Consequently, FDA has revised its draft guidance for industry for bioequivalence testing for methylphenidate hydrochloride extended-release tablets (Concerta). Is Europe Doing a Better Job of Treating ADHD Than the U.S.? XLMWSJJIV[MXL]SYXS]SYVTLEVQEG][MXLEZEPMHTVIWGVMTXMSRIEGLXMQI]SY½PP(E]XVERE ® (methylphenidate transdermal system). Due to a manufacturing delay, the 20mg tablets, 30mg tablets, and 40mg tablets in . Akili Interactive Labs Inc. will hold an ongoing license to Tali's technology to become the exclusive commercialization partner for all pediatric . An internationally renowned conductor examines what his career has taught him about music, science, and the nature of reality, while describing his witness to the power of music as a vehicle for social change. Find out why feelings of... A parent's guide to using mindfulness meditation to strengthen a child's attention, manage symptoms of ADHD,... With all the behavioral therapies for autism, parents may feel at a loss. This full account brings readers behind the heist memorialized in Goodfellas, a crime that has baffled law enforcement for decades. From Henry Hill himself, The Lufthansa Heist is the last book he worked on before his 2012 death. Updated - September 2021 Drug Shortage PIN List to September 2, 2021 No Generic Manufacturer Is Able to Supply . Survival Tips for the Spouse Who Doesn't Have ADHD. Contains protocols to implement Z score neurofeedback Reviews research on disorders for which this is effective treatment Describes advanced techniques and applications Current Drug Shortages. Shortage Of ADHD Drugs Has Parents, Doctors Scrambling : Shots - Health News For reasons that are unclear, in recent months the hard-to-get drugs include ADHD medications such as Adderall. Based on an analysis of data, FDA has concerns about whether or not two approved generic versions of Concerta tablets (methylphenidate hydrochloride extended-release tablets), used to treat attention-deficit hyperactivity disorder in adults and children, are therapeutically equivalent to the brand-name drug. Drug Identification Number. Called the doctor and he said the same. Before sharing sensitive information, make sure you're on a federal government site. Speech pathology has changed the life of an eight year old Tassie boy who has autism, ADHD and dyslexia, by teaching him to read . "With over 90 well-known contributors, in-depth coverage of more than 70 specific diseases, and 10,000 citations of peer-reviewed research literature, you'll find accurate, detailed pharmacologic information on herbs and supplements, and ... She's also mom to a daughter with ADHD . “The agency didn’t give the generic manufacturers and wholesalers an accurate quota to meet the demand for these new, popular generics.”. Who wants or needs to go to college for 5 years just to qualify? An analysis of adverse event reports, an internal FDA re-examination of previously submitted data, and FDA laboratory tests of products manufactured by Mallinckrodt and Kudco have raised concerns that the products may not produce the same therapeutic benefits for some patients as the brand-name product, Concerta, manufactured by Janssen Pharmaceuticals, Inc. Janssen also manufactures an authorized Concerta generic, which is marketed by Actavis under a licensing agreement and is identical to Janssen’s Concerta. The Future Of Transportation . Shortages in the supply of medicines that treat attention deficit hyperactivity disorder are due to a problematic relationship between . Influenza Season 2020-2021. Each firm must respond in writing, within 30 days, to request a hearing. What can parents do the next time the drug quota process breaks down? The AICPA created this shortage by requiring 150 hours. Albuterol Sulfate Metered Dose Inhalers. August 5, 2021: ADHD Medication Adherence; Schizophrenia Drug with No Weight Gain; Spanish-Speaking Therapist Shortage; June 7, 2021: Antidepressant Tapering, New Schizophrenia Drug, Psychosis Family Interventions; December 14, 2020: New Depression Screen, Schizophrenia Research, Predicting Disengagement Designed primarily for students in gerontological nursing courses in BSN and graduate programs, the book provides: Essential clinical information and "best practices" needed to care for older adults Current research and new patient ... If you or your health care professional are concerned the drug product is not providing the desired effect and you do not know the manufacturer, contact the pharmacy where the prescription was filled to verify the product’s manufacturer. In some individuals, the Mallinckrodt and Kudco products may deliver drug in the body at a slower rate during the 7- to 12-hour range. August 16, 2021 By: Antonia Stroe. This has been amplified by the so-called "pingdemic" which saw drivers forced to self-isolate by the NHS app after