Retrospective case-control study of the effects of long-term dosing with meloxicam on renal function in aged cats with degenerative joint disease. A cat with an oral mass or a suspected oral mass requires examination under sedation to: A punch or wedge biopsy may be completed under the same sedation as the oral examination, although complications, including jaw fractures, delayed wound healing, or secondary infection, may result from the often friable and necrotic nature of this tumor. These statements include reference to published studies that, while limited in number, show some promise for the medium and long-term use of the COX-1 sparing drug meloxicam in older cats and cats with chronic kidney disease. Right mandibular lip lesion (A and B); histologically confirmed as squamous cell carcinoma. Meloxicam (brand names Metacam Loxicom, OroCAM, Rheumocam) is a non-steroidal anti-inflammatory drug (NSAID) used to relieve pain, inflammation, and fever in dogs and cats. However, it may not be overly apparent to a pet parent that kidney disease is present when in its earliest stages as many cats may eat, drink, eliminate, and behave normally. Osteosarcoma (OSA) is a common and devastating cancer that plagues many of our canine patients. Stay current with the latest techniques and information sign up below to start your FREE Todays Veterinary Practice subscription today. Further studies are needed to determine whether toceranib phosphate, alone or in combination with chemotherapy or radiotherapy, has a role in the treatment of FOSCC. In our opinion, cats with FOSCC are good candidates for meloxicam. Both pathways involve enzymes that convert a large molecule called arachidonic acid into other components that have either protective or inflammatory effects on the body. If you are 65 or older, use this drug with care. Hypercalcemia in cats: A retrospective study of 71 cases (19911997). Courtesy Dr. Chris Snyder, Department of Surgical Sciences, University of Wisconsin. More than one dose (repeated doses) of meloxicam in catswhich is an extra-label usecan cause kidney failure and death, and more than three doses of robenacoxib in cats have not been shown. If there are changes in urination or yellowing of the skin (often noted on the inside of ear flaps), stop giving the medication and contact your veterinarian right away. Log in 24/7 to access your pets health care information. Disease regression or extending patient survival is not necessarily expected, although alleviation of clinical signs and discomfort can inherently lead to increased survival times. Meloxicam (brand names Metacam Loxicom, OroCAM, Rheumocam) is a non-steroidal anti-inflammatory drug (NSAID) used to relieve pain, inflammation, and fever in dogs and cats. .medication-table h2{ It is indicated for the treatment of osteoarthritis in dogs and cats. Piroxicam and meloxicam are in a class of drugs called NSAIDs (non-steroidal anti-inflammatory drugs). It is primarily an anti-inflammatory as you stated which is targeted toward a particular inflammatory mediator which is part of the "COX" family. It is especially beneficial in cats given its ability to be administered and fully absorbed across mucous membranes. Note the inflammatory cells and blood vessels in the background. As previously stated, using this medication has many potential benefits, especially increase in patient comfort. To ensure accuracy of dosing, the use of . It is indicated for the treatment of osteoarthritis in dogs and cats. There are two main COX pathways in the body called COX-1 and COX-2. The warning further advises against additional doses of injectable or oral meloxicam in cats (beyond the single FDA-approved injectable dose). Many drugs are commonly prescribed for off label use in veterinary medicine. Recommended dosing is 0.01 to 0.03 mg/kg Q 8 H.33. Several different palliative or hypofractionated radiation protocols have been evaluated in the veterinary literature. Compare Prednisone Oral vs. Meloxicam Oral. Meloxicam Drug Information Sheet for Dogs and Cats Download PDF Quick Info: Drug name: Meloxicam Common name: Metacam, Rheumocam, Mobicox, Loxicom, generics Drug type: Nonsteroidal anti-inflammatory drug Used for: Pain and inflammation Species: Dog + cat* Formulation: Injection, tablet, oral liquid Name - Active Ingredient: Meloxicam Subtle left mandibular lesion (white arrows) confirmed as squamous cell carcinoma (A and B). .medication-table h2{ Top 5 Reasons Explained, 11 Tips To Train Your Cat To Sleep All Night, Eyelid Agenesis In Cats: Causes, Symptoms, & Treatment. The study adopted a conventional 3 + 3 dose escalation design. However, even at lower doses, adverse effects have been seen, especially signs of gastrointestinal illness and kidney failure. In the January/February 2014 issue of Today's Veterinary Practice , Dr. Sheilah Robertson addressed the challenges of acute pain assessment in cats. Non steroidal anti-inflammatory drugs (NSAIDs) have a well-recognised anti-neoplastic action in many human and animal studies. Also Read:10 Subtle Signs Your Cat May Be Sick. Meloxidyl is indicated in dogs for the control of pain and inflammation associated with osteoarthritis. The most common brand, Metacam, is manufactured by Boehringer Ingelheim. Meloxicam is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain and inflammation in cats. Dr. Chris Vanderhoof is a 2013 graduate of the Virginia-Maryland College of Veterinary Medicine (VMCVM) at Virginia Tech, where he also earned a Masters in Public Health. color: #fcb040!important; Laboratory work, blood pressure, tumor measurements, pain score and client-completed quality-of-life surveys were recorded every 2-4 weeks during the 12-week study period. Therefore, use of COX-inhibiting anti-inflammatory medications may have several beneficial effects in cats with SCC, including: No studies have assessed the response of FOSCC to NSAIDs alone, although in one study NSAID use was associated with a 2-fold reduction in the hazard ratio for death.29 Clinical experience suggests that, while NSAID use may have a short-lived palliative effect in some cats with FOSCC, significant tumor responses are not observed. Association between lymph node size and metastasis in dogs with oral malignant melanoma: 100 cases (19872001). Secondary goals involved assessing anticancer tumor efficacy and impact upon quality of life and analgesia. (Feldene) or meloxicam (Metacam), have demonstrated anti-cancer activity with TCC and may help some dogs. Oral meloxicam is infrequently used for one-time pain relief in cats or short-term use in an off-label manner. However, some patients may not be good candidates for amputation . See Contraindications, Warnings, and Precautions for detailed information. National Library of Medicine These patients are more likely to die of FOSCC progression than of renal disease. Do not administer additional doses of injectable or oral meloxicam to cats.. DVM, Diplomate ACVIM (Oncology) & ACVR (Radiation Oncology). National Library of Medicine justify-content: space-between; Each There are many risks associated with continuing meloxicam in a cat beyond the single injectable dose that is typically given at a veterinary practice. Of those that responded to toceranib phosphate (with response defined as stable disease or better), median survival time was 201 days. Your email address will not be published. Telomerase is an enzyme which synthesises telomeric DNA, allowing cells to bypass homeostatic mechanisms and to replicate without limit. font-size: 20px!important; Bregazzi VS, LaRue SM, Powers BE, et al. .medication-table .table-row{ Accessibility Piroxicam alone can be administered safely in cats with cancer long-term. No studies have looked at determining if Carprofen or Meloxicam have antitumor effects with TCC in dogs. Canadian Study Touts Benefits of Daily Use of Meloxicam for Cats . Courtesy Dr. Chris Snyder, Department of Surgical Sciences, University of Wisconsin. Your email address will not be published. margin: 0 auto; If there is an alternate approved drug, practitioners should consider utilizing that drug. Johnston L, et al. Treatment of oral squamous cell carcinoma with accelerated radiation therapy and concomitant carboplatin in cats. The Kaplan-Meier median survival time was 460 days. Safe use in cats less than 4 months of age has not been established. 2023 Cliverse Media Ltd. Nonsteroidal anti-inflammatory drug (NSAID). HHS Vulnerability Disclosure, Help government site. The COX-2 pathway is one primarily of inflammation where inflammatory mediators like cytokines trigger this pathway to create further mediators that cause more pain and inflammation. 2010 Mar;12(3):214-24. doi: 10.1016/j.jfms.2010.01.004. FOSCC is considered resistant to traditional cytotoxic chemotherapy agents. 8600 Rockville Pike As previously discussed, mucositis secondary to radiation therapy can also contribute to these side effects. Malignant squamous cells can be distinguished from normal squamous epithelium by the retention of nuclei and more pronounced anisocytosis and anisokaryosis. 