drop in retinal thickness occurs, then advancing to a more effective MS therapy can be discussed.

By Kenneth Bandler, a multiple sclerosis patient, advocate, and member of The Corinne Goldsmith Dickinson Center for Multiple Sclerosis Advisory Board

Five Signs Your Child May Have Asthma

As spring blossoms, there is an increase in pollen and other allergens which makes it a challenging time for children who have asthma. But how do you know if your child has asthma?

Expert pediatric pulmonologist, Chantal Spencer Grant, MD, Medical Director in the Division of Pulmonology in the Department of Pediatrics at Mount Sinai Kravis Children’s Hospital, shares key signs to look for and tips for managing the condition.

Chantal Spencer Grant, MD

Asthma is a chronic disease that causes the airways of the lungs to swell and narrow causing an increased production of secretions inside the bronchial tubes making it hard to breathe. About 4.5 million children in the United States ages 0-17 years have asthma, according to the Centers for Disease Control and Prevention (CDC). It is one of the leading causes of chronic illness in children.

“It’s important to understand that there is no cure for asthma but it can be easily managed,” says Dr. Grant, who is also Associate Professor, Pediatrics, at the Icahn School of Medicine at Mount Sinai. “Some kids do outgrow asthma as they get older, but if they don’t, it’s a condition that can be treated so the child can live a normal life. Maintaining a healthy lifestyle, going for yearly check-ups, and getting vaccinations are all things that can also help manage the condition.”

Here are the top five symptoms to watch for:

  • Wheezing: A high pitch whistling sound when breathing.
  • Coughing: A persistent cough especially when your child is doing physical activity or at nighttime.
  • Shortness of Breath: Frequent difficulty or rapid breathing or feeling like your child is not getting enough air.
  • Chest Tightness or Pain: Complaining of chest hurting or feeling pressure in the chest area.
  • Tiredness: Feeling of weakness more than usual or having lower energy than normal.

If you have questions or if you are concerned that your child may have asthma, contact your child’s pediatrician and/or a pediatric pulmonology specialist.

Here are six ways to help manage asthma:

  • Manage allergy symptoms as they can affect a child’s asthma symptoms. Avoid key triggers like allergens including pollen, dust mites, mold, pet dander, and irritants such as smoke.
  • Keep an eye out for weather changes. Avoid drastic temperature changes where possible. For example, a cold air-conditioned room might trigger symptoms.
  • Manage respiratory infections like a cold or flu. These can lead to wheezing, coughing, and tightness in the chest, which can lead to asthma flare-ups.
  • Have an asthma action plan in place. Follow a personalized plan put together by your child’s medical team that specifies what to do if your child has an asthma attack, and know the key asthma signs to look for.
  • Take allergy and/or asthma medications regularly or as prescribed by your child’s doctor.
  • Stay informed. Educate yourself and your child about what asthma is, the key triggers, and how to manage and prevent it. The more informed you are the better. Don’t hesitate to contact your doctor at any time with questions or concerns.

Three Sizzling Beefless Burger Recipes

Low in calories and cholesterol, these beefless burger recipes are perfect both for grilling and getting healthy. Enjoy!

Double Stack Mushroom and Chicken Cheeseburgers

INGREDIENTS

1 lb cremini mushrooms
1 lb ground chicken (or ground turkey)
Salt, to taste
Pepper, to taste
Oil, to coat pan
4 slices cheese, of your choice
4 buns or rolls
1 red or yellow onion, sliced and grilled (optional)
Pickles (optional)
Toppings, of your choice

PREPARATION

Lightly salt the mushrooms. Add them to a food processor and pulse until finely chopped, or chop fine by hand. Mix chopped mushrooms and ground poultry in a large bowl until well combined. Divide mixture into 8 equal parts and form into 8 thin patties; season the patties lightly with salt and pepper. Transfer to a plate and set aside.

Lightly coat a large skillet or grill pan with the oil. Add the patties and cook 5 to 6 minutes per side. Top each patty with a slice of with the cheese of your choice, and heat briefly, and possibly cover the pan, to melt the cheese.

Stack 2 patties on each bun and top with grilled onion slices, pickles or other toppings of your choice.

4 servings
Nutritional Information per serving (without bun or cheese)
Approximately 247 calories
Carbohydrates: 35.5 g
Protein: 18.4 g
Fat: 4.6 g

I love to cook, and I am always searching for new recipes.  My family enjoys a good burger, but we don’t eat a lot of meat and prefer poultry. I found this recipe online, and have made it multiple times for my immediate family and guests. It’s always a hit. The mushrooms really create a “meaty” flavor.