coming into contact with positive Covid cases. Parenting When the Parent Has ADHD — a chat with Patricia Quinn, MD. Mental health issues are rising on college campuses, but Virginia has a shortage of child psychiatrists Eric Kolenich Jul 30, 2021 Found insideA practical guide to the origins and treatment options for agitation, a common symptom of psychiatric and neurologic disorders. Language Assistance Available: Español | 繁體中文 | Tiếng Việt | 한국어 | Tagalog | Русский | العربية | Kreyòl Ayisyen | Français | Polski | Português | Italiano | Deutsch | 日本語 | فارسی | English, U.S. Department of Health and Human Services. Last updated on 2021-06-30 History. As at 4 June 2021, no cases of foetal cardiac malformations associated with methylphenidate had been reported to the Therapeutic Goods Administration. U.S. Food and Drug Administration 10903 New Hampshire Avenue Silver Spring, MD 20993 1-888-INFO-FDA (1-888-463-6332) Contact FDA With the Obama administration characterizing prescription drug misuse as this generation's crack epidemic, something like this seemed fated to happen: patients, pharmacists and manufacturers are reporting a serious shortage of medications to treat attention deficit hyperactivity disorder (ADHD) due to a hold in 2010 by the DEA on the drugs' main ingredients. If approval of these ANDAs is withdrawn by the FDA, the products will no longer be able to be marketed in the U.S. Each NOOH explains that the firm may request a hearing to show why approval of their ANDA should not be withdrawn and has the opportunity to raise, for administrative determination, all issues relating to the legal status of the drug products covered by these applications. Found insideThe book is also designed to be a useful resource for parents, grandparents and spouses interested in promoting the spiritual growth of loved ones with mental illness. a pretty tricky call to make when dealing with an objectively unverifiable psychiatric condition like attention deficit hyperactivity disorder. Although perceived to be highly therapeutic and natural, please do your research to make safe, educated decisions if you plan to use this substance. FDA says ADHD drug shortage to end in April. Status: Currently in Shortage Drug Shortage Report for APO-METHYLPHENIDATE ER. . SECOND GENERATION August 5, 2021: ADHD Medication Adherence; Schizophrenia Drug with No Weight Gain; Spanish-Speaking Therapist Shortage; June 7, 2021: Antidepressant Tapering, New Schizophrenia Drug, Psychosis Family Interventions; December 14, 2020: New Depression Screen, Schizophrenia Research, Predicting Disengagement From Distress to DE-STRESS. This forced parents to speed-dial doctors and dozens of pharmacies to find the medication their child depends on to manage symptoms. Methylphenidate hydrochloride extended-release products approved as generics for Concerta are intended to release the drug in the body over a period of 10 to 12 hours. The UK is facing a shortage of chips due to high demand for British potatoes from the Continent. William B. Dodson, M.D., who treats adults with ADHD in Greenwood, Colorado, and is a medical advisor to ADDitude, was one of them. ADHD Drug Shortages a Major Problem for US Physicians. Jun 26, 2019. Aug 24, 2021. Search by Generic Name or Active Ingredient: Methylphenidate Hydrochloride ER Capsules/Tablets, Instructions for Downloading Viewers and Players. Pubs and eateries planning for . FDA’s Scientific Evaluation of Generic Concerta Products. Companies are required under Section 506C of the Federal Food, Drug, and Cosmetic Act (FD&C Act) (as amended by the Food and Drug Administration Safety and Innovation Act) to notify FDA of a permanent discontinuance of certain drug products, six months in advance, or if that is not possible, as soon as practicable. Last updated on 2021-09-03 History. Can CBD oil improve cognition in ADHD sufferers? Parents taking their child in for a prescription refill should call the pharmacy before their child’s appointment — even in the doctor’s waiting room — to find out whether the store has the child’s prescription in stock and, if so, in what dosage. Mallinckrodt Pharmaceuticals and UCB/Kremers Urban (formerly Kudco) the companies that make the generic products, have failed to demonstrate that their products provide the same therapeutic effect as (are bioequivalent to) the brand-name drug they reference. U.S. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. 00727369 00911809 August 11, 2021 Y Concerta 18 mg 02247732 00911682 May 27, 2021 Y Concerta 27 mg 02250241 00911699 May 27, 2021 Y Hydromorphone 1 mg/mL Become an Empowered Parent. FDA will continue to evaluate its testing and approval standards and bioequivalence guidances for other generic methylphenidate hydrochloride extended-release products and revise as needed. Responding with Compassion. 21-03-2019. 