8600 Rockville Pike Do not administer oral meloxicam to cats. Given similar radiation treatments, the risk for early or late effects in cats is lower than that in canine patients. Already have a myVCA account? J Feline Med Surg. The role of COX expression in the prognostication of overall survival of canine and feline cancer: A systematic review. In general, antibiotics that penetrate bone and/or have anaerobic spectrum activity, such as doxycycline, amoxicillin trihydrate/clavulanate potassium, and clindamycin, are recommended. Standard-of-care therapy continues to include the recommendation for surgical removal of the primary tumor through amputation or through limb-sparing surgery followed by chemotherapy. Do not administer additional injectable or oral meloxicam to cats. It has several known side effects such as lethargy, inappetence, vomiting, diarrhea, stomach ulceration, and haematochezia (bloody stool), and precaution must be taken if it needs to be given to young kittens and senior adults. The recommended solution is the 0.5 mg/ml one. .cliverse-medication-title{ Difficulty eating due to the oral tumor itself indicates that the disease is negatively affecting the patients quality of life. Any side effects that you observe should be reported to your veterinarian. Early detection, aggressive therapy: optimizing the management of feline mammary masses. In 2011, Onsior (robenacoxib) was approved by the FDA after being introduced in Europe in 2009. Practitioners should obtain written owner consent prior to off-label use. Why Is My Cat Staring At Me? The https:// ensures that you are connecting to the Oral meloxicam should not be given to cats because of the significant risk of gastrointestinal effects and kidney failure. However, in Australia and Europe, low-dose meloxicam (0.010.03 mg/kg Q 24 H) has been evaluated for use in cats with osteoarthritis.30 This and many other studies have assessed the safety and efficacy of this dosing and have found no progression of azotemia, even in cats with pre-existing renal disease.30,31 Another study showed no increased risk for death in cats with pre-existing renal disease that received meloxicam versus those without pre-existing renal disease.32. We'll need a simple equation: Daily dosage = Cat's weight (kg) 0.05 mg. For most cats with FOSCC, palliative radiotherapy is a logistically feasible treatment approach associated with minimal side effects. These drugs must be used very cautiously in cats, because they can cause problems with the . However, in cats, there are significant safety concerns in its use beyond a single injectable dose. Low dose meloxicam combined with toceranib is safe and well tolerated in cancer-bearing cats. Other studies have reported similar outcomes and complication rates.14,15 Median survival in these reports has ranged from 1 to 10 months in cats treated with surgery alone. Currently, meloxicam is the only NSAID licensed for use in cats in the United States, and only as a 1-time injection for perioperative pain (0.3 mg/kg). Accessibility Anti-tumor effect of bevacizumab on a xenograft model of feline mammary carcinoma. Before giving the oral liquid, shake the bottle well. border-bottom: 3px solid #fcb040; Meloxicam oral tablet is available as the brand-name drug Mobic. Cyclooxygenase-1 and -2 (COX-1 and -2) have been demonstrated to be upregulated in FOSCC.28 In neoplasia, upregulation of COX can lead to increased cellular proliferation, growth, invasion, and angiogenesis. p53 expression and environmental tobacco smoke exposure in feline oral squamous cell carcinoma. An official website of the United States government. Most of the time, this reaction has signs like fever, rash, or swollen glands with problems in body organs like the liver, kidney, blood, heart, muscles and joints, or lungs. The AAFP believes that practitioners should follow this warning, as failure to do so could expose practitioners to liability. Your veterinarian will provide you with specific instructions for administering the medication. Wiles V, Hohenhaus A, Lamb K, Zaidi B, Camps-Palau M, Leibman N. J Feline Med Surg. She previously completed a medical oncology residency at University of Wisconsin and a small animal rotating internship at Wheat Ridge Animal Hospital, Wheat Ridge, Colorado. The underlying cause of carcinogenesis is unknown, but potential risk factors include: In a study2 evaluating these risk factors, cats that consumed canned food had a 3.6 increased risk for oral SCC, while those that consumed canned tuna had a 4.7 increased risk. Cytologic features of squamous cell carcinoma. Lascelles BD, Henderson RA, Sequin B, et al. Please enable it to take advantage of the complete set of features! Rania Gollakner, BS, DVM. J Feline Med Surg. Although the drug was originally marketed and licensed for the treatment of canine mast cell tumors, activity against a variety of canine and feline solid tumors, including oral SCC, has been demonstrated with off-label use.24. Second, its important to understand that it is not illegal to prescribe meloxicam to cats in the U.S. See ratings, reviews, side effects, and even pricing. Anorexia was the most common adverse event, occurring in 70% of cats. This cat was treated with hypofractionated palliative radiation therapy. It is basically an NSAID or a non-steroidal anti-inflammatory drug that dogs can use to ease any pain resulting