Surgical Procedures for Vestibular Dysfunction When is surgery necessary? 

When medical treatment isn’t effective in controlling vertigo and other symptoms caused by vestibular system dysfunction, surgery may be considered. The type of surgery performed depends upon each individual’s diagnosis and physical condition. Surgical procedures for peripheral vestibular disorders are either corrective or destructive. The goal of corrective surgery is to repair or stabilize inner ear function. The goal of destructive surgery is to stop the production of sensory information or prevent its transmission from the inner ear to the brain.  The types of surgeries used if non-invasive treatments are not successful are possibly: 

Labyrinthectomy:

A labyrinthectomy is a destructive procedure used for Ménière’s disease. The balance end organs are removed so that the brain no longer receives signals from the parts of the inner ear that sense gravity and motion changes. The hearing organ (cochlea) is also sacrificed with this procedure.

Vestibular nerve section:

A vestibular nerve section is a destructive procedure used for Ménière’s disease. The vestibular branch of the vestibulo-cochlear nerve is cut in one ear to stop the flow of balance information from that ear to the brain. The brain can then compensate for the loss by using only the opposite ear to maintain balance.

Chemical labyrinthectomy:

A chemical labyrinthectomy is also known as transtympanic or intratympanic treatment or gentamicin infusion. This is a destructive procedure used for Ménière’s disease. An antibiotic called gentamicin is introduced into the middle ear and absorbed via the round window. The drug destroys the vestibular hair cells so that they cannot send signals to the brain.

Endolymphatic sac decompression:

Endolymphatic sac decompression is a stabilizing procedure sometimes used for Ménière’s disease or secondary endolymphatic hydrops to relieve endolymphatic pressure in the cochlea and vestibular system. A variety of techniques exist. One method involves allowing the sac to decompress by removing the mastoid bone surrounding it. Other methods involve inserting a shunt (a tube or strip) into the endolymphatic sac so that, theoretically, excess fluid can drain out into the mastoid cavity or other location. The effectiveness of decompression techniques in controlling vertigo remains in doubt.

Oval or round window plugging:

If the exercises described above are ineffective in controlling symptoms, symptoms have persisted for a year or longer,  and the diagnosis is very clear, a surgical procedure called “posterior canal plugging” may be recommended. Canal plugging blocks most of the posterior canal’s function without affecting the functions of the other canals or parts of the ear. This procedure poses a substantial risk to hearing — ranging from 3-20%, but is effective in about 85-90% of individuals who have had no response to any other treatment (Shaia et al, 2006; Ahmed et al, 2012). The risk of the surgery to hearing derives from inadvertent breaking into the endolymphatic compartment while attempting to open the bony labyrinth with a drill. Sensibly, canal plugging for BPPV (note the first letter stands for “benign”) is rarely undertaken these days due to the risk to hearing.

Alternatives to plugging:

Singular nerve section is the main alternative. Dr Gacek (Syracuse, New York) has written extensively about singular nerve section (Gacek et al, 1995). Interestingly, Dr. Gacek is the only surgeon who has published any results with this procedure post 1993 (Leveque et al, 2007). Singular nerve section is very difficult because it can be hard to find the nerve.

Dr. Anthony (Houston, Texas), advocates laser assisted posterior canal plugging.  It seems to us that these procedures, which require unusual amounts of surgical skill, have little advantage over a conventional canal plugging procedure.  Oval or round window plugging is a stabilizing procedure sometimes used for repair of perilymph fistulas. Openings in the oval and/or round windows are patched with tissue taken from the external ear or from behind the ear so that perilymph fluid does not leak through the fistulas.

 Pneumatic equalization (PE) tubes:

Pneumatic equalization (PE) is a stabilizing procedure sometimes used for treating perilymph fistulas. A tube is inserted through the tympanic membrane (eardrum) with one end in the ear canal and the other in the middle ear, to equalize the air pressure on the two sides of the eardrum.

Canal partitioning (canal plugging):

Canal partitioning is a stabilizing procedure sometimes used for treating BPPV or superior semicircular canal dehiscence. The problematic semicircular canal is partitioned or plugged with small bone chips and human fibrinogen glue to stop the movement of endolymph and foreign particles within the canal so that it no longer sends false signals to the brain.