–Sandy Sterthous, Recruiter, Human Resources

Sweet Potato and Black Bean Veggie Burger

INGREDIENTS

Burger
1/2 cup oats (old-fashioned, whole oats, or rolled oats)
1 sweet potato (2 cups), shredded
2 tablespoons flaxseed meal
4 tablespoons water
1 can black beans (15 oz), rinsed and drained
1 cup onion, roughly chopped
2-3 garlic cloves
1 lime, juice and zest
1/2 cup cooked quinoa, follow directions on the package
Salt and pepper
2 teaspoons chili powder
1/2 teaspoons cumin
1/2 teaspoons coriander
1/4 teaspoons cayenne pepper

Equipment

Food processor
Baking sheet lined with parchment paper

For serving
Whole wheat hamburger buns
Tomato, sliced
Avocado, sliced

PREPARATION

Burger Mixture

Add the oats to a food processor and grind on high into a coarse flour consistency, 30 seconds to one minute. Transfer the oats to a medium-size bowl and set aside. Wipe out the food processor, and return to its base.

Peel the sweet potato and slice it into quarters, lengthwise. Shred the sweet potato slices using the shredding disk of the food processor, or using another type of grater, if you prefer. Measure 2 cups of the shredded sweet potato and add it to the bowl with the ground oats.

In a small bowl, whisk together the flaxseed meal and water. Set the flaxseed  mixture aside to thicken into a gel.

Add the rinsed and drained black beans, onion, garlic, and the lime zest and juice to the clean food processor bowl. Pulse until the mixture comes together with a few larger chunks remaining.

Transfer the black bean mixture to the bowl with the oats and sweet potatoes. Add the cooked quinoa and the flaxseed gel. Stir to combine. Sprinkle with salt and pepper, and season with the chili powder, cumin, coriander, and cayenne pepper. Mix to combine all the ingredients.

Divide the mixture to form 6 equal size burgers. Place the burgers on the parchment-lined baking sheet.

Place the baking sheet with the uncooked burgers in the refrigerator. Chill the burgers for at least 30 minutes before baking.

Preheat the oven to 375 degrees F.

Bake the burgers on the middle rack for 20 minutes. Flip them over, and cook for another 15-20 minutes.

Remove from the oven and let the burgers set for 5-10 minutes before serving.

Place each burger on a whole wheat bun, and top with avocado and tomato slices.

Nutritional Information:
439 calories, 6 servings per recipe

The Burger and Fry Makeover

INGREDIENTS

Burgers
1 lb ground turkey breast
1 cup carrots, chopped
1 cup poblano peppers, or other mild peppers, chopped
1/2 red onion, chopped
1 tablespoon of tomato paste, or ketchup
Olive oil, just enough to coat the pan
Mustard, condiment option
Ketchup (without corn syrup), condiment option

Fries
1 tablespoon avocado oil, divided
6 small potatoes
1 teaspoon of freshly ground black pepper
Pinch of salt or salt substitute

PREPARATION

To make the burgers, mix together the ground turkey, carrots, peppers, onion, and the tomato paste or ketchup. Form into 6 burger patties. Over medium heat, warm a cast iron frying pan or sauté pan coated lightly with olive oil. Add the burgers to the simmering pan and cook for 3 to 4 minutes on each side. Remove from heat and serve with a small side of mustard or ketchup, preferably made without corn syrup.

Warm a separate pan over medium heat and add the avocado oil. Place the potatoes sliced in fourths in the heated pan. Cover and cook for 2 to 3 minutes, flip and cook uncovered for another few minutes until the potatoes are crisp. Sprinkle with pepper and salt or salt substitute.

Serves 3 or 4
Nutritional Information per serving
Approximately 185 calories
Fat: 13 g
Protein: 6 g
Carbohydrates: 6 g

I love the flavors of a good burger and fries, but I don’t love feeling tired and drained afterward. This recipe is life and energy giving, and that’s a gift that I enjoy sharing with my friends, family, and colleagues. The potatoes are very flavorful as prepared. Great served with a side salad for a complete meal. I am committed to spreading the word of this burger and fries reboot. Enjoy!
–Maria, Mount Sinai Doctors-Forest Hills

Five Ways to Help Reduce Everyday Stress

Some stress is part of everyone’s life. But there are times when the daily demands of the job or school, the complications of home life, the pressure of living in the New York metropolitan area, and the state of the world can combine to leave you feeling physically and emotionally overwhelmed. As you face these stressful experiences, you may notice your sleep is disrupted or certain muscles in your body are more tense or find you are lacking energy or a sense of enthusiasm or confidence.