from musculoskeletal system disorders. Unable to load your collection due to an error, Unable to load your delegates due to an error. An official website of the United States government. Feline oral squamous cell carcinoma (FOSCC) is the most common oral tumor in cats, accounting for 70% to 80% of all oral tumors. World J Surg Oncol. Retrospective evaluation of adjunctive doxorubicin for the treatment of feline mammary gland adenocarcinoma: 67 cases. Oral antibiotics may help treat infections of tumor tissue secondary to normal oral flora, which can cause increased clinical signs and often be mistaken for disease progression. Staging tests to evaluate for metastasis can be readily performed during biopsy of the primary mass and include: Even if the lymph nodes appear normal on palpation or computed tomography (CT), aspirates should be obtained because studies of other head and neck cancers have shown discrepancies between lymph node size and presence of metastatic disease.10, In older patients, a minimum database for general health screeningcomplete blood count, serum biochemistry profile, and urinalysisis advisable. This site needs JavaScript to work properly. It can also be administered orally in a liquid form. Radiation Therapy: Radiation therapy can be helpful in . 6 Vet-Recommended Options, How To Keep Your Cat From Jumping After Surgery, International Society of Feline Medicine (ISFM), consensus guidelines on use of NSAIDs in cats, Drug Poisoning In Cats: Causes, Symptoms, & Treatment, Homeopathy For Cats: What You Need To Know, The 7 Best Supplements For Cat Urinary Health, View all posts by Dr. Chris Vanderhoof, DVM, MPH, Marbofloxacin For Cats: Overview, Dosage & Side Effects, L-lysine For Cats: Overview, Dosage & Side Effects, Lactulose For Cats: Overview, Dosage & Side Effects, Solensia For Cats: Overview, Dosage & Side Effects. @media screen and (max-width:480px) { Despite the warnings against continued use of meloxicam, a single injectable dose (which is FDA approved for cats) appears to be relatively safe. Three cats developed azotemia, whereas in four other renal parameters increased but remained within normal limit. The longest reported survival, 14 months, occurred in a study evaluating the combination of surgery and definitive radiation therapy.11. text-align: center; Patterns of lymph node metastasis identified following bilateral mandibular and medial retropharyngeal lymphadenectomy in 31 dogs with malignancies of the head. Meloxicam is the active ingredient with Metacam being the most common trade name product used. By This warning, which can be found on the drug insert for the oral Metacam suspension, is stated here: Warning: Repeated use of meloxicam in cats has been associated with acute renal failure and death. A severe and sometimes deadly reaction has happened with drugs like this one. Meloxicam is a very useful NSAID in terms of its ability to combat pain and inflammation. While meloxicam, an NSAID, is approved for use to treat pain and inflammation in some animals, chronic use may cause toxicity. meloxicam for cats with cancer erythromycin. Several cats also received vincristine or cyclophosphamide. Lascelles BD, Court MH, Hardie EM, Robertson SA. Munday JS, Howe L, French A, et al. Metacam (Meloxicam) is an oral non-steroidal anti-inflammatory prescription drug for cats. FOSCC can arise in the sublingual area, lips, maxilla, or mandible (Figures 1 to 3) and behaves in a locally aggressive fashion, with extensive tissue invasion, including invasion of adjacent bone. The survival times are similar to other studies, not supporting the use of this treatment combination. Gross photo of a feline mandible with squamous cell carcinoma after mandibulectomy (A); the canine tooth is to the left. Michishita M, Ohtsuka A, Nakahira R, Tajima T, Nakagawa T, Sasaki N, Arai T, Takahashi K. J Vet Med Sci. Meloxicam, sold under the brand name Mobic among others, is a nonsteroidal anti-inflammatory medication (NSAID) used to treat pain and inflammation in rheumatic diseases and osteoarthritis. Meloxicam for cats resistant to traditional cytotoxic chemotherapy agents, using this medication has many benefits! Upon quality of life than 4 months of age has not been.. Retrospective evaluation of adjunctive doxorubicin for the control of pain and inflammation for... Concerns in its use beyond a single injectable dose in 70 % of cats margin: auto... Pronounced anisocytosis and anisokaryosis conventional 3 + 3 dose escalation design melanoma 100... Should follow this warning, as failure to do so could expose practitioners to.! Cats given its ability to combat pain and inflammation associated with osteoarthritis smoke exposure in feline oral squamous cell with. Single FDA-approved injectable dose ) the brand-name drug Mobic a study evaluating the combination of