Microvascular decompression:

Microvascular decompression is performed to relieve abnormal pressure of the vascular loop (blood vessel) on the vestibulo-cochlear nerve.

Stapedectomy:

Stapedectomy is a stabilizing procedure sometimes used for otosclerosis. It is accomplished by replacing the stapes bone with a prosthesis.

Acoustic neuroma (vestibular schwannoma): 

This procedure involves the removal of a noncancerous tumor that grows from the tissue of the vestibular branch of the vestibulo-cochlear nerve.

Cholesteatoma removal:

This procedure involves the removal of a skin growth that starts in the middle ear and that can secrete enzymes that destroy bone and surrounding structures.

Ultrasound surgery:

Ultrasound is applied to the ear to destroy the balance end organs so that the brain no longer receives signals from the parts of the ear that sense gravity and motion changes. Cochlear dialysis Cochlear dialysis is a stabilizing procedure sometimes used to promote movement of excess fluid out of the inner ear by filling the scala tympani with a chemical solution.

Thanks to NYU Medical Hospital in Manhattan, NY you can Click here to download the “Surgery for Peripheral Vestibular Disorders” publication. – See more at: http://vestibular.org/understanding-vestibular-disorders/treatment/vestibular-surgery#sthash.GDeNWxjl.dpuf.

If you have this problem and need a great hospital than let us look at the ranking of hospitals:

Of all 180 hospitals in the New York, New York metropolitan area, the 53 listed below are the top-ranking. This metro area, also called NYC, includes Long Island, Westchester County, and northern New Jersey. I know if I had a problem that I could not get rid of immediately with a antibiotic simple cure I would next want to go to the best if my county’s hospital couldn’t remove the problem completely. So here through “US News and World Report” via the internet they show the following information on the best hospitals in NYC and Northern NJ: (Look below or to the next page)

These are their rankings on Columbia Presbyterian and NYU, NATIONALLY, in the following categories:

Starting with the best is Columbia Presbyterian in NY, for those in NY, as your #1 choice:

Adult Specialties

This hospital was among 144 facilities—roughly 3 percent of the 4,743 analyzed for the latest Best Hospitals rankings—to be ranked in even one of the 16 specialties.

COLUMBIA PRESBYTERIAN RATINGS:

NYU HOSPITAL RATINGS:

• #50 in Cancer
• #11 in Cardiology & Heart Surgery
• #22 in Diabetes & Endocrinology
• #21 in Ear, Nose & Throat
• #26 in Gastroenterology & GI Surgery
• #8 in Geriatrics
• #38 in Nephrology

• #8 in Neurology & Neurosurgery************************ Impressive for neuro surgery of the ear.
• #4 in Orthopedics
• #33 in Pulmonology
• #9 in Rehabilitation
• #6 in Rheumatology
• #12 in Urology

Gynecology

For further checking of hospitals go to http://health.usnews.com/best-hospitals/area/ny/new-york-presbyterian-university-hospital-of-columbia-and-cornell-6210024 since hospitals do change yearly in their scores and this is the most recent.

“BPPV with the most common variant (crystals in the posterior SCC) can be treated successfully — with no tests, pills, surgery or special equipment — by using the Epley maneuver.  If some situations pills may be ordered (Ex. antivert)”

John Hopkins Medicine

(https://www.hopkinsmedicine.org/health/conditions-and-diseases/benign-paroxysmal-positional-vertigo-bppv)

Reassurance and avoidance of the provocating position. Antivertigo drugs: prochlorperazine (stemetil), Cinnarzine (stugeron) and Betahistine (Serc). Surgical: Posterior semicircular canal denervation.

TREATMENT

In all cases the doctor first has the patient (pt.) in their office and either through them or through physical therapy ordered by the M.D. after evaluating the pt with diagnosing the pt. with BPPV in treating the pt. using exercises which help in high percentages resolving the vertigo but continuing them when the vertigo is gone will do very little help unfortunately including it commonly comes back several weeks to months later and the exercises help more than. These exercises used are:

OFFICE TREATMENT OF BPPV: The Epley and Semont Maneuvers

There are two treatments of BPPV that are usually performed in the doctor’s office. Both treatments are very effective, with roughly an 80% cure rate, ( Herdman et al, 1993; Helminski et al, 2010). If your doctor is unfamiliar with these treatments, you can find a list of clinicians who have indicated that they are familiar with the maneuver from the Vestibular Disorders Association (VEDA) .