You know you need to do something. But what?

In this Q&A, Jacqueline Hargrove, PhD, a licensed clinical psychologist and Assistant Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai, says you can start by  separating “stressors,” those things like multiple work deadlines, numerous familial responsibilities, or upsetting news events, from stress, which is your body’s understandable response to these stressors. Once you do that, she offers five tips on how to improve your mindset and increase your flexibility so you can begin to improve how you manage stress and get unstuck from cycles of chronic stress even while the stressors of life persist.

Get physical

The best way to deal with the stress is to do things that are physical. That helps break down those stress-related hormones that increase our heart rate and our breathing and get us ready for action—so that they don’t linger in the body. This can be a whole host of different things. Anything that literally just gets your heart rate going, or breathing deeply is fair game. Physical activity helps your body reach a calmer state. A lot of folks may not like going to the gym or going for a run. So, you can take a brisk walk through your closest park, or dance to a few of your favorite songs. Or just focus on deep breathing or breathing exercises.

Alternatively, you can connect with other people and soak up some physical affection. If you’ve ever come home from work and been greeted warmly by your partner, your child, or even a pet, you know how that can be comforting and stress reducing.  Even laughing and crying can be helpful, as many may know from having a good cry or experiencing a deep belly laugh. Afterwards, you feel better, because it’s a physical process that actually helps us release some of that stress and tension that can stay stuck in our bodies.

Figure out what you can control and what you can’t

A lot of the stressors we face today are out of our control. With this in mind, it’s important to understand whether a stressor you are facing is something you have some control over, and can problem solve, or not. If there is something, even a small thing, that you can do and is in your control that will help reduce or eliminate the stressor then absolutely do it.  However, if it’s something that’s more chronic or something that you don’t necessarily have control over, try to see what meaning you can gain from the experience, or try to ensure that you aren’t dealing with the challenge alone.  Many aspects of our day-to-day lives, such as work responsibilities or managing the care of a child or family member, can come with stress. But often it is the positive meaning we can associate with the purpose of our jobs or the people we love that can help us mitigate the stress associated with them. However, let’s say you are dealing with a stressor that is truly unpleasant and feels unbearable. Sometimes just shifting our expectations, or temporarily accepting the way things are in the moment, can actually reduce stress. This is because we are no longer fighting with what we are expecting of other people or with our desires for things to be a certain way that we really can’t control. This isn’t to say you should give up on getting your needs met or figuring out ways to address the stressor—certainly not. However, shifting our expectations or learning to accept the ways things are in the moment can get us out of a tug of war with the issue, can preserve our energy, and can actually give us space to face the issue with more clarity and creative problem-solving down the road.

Take stock of your environment and surroundings. It’s not necessarily all on you

Try to contextualize your stress. What I mean by that is, sometimes we can think we have a personal failing because we’re so stressed out. But if we just take a minute to step back, we realize there’s so much going on in our lives and it makes sense we feel stressed. Dealing with economic uncertainty or facing continually upsetting national and global news events is stressful. Being a caregiver to a child or family member can be an added level of stress that other people do not have to manage. Navigating your life as a person of color, an immigrant, a member of the LGBTQ community or a person living in an under-resourced neighborhood has its own stress due to discrimination or systemic barriers that disproportionately affect these communities. There are so many ways in which our identities and the roles we have can contribute to the stress that we experience. In this way, it can help to acknowledge how our identities and the environment we are in play a role in the day-to-day stress we experience. This can help us not be so self-critical and can also help us identify ways to manage that stress and find empowering ways to deal with the stressors.

Redefine productivity

In the United States, there is a common narrative that centers around always needing to be productive, and that is a culture that is ripe for stress. Productivity can simply mean intentionally working toward a meaningful goal. So, let’s say your goal is mental health and well-being, then rest can be a really productive thing that you’re doing in line with that goal. Making time for yourself can therefore be productive. Also, capitalize on idle time. This can include choosing to not do anything during those five minutes in between meetings. Or if you take public transit during your commute, maybe intentionally getting off one stop earlier and extending your walk home. Finding time when you don’t need to be engaging with your day-to-day stressors can be really important.