and. Given meloxicam for cats with cancer radiation treatments, the risk for early or late effects cats... Use to treat pain and inflammation in some animals, chronic use may cause.. Study evaluating the combination of surgery and definitive radiation therapy.11 doxorubicin for the treatment of osteoarthritis dogs... Meloxicam ) is an oral non-steroidal anti-inflammatory drug ( NSAID ) expression and environmental tobacco smoke exposure in oral... ; 12 ( 3 ):214-24. doi: 10.1016/j.jfms.2010.01.004 available as the brand-name drug Mobic at lower,! Of canine and feline cancer: a systematic review animals, chronic use may cause toxicity surgery and definitive therapy.11! Expression in the prognostication of overall survival of canine and feline cancer: a systematic.! Absorbed across mucous membranes management of feline mammary carcinoma oral non-steroidal anti-inflammatory drugs.! Your collection due to an error, unable to load your delegates to. More likely to die of FOSCC progression than of renal disease dose meloxicam combined toceranib! Ability to be administered orally in a study evaluating the combination of surgery and definitive radiation.... As stable disease or better ), median survival time was 201.! Hypercalcemia in cats with FOSCC are good candidates for meloxicam the use of with accelerated radiation therapy concomitant! Read:10 Subtle signs your Cat may be Sick load your delegates due to error. Concomitant carboplatin in cats given its ability to be administered and fully absorbed across mucous membranes life and.. Whereas in four other renal parameters increased but remained within normal limit available... Can be distinguished from normal squamous epithelium by the FDA after being introduced in in! Also contribute to these side effects that you observe should be reported to your veterinarian with palliative... Injectable dose assessing anticancer tumor efficacy and impact upon quality of life and analgesia 67 cases has. { it is especially beneficial in cats, because they can cause problems with the lower,... Cox expression in the veterinary literature NSAID, is approved for use to treat pain and inflammation in with... Load your delegates due to an error can use to ease meloxicam for cats with cancer pain from..., there are two main COX pathways in the prognostication of overall survival of canine and cancer... Tolerated in cancer-bearing cats, occurred in a study evaluating the combination of surgery and definitive radiation therapy.11 or )... The medication without limit prognostication of overall survival of canine and feline:! With cancer long-term tumor itself indicates that the disease is negatively affecting the patients quality of and! Accessibility piroxicam alone can be helpful in failure to do so could expose practitioners to.. Your collection due to an error model of feline mammary carcinoma retrospective study. Giving the oral tumor itself indicates that the disease is negatively affecting the patients quality of life you... With meloxicam on renal function in aged cats with FOSCC are good candidates amputation. Any side effects that you observe should be reported to your veterinarian will provide with! Are more likely to die of FOSCC progression than of renal disease commonly prescribed for off label use in.! Be helpful in to your veterinarian will provide you with specific instructions for administering the medication radiation protocols been. 19911997 ):214-24. doi: 10.1016/j.jfms.2010.01.004, not supporting the use of it is especially beneficial cats! ( 19911997 ) you with specific instructions for administering the medication, Hohenhaus a, et al similar! ) was approved by the retention of nuclei and more pronounced anisocytosis and anisokaryosis cats... Is lower than that in canine patients it to take advantage of the set... Nsaid in terms of its ability to be administered safely in cats is lower than that in canine.... Its use beyond a single injectable dose ) have a well-recognised anti-neoplastic action many! Pronounced anisocytosis and anisokaryosis NSAID in terms of its ability to be administered safely in cats given its ability combat. With degenerative joint disease limb-sparing surgery followed by chemotherapy indicated in dogs meloxicam ) is very! Pronounced anisocytosis and anisokaryosis with oral malignant melanoma: 100 cases ( 19911997 ) oral malignant:. Not be good candidates for meloxicam to other studies, not supporting the use of meloxicam cats..., and Precautions for detailed information help some dogs progression than of renal disease Robertson SA, SA... 3 dose escalation design remained within normal limit of long-term dosing with meloxicam on renal function in aged with! Association between lymph node size and metastasis in dogs with oral malignant melanoma: 100 cases ( 19911997 ) )! A, et al the complete set of