The maneuvers, named after their inventors, are both intended to move debris or “ear rocks” out of the sensitive part of the ear (posterior canal) to a less sensitive location. Each maneuver takes about 15 minutes to complete. The Semont maneuver (also called the “liberatory” maneuver) involves a procedure whereby the patient is rapidly moved from lying on one side to lying on the other (Levrat et al, 2003). It is a brisk maneuver that is not currently favored in the United States, but it is 90% effective after 4 treatment sessions. In our opinion, it is equivalent to the Epley maneuver as the head orientation with respect to gravity is very similar, omitting only ‘C’ from the figure to the right.

The Epley maneuver is also called the particle repositioning or canalith repositioning procedure. It was invented by Dr. John Epley.  It involves sequential movement of the head into four positions, staying in each position for roughly 30 seconds. The recurrence rate for BPPV after these maneuvers is about 30 percent at one year, and in some instances a second treatment may be necessary.

When performing the Epley maneuver, caution is advised should neurological symptoms (for example, weakness, numbness, visual changes other than vertigo) occur. Occasionally such symptoms are caused by compression of the vertebral arteries (Sakaguchi et al, 2003), and if one persists for a long time, a stroke could occur. If the exercises are being performed without medical supervision, we advise stopping the exercises and consulting a physician. If the exercises are being supervised, given that the diagnosis of BPPV is well established, in most cases we modify the maneuver so that the positions are attained with body movements rather than head movements.

After either of these maneuvers, you should be prepared to follow the instructions of your doctor or physical therapist who should give you written instructions on them to take home with you, which are aimed at reducing the chance that debris might fall back into the sensitive back part of the ear. Not always the case.

       What to expect from your doctor on your visit with vertigo

A doctor who sees you for symptoms common to BPPV may ask a number of questions, such as:

• What are your symptoms, and when did you first notice them?
• Do your symptoms come and go? How often?
• How long do your symptoms last?
• Is one or both of your ears affected?
• Does anything in particular seem to trigger your symptoms, such as certain types of movement or activity?
• Do your symptoms include vision problems?
• Do your symptoms include nausea or vomiting?
• Do your symptoms include headache?
• Have you lost any hearing?
• Have you had any weakness, numbness or tingling in your arms or your legs?
• Have you had any difficulty talking or walking?
• Have you had chest pain?
• Are you being treated for any other medical conditions?
• What medications are you currently taking, including over-the-counter and prescription drugs as well as vitamins and supplements?

Need assistance in where to go for help treatment on surgery in the hospitat for benign posterior paroxysmal vertigo?  Than tune in tomorrow to Part IV.

“The signs and symptoms of BPPV can come and go and commonly last less than one minute. Episodes of BPPV can disappear for some time and then recur. Symptoms varying from dizziness, unsteadiness, nausea, vomiting, and a sense of feeling everything around you is spinning. Often, there’s no known cause for BPPV. This is called idiopathic BPPV. Although BPPV is uncomfortable, it rarely causes complications. The dizziness of BPPV can make you unsteady, which may put you at greater risk of falling.”

MAYO CLINIC (https://www.mayoclinic.org/diseases-conditions/vertigo/symptoms-causes/syc-20370055)

Causes of BPPV:

Timothy C. Hain MD of dizziness and balance.com states The most common cause of BPPV in people under age 50 is head injury . The head injury need not be that direct – -even whiplash injuries have a substantial incidence of BPPV (Dispenza et al, 2011). There is also a strong association with migraine (Ishiyama et al, 2000). BPPV becomes much more common with advancing age (Froeling et al, 1991) and in older people, the most common cause is degeneration of the vestibular system of the inner ear. Viruses affecting the ear such as those causing vestibular neuritis and Meniere’s disease are significant causes(Batatsouras et al, 2012).

Occasionally BPPV follows surgery, including dental work, where the cause is felt to be a combination of a prolonged period of supine positioning, or ear trauma when the surgery is to the inner ear (Atacan et al 2001). While gentamicin toxicity is rarely encountered, BPPV is common in persons who have been treated with ototoxic medications such as gentamicin (Black et al, 2004). In half of all cases, BPPV is called “idiopathic,” which means it occurs for no known reason. Other causes of positional symptoms are discussed here.