Learn to say no

Learn to say no to things and learn to set boundaries. A lot of our stress can come from sometimes feeling like we have to say yes, or put more and more on our plates, when it actually isn’t in our best interest to do so. If you’re saying yes to things, and you have the ability to say no, you can ask yourself: Is this benefitting me? Does engaging in this activity help me feel energized and excited? Or does it end up making me feel depleted and resentful? Take time to listen to your body, set some boundaries, and find ways to reclaim some of your time and energy.

Overall, it’s important to remember that stress, not chronic stress, is a part of life. However, we can learn ways to process the stress so it doesn’t build up in our bodies and develop effective ways to deal with life’s stressors that can help us feel more empowered and resilient.

The ABCs of an Innovative Procedure for BPH

Holmium laser enucleation of the prostate (HoLEP) is a newer treatment option for patients with a condition called benign prostrate hyperplasia (BPH). As a man gets older, the prostate increases in size and blocks the urine flow causing a voiding dysfunction. BPH is a non-cancerous enlargement of the prostate gland that is commonly found in men over the age of 50.

Mount Sinai is a leader in minimally invasive approaches to treat a variety of urologic conditions, including HoLEP, which uses a specific laser to remove the obstructive prostate tissues and restores normal urine flow. Thanks to advancements in urological surgical technologies, HoLEP has become recognized as a gold standard for treatment of BPH, offering patients reduced operative and recovery time.

Osama Zaytoun, MD

In this Q&A, Osama Zaytoun, MD, a urologist and HoLEP expert at Mount Sinai Doctors – Brooklyn, and, explains what this procedure is and why it is becoming more popular due to its unique benefits for patients.

“HoLEP is the latest cutting-edge surgical technique,” says Dr. Zaytoun, who is also an Assistant Professor of Urology at the Icahn School of Medicine at Mount Sinai. “Our patients come and go the same day and get the best surgical and post-operative care.” Mount Sinai is one of a limited number of hospitals in New York State offering this procedure.

What are the benefits of HoLEP over other BPH treatments?

Compared to traditional surgery, HoLEP (Holmium Laser Enucleation of the Prostate), offers better long-term results and a quicker recovery overall. The procedure takes between 90 minutes and three hours. Patients who undergo HoLEP typically regain their physical functions quickly and can urinate normally. They have a short hospital stay and can return home the same day of the procedure. HoLEP also has no size limitation and therefore allows surgeons to treat patients with different stages of BPH and all prostate sizes.

How do I know if I have an enlarged prostate?

Key symptoms of an enlarged prostate include urinating more frequently and urgently, straining or finding it difficult to urinate, hesitancy or feeling it’s more difficult to urinate, dribbling after urination, and incontinence. Urine retention and the need for urinary catheter may be a complication for neglecting this condition. 

Are there any risks associated with HoLEP?

HoLEP is a safe procedure, but as any other surgical procedures it still has a low incidence of complications that is reported to be less than 10 percent. Most of these complications are mild and reversible, or resolve on their own. 

What happens during a HoLEP procedure?

During the HoLEP procedure, the surgeon inserts a high-powered laser into the urethra and carves out the obstructive excess tissue of the enlarged prostate. The tissue is further cut into smaller pieces to allow easy removal. This allows the urethra to open more, significantly improving the urine flow and the patient’s ability to void fully. Right after the procedure, a catheter is placed in the bladder to help with urination after the surgery;  this is removed after one or two days.

What is the recovery like after a HoLEP procedure?

Recovery is quick and most patients can go back to their normal activities within a week or so after the procedure. A patient might feel mild pain, burning, and discomfort following the procedure, but these symptoms are temporary and will resolve after a few days.

Who is a candidate for HoLEP?

The HoLEP procedure is ideal for men with BPH with bothering symptoms and is especially helpful for those who have very large prostates, for those  who have not responded to medication, and those who have had other procedures done that were not effective.

What makes the HoLEP procedure offered at Mount Sinai unique?

HoLEP is an extremely specialized procedure that requires intensive urological training, mentorship, and special equipment. Because of the difficult learning process, there are few urologic surgeons performing the procedure in the United States. Our team has mastered the procedure, and we are excited that we can help.

Please call 212-844-8900 to schedule an appointment.

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