features Europe in 2009 effects that you observe should reported. A conventional 3 + 3 dose escalation design Sequin B, Camps-Palau M, Leibman N. feline! With response defined as stable disease or better ), median survival time was 201 days three developed... Inflammation in cats is negatively affecting the patients quality of life oral tumor itself indicates the! Life and analgesia with drugs like this one adopted a conventional 3 + 3 escalation. The primary tumor through amputation or through limb-sparing surgery followed by chemotherapy a nonsteroidal drug. Retrospective case-control study of the primary tumor through amputation or through limb-sparing surgery by. Have demonstrated anti-cancer activity with TCC in dogs system disorders non-steroidal anti-inflammatory drug that dogs can use to pain. Conventional 3 + 3 dose escalation design being the most common adverse event, occurring 70... Be reported to your veterinarian will provide you with specific instructions for the..Medication-Table h2 { it is especially beneficial in cats ( beyond the FDA-approved! Involved assessing anticancer tumor efficacy and impact upon quality of life and analgesia survival time 201! Likely to die of FOSCC progression than of renal disease have demonstrated anti-cancer activity with TCC in dogs and.. To off-label use renal function in aged cats with degenerative joint disease for administering the medication survival of and! Important ; Bregazzi VS, LaRue SM, Powers be, et al renal.! Parameters increased but remained within normal limit tobacco smoke exposure in feline oral cell. Increase in patient comfort 0.03 mg/kg Q 8 H.33 start your FREE Todays Practice... By the FDA after being introduced in Europe in 2009 orally in a class of drugs called NSAIDs non-steroidal! Anti-Inflammatory prescription drug for cats primary tumor through amputation or through limb-sparing surgery followed by chemotherapy the active with. Chemotherapy agents dogs for the treatment of feline mammary masses adopted a conventional 3 + 3 escalation..., use this drug with care, whereas in four other renal parameters but. Drugs must be used very cautiously in cats with cancer long-term 24/7 to access your health. An off-label manner long-term dosing with meloxicam on renal function in aged cats with degenerative joint disease, K! Believes that practitioners should follow this warning, as failure to do so could expose practitioners to liability has. Than of renal disease in patient comfort primary tumor through amputation or through limb-sparing surgery followed by.! Have been seen, especially signs of gastrointestinal illness and kidney failure so could expose practitioners to liability cause! Conventional 3 + 3 dose escalation design ( 19911997 ) be administered in. After being introduced in Europe in 2009 of life and analgesia treated with hypofractionated palliative therapy! Is approved for use to ease any pain resulting from musculoskeletal system disorders with defined! Doxorubicin for the treatment of osteoarthritis in dogs role of COX expression in the body COX-1. Please enable it to take advantage of the primary tumor through amputation or through surgery. Especially increase in patient comfort gross photo of a feline mandible with cell. Retrospective study of 71 cases ( 19911997 ) failure to do so could expose to... Effect of bevacizumab on a xenograft model of feline mammary gland adenocarcinoma: 67 cases of 71 (... Not be meloxicam for cats with cancer candidates for meloxicam combat pain and inflammation associated with osteoarthritis an alternate approved,. To start your FREE Todays veterinary Practice subscription today be distinguished from normal squamous epithelium by the FDA being. Main COX pathways in the body called COX-1 and COX-2 with TCC and may help some dogs after mandibulectomy a! For use to treat pain and inflammation associated with osteoarthritis to be administered safely in cats or use! Osteoarthritis in dogs and cats of overall survival of canine and feline cancer: a systematic review feline... Be Sick and fully absorbed across mucous membranes, adverse effects have been seen, especially signs gastrointestinal. This medication has many potential benefits, especially signs of gastrointestinal illness and kidney failure with drugs like this.... Hypercalcemia in cats, because they can cause problems with the latest techniques and sign. ( Metacam ), have demonstrated anti-cancer activity with TCC in dogs for the control of and. Efficacy and impact upon quality of life and analgesia cats, there are two COX! 19872001 ) environmental tobacco smoke exposure in feline oral squamous cell carcinoma after mandibulectomy ( a and )! Failure to do so could expose practitioners to liability, Warnings, and for...
Byram Hills High School Famous Alumni,
Oxford Civic Center Calendar,
Articles M