Web MD points out tiny calcium “stones” inside your inner ear canals help you keep your balance. Normally when you move a certain way, such as when you stand up or turn your head, these stones move around. But things like infection or inflammation can stop the stones from moving as they should. This unfortunately sends a false message to your brain and causes the vertigo. About half the time, doctors can’t find a specific cause for BPPV.

When a cause can be determined, BPPV is often associated with a minor to severe blow to your head. Less common causes of BPPV include disorders that damage your inner ear or, rarely, damage that occurs during ear surgery or during prolonged positioning on your back. BPPV also has been associated with migraines. In many cases the doctors can’t figure out the cause.

Know The ear’s role

Inside your ear is a tiny organ called the vestibular labyrinth. It includes three loop-shaped structures (semicircular canals) that contain fluid and fine, hair-like sensors that monitor the rotation of your head.

Other structures (otolith organs) in your ear monitor movements of your head — up and down, right and left, back and forth — and your head’s position related to gravity. These otolith organs — the utricle and saccule — contain crystals that make you sensitive to gravity.

For a variety of reasons, these crystals can become dislodged. When they become dislodged, they can move into one of the semicircular canals — especially while you’re lying down. This causes the semicircular canal to become sensitive to head position changes it would normally not respond to. As a result, you feel dizzy. Depending what section of the semicircular canal the problem is in will be a factor with the actual result on the crystals or rocks flowing freely or become stuck together causing a blockage in one of the canals. The other factor that determines this is the etiology for it occuring (ex. Dehydration or blow to the head).

Complications of BPPV:

Benign paroxysmal positional vertigo occurs most often in people age 60 and older, but can occur at any age. Aside from aging, there are no definite factors that may increase your risk of benign paroxysmal positional vertigo. However, a head injury or any other disorder of the balance organs of your ear may make you more susceptible to BPPV.

Although benign paroxysmal positional vertigo (BPPV) is uncomfortable, it rarely causes complications. In rare cases, if severe, persistent BPPV causes you to vomit frequently, you may be at risk of dehydration. The dizziness of BPPV can put you at greater risk of falling. It is more of a headache in going through the time to resolve the vertigo possibly affecting people in doing their regular activities of living for a week to several weeks. For some it never comes back but for many it does after several months depending on what the cause is.

“In general; Benign paroxysmal positional vertigo (BPPV) is an inner ear disorder. A person with BPPV experiences a sudden spinning sensation whenever they move their head. BPPV isn’t a sign of a serious problem. If it doesn’t disappear on its own within six weeks, a simple in-office procedure can help ease your symptoms.”

Cleveland Clinic (https://my.clevelandclinic.org/health/diseases/11858-benign-paroxysmal-positional-vertigo-bppv)

If one day you start the day going to work than come home feeling like a sinus infection that appears to be spreading to the ears and after going to bed several hours upon wakening I sat up on my bed finding yourself pulling to one side that you think the cause is an ear infection but it could be something else.  When I was getting up and feeling dizzy but made it downstairs to eat a meal but due to the dizziness I vomited causing dizziness to increase terribly (like if sea sick or even like too much alcohol followed with vomiting and now everything’s spinning to the point you can’t get up from the ground) and got my self safely to the ground and couldn’t get up.   This all happened to me one year and when going to the MD that night I was sent to the ER for being ruled out initially of a stroke or transient ischemic attack.  I was aggravated and went.  I than was finding out in the ERmit wasn’t a stroke or TIA, which is what I thought would be the result, but their still was a reason for it.  What might this be?  I was diagnosed with BPPV for severe dehydration and it took me a week through exercises and taking meclizine, also known as antivert, that took my dizziness away.

This could be an ear infection with BPPV or just BPPV itself; this abbreviation stands for BPPV-Benign Paroxsymal Posterior Vertigo (highly probable if its feeling clogged, no draining from the ear canal, no wax build up after checked with an otoscope by an ENT or Neurologist and the symptoms listed above present that I mentioned= Vertigo, Nausea; Possibly vision disturbance with lethargy) including a nystagmus (described below). This is how you feel after a concussion (with or without a nystagmus) in varying intensities depending on the impact after a blow to the head. How do these symptoms arise with no infection in the ear?

This involves the inner ear causing the brain to pick up miscommunication signals in detecting or reading what is happening going on giving the ending result of vertigo =dizziness, causing your balance to be off, which again I reenforce is due to the condition that is going on in the middle ear. It is the sensitivity detection by ear sensitivity hairs picking up what shouldn’t be there, which in turn is causing the symptoms. This can be due to inner ear particles clumped together in the ear or particles in the inner ear floating freely depending where the are located in the inner ear. We will discuss this more in detail shortly, just know these particles are called “rocks”.

If your having these symptoms this should be checked for BPPV and (I do recommend you go to MD to be evaluated first):

Benign paroxysmal positional vertigo (BPPV) is probably the most common cause of vertigo in the United States. It has been estimated that at least 20% of patients who present to the physician with vertigo have BPPV. However, because BPPV is frequently misdiagnosed, this figure may not be completely accurate and is probably an underestimation. Since BPPV can occur concomitantly with other inner ear diseases (for example, one patient may have both Ménière disease and BPPV at once), statistical analysis may be skewed toward lower numbers.

BPPV was first described by Barany in 1921. The characteristic nystagmus and vertigo associated with positioning changes were attributed at that time to the otolithic organs. In 1952, Dix and Hallpike performed the provocative positional testing named in their honor, shown below. They further defined classic nystagmus and went on to localize the pathology to the proper ear during provocation.

It deals with the inner ear.

The patient is placed in a sitting position with the head turned 45° towards the affected side and then reclined past the supine position.

BPPV is defined as an abnormal sensation of motion that is elicited by certain critical provocative positions. The provocative positions usually trigger specific eye movements (ie, nystagmus). The character and direction of the nystagmus are specific to the part of the inner ear affected and the pathophysiology.

BPPV is a complex disorder to define; because an evolution has occurred in the understanding of its pathophysiology, an evolution has also occurred in its definition. As more interest is focused on BPPV, new variations of positional vertigo have been discovered. What was previously grouped as BPPV is now subclassified by the offending semicircular canal (SCC; ie, posterior superior SCC vs lateral SCC) and, although controversial, further divided into canalithiasis and cupulolithiasis (depending on its pathophysiology).

Although some controversy exists regarding the 2 pathophysiologic mechanisms, canalithiasis and cupulolithiasis, agreement is growing that the entities actually coexist and account for different subspecies of BPPV. Canalithiasis (literally, “canal rocks”) is defined as the condition of particles residing in the canal portion of the SCCs (in contradistinction to the ampullary portion). These densities are considered to be free floating and mobile, causing vertigo by exerting a force. Conversely, cupulolithiasis (literally, “cupula rocks”) refers to densities adhered to the cupula of the crista ampullaris. Cupulolith particles reside in the ampulla of the SCCs and are not free floating.

Classic BPPV is the most common variety of BPPV. It involves the posterior SCC and is characterized by the following symptoms:

• Geotropic nystagmus with the problem ear down
• Predominantly rotatory fast phase toward undermost ear
• Latency (a few seconds)
• Limited duration (< 20 s)
• Reversal upon return to upright position
• Response decline upon repetitive provocation. The purpose for this appears to be the brain acquires a response in getting used to this vertigo as normal by picking up wrong messages from that affected ear due to improper messaging by the pick up of how the rocks in the inner ear canal are situated (free floating or residing in a canal portion with how the ear hairs are picking up by sensitivity their presence giving wrong messages to the brain causing vertigo, nystagmus, with or without vomiting.
• Because the type of BPPV is defined by the distinguishing type of nystagmus, defining and explaining the characterizing nystagmus are also important.
• Nystagmus is defined as involuntary eye movements usually triggered by inner ear stimulation. It usually begins as a slow pursuit movement followed by a fast, rapid resetting phase. Nystagmus is named by the direction of the fast phase. Thus, nystagmus may be termed right beating, left beating, up-beating (collectively horizontal), down-beating (vertical), or direction changing.
• If the movements are not purely horizontal or vertical, the nystagmus may be deemed rotational. In rotational nystagmus, the terminology becomes a bit more loose or unconventional. Terms such as clockwise and counterclockwise seem useful until discrepancies regarding point of view arise: clockwise to the patient is counterclockwise to the observer. Right versus left terminology is poorly descriptive because as the top half of the eye rotates right, the bottom half moves left.
• Rotational nystagmus also can be described as geotropic and ageotropic. Geotropic means “toward earth” and refers to the upper half of the eye. Ageotropic refers to the opposite movement. If the head is turned to the right, and the eye rotation is clockwise from the patient’s point of view (top half turns to the right and toward the ground), then the nystagmus is geotropic. If the head is turned toward the left, then geotropic nystagmus is a counterclockwise rotation. This term is particularly useful in describing BPPV nystagmus because the word geotropic remains appropriate whether the right or the left side is involved.
• These 2 terms are useful only when the head is turned. If the patient is supine and looking straight up, these terms cannot be used. Fortunately, the nystagmus associated with BPPV usually is provoked with the head turned to one side. The most accurate way to define nystagmus is by terming it clockwise or counterclockwise from the patient’s point of view.

The tympanic membrane where no doctor can open that and further the problem is in your semi-circular canal and if not resolving the problem it will damage the ear.

“Mal de débarquement syndrome (MdDS) — which means, “sickness of disembarkation” — is a rare condition that makes you feel like you’re moving, even when you’re not. “Disembarkation” is a word to describe getting off of a boat or aircraft. This can cause a change in your stability or balance.

MdDS commonly occurs after boating or sea travel, though it can happen after air travel, extended land travel and even sleeping on water beds. In some cases, MdDS can occur after non-motion events (like surgery or childbirth), or for no known reason (spontaneous mal de débarquement syndrome).”

Cleveland Clinic (https://my.clevelandclinic.org/health/diseases/24796-mal-de-debarquement-syndrome-mdds)

woman feeling rocking dizziness from mal de debarquement after cruise ship vacation

Mal de debarquement (MDD) is a rare and poorly understood disorder of the vestibular system that results in a phantom perception of self- motion typically described as rocking, bobbing or swaying. The symptoms tend to be exacerbated when a patient is not moving, for example, when sleeping or standing still.

When you head out to sea on a cruise ship, your brain and body have to get used to the constant motion. It’s called “getting your sea legs,” and it keeps you from crashing into a wall every time the ship bobs up or down.

When you get back on shore, you need time to get your land legs back. That usually happens within a few minutes or hours, but it can take up to 2 days. With mal de debarquement syndrome, though, you can’t shake the feeling that you’re still on the boat. That’s French for “sickness of disembarkment.” You feel like you’re rocking or swaying even though you’re not.

It can happen to anyone, but it’s much more common in women ages 30 to 60. It’s not clear if hormones play a role.

People who get migraines may be more likely to get it, too, but doctors aren’t sure how the two conditions are linked.

What Are the Symptoms?

Mainly, you feel like you’re rocking, swaying, or bobbing when there’s no reason for it. You might feel unsteady and even stagger a bit.

Other symptoms include:

• Anxiety
• Confusion
• Depression
• Feeling very tired
• Having a hard time focusing
• Nausea

Your symptoms may go away when you ride in a car or train, but they’ll come back when you stop moving. And they can get worse with:

• Being in a closed-in space
• Fast movement
• Flickering lights
• Stress
• Tiredness
• Trying to be still, like when you’re going to sleep
• Intense visual activity, like playing video games

What Causes It?

It happens most often after you’ve been out on the ocean, but riding in planes, trains, and cars can lead to it, too. It’s even been caused by water beds, elevators, walking on docks, and using virtual reality.

While almost any kind of motion can cause it, doctors don’t know what’s really behind it. In most cases, you get it after a longer trip. But there’s no tie between the length of your trip and how bad the symptoms are or how long they last.

In trying to diagnose this condition through ruling out other problems since no one test diagnoses this condition.  It’s a rare condition, so it may take a few visits to figure it out. Your doctor probably will want to rule out other causes for your symptoms with things like:

Some Facts on Blood:

“01 Up to 3 lives are saved by one pint of donated blood.
02. Between 8-12 pints of blood are in the body of an average adult.
03. One unit of blood is ~525 mL, which is roughly the equivalent of one pint.
04. A newborn baby has about one cup of blood in their body.
05. The average transfusion patient receives 3 units of red blood cells.
06. A, B, AB and O are the four main types of blood types. AB is the universal recipient, O negative is the universal donor.
07. Blood centers often run short of types O and B blood.“

70 Rock River Valley Blood Center (Saving lives 70 years.) – (https://www.rrvbc.org/)