7/18/2021: 8 a.m. - 2 p.m., Hope Worldwide North County Albertsons, 1571 San Elijo Road 7/21/2021: 10 a.m. - 4 p.m., The Lodge at Lake San Marcos, 1105 La Bonita Drive Some doctors have switched patients to brand-name medications that parents have to pay for out of pocket. Drug shortages can have a significant impact on patient care and public health. Brand name. METHYLPHENIDATE You can Google 'FDA Drug Shortages' to see if particular amphetamine salt brands are having problems and when a fix is expected. FDA says ADHD drug shortage to end in April. “In a nutshell, the shortage occurred because the Drug Enforcement Agency did not take into account, during the [affected] allotment period, the fact that the two biggest selling stimulants — Concerta and Adderall XR — were going generic,” adds Dodson. Jul 08, 2021. Make sure that the substituted medication is covered by your medical insurance. "Every NP should own a copy of this book! If the prescription isn’t in stock, ask your doctor to see if another medication in stock can be substituted. The Admission Test Series prepares students for entrance examinations into college, graduate and professional school as well as candidates for professional certification and licensure. 2021 Medley #9 - Culture War, Teacher Shortage, and NCTQ Fails The CRT Wars, . A drug representative for Shire Pharmaceuticals, a company known for ADHD medications among others, told him recently that the shortage is the result of federal quotas on how much of the drugs can . Twenty percent of the teens with ADHD got less than seven hours of sleep on school nights, compared to 10 percent of students without ADHD. By using this offer, you acknowledge that you meet the eligibility criteria and will comply with these terms and conditions. GREEN BAY, Wis. (WBAY) - The first month of the new year has come with unexpected challenges for thousands of people across the state who take prescription . Breastfeeding and Human Lactation, Sixth Edition is the ultimate reference for the latest clinical techniques and research findings that direct evidence-based clinical practice for lactation consultants and specialists. . This first person account of ADHD is among the only books to offer a non-clinical perspective of ADHD where we can all understand on a deeper level the blessing and the curse that is Attention Deficit Hyperactivity Disorder. The two approved generic versions of Concerta are manufactured by Mallinckrodt Pharmaceuticals and Kudco Ireland Ltd. FDA has not identified any serious safety concerns with these two generic products. The diminished release rate may result in patients not having the desired effect. Drug Safety and Availability, Recalls, Market Withdrawals and Safety Alerts, Information about Nitrosamine Impurities in Medications, Medication Errors Related to CDER-Regulated Drug Products, Postmarket Drug Safety Information for Patients and Providers, Risk Evaluation and Mitigation Strategies | REMS, Multistate outbreak of fungal meningitis and other infections, Methylphenidate Hydrochloride Extended Release Tablets (generic Concerta) made by Mallinckrodt and Kudco, Questions and Answers Regarding Methylphenidate Hydrochloride Extended Release Tablets (generic Concerta) made by Mallinckrodt and UCB/Kremers Urban (formerly Kudco), FR Notice: Bioequivalence Recommendations for CONCERTA (Methylphenidate Hydrochloride) Extended-Release Tablets; Draft Guidance for Industry; Availability. Start Over | At that time, the FDA announced that, based on an analysis of data, it had concerns that the Mallinckrodt and Kudco (now UCB/Kremers Urban) products may not produce the same therapeutic effects as Concerta. ADHD Australia has been… Your use of this site is governed by our, When to Consider Medical Supports for Autism, Multiple Medications for Your Child: What You Need to Know, How to Tame the Tics Associated with ADHD Medication, 6 Things You Didn’t Know About the ADHD Brain. If you fill prescriptions to treat Attention Deficit Hyperactivity Disorder (ADHD), such as Ritalin or Adderall, you know the generic versions of these . Report ID. If the firm fails to do so, the opportunity for a hearing will be waived. 14.6% Sodium Chloride Concentrated Solution for Injection. Seafood Prices Spike Amid Inflation and Labor Shortage - A New Concern for Restaurants. If you or your health care professional are concerned that a methylphenidate hydrochloride ER product you are taking is not providing the desired effect, and you do not know the manufacturer, contact the pharmacy where the prescription was filled to verify the product’s manufacturer. Methylphenidate hydrochloride extended-release products approved as generics for Concerta are intended to release the drug in the body over a period of 10 to 12 hours. These tips may save you worry, time, money, and gas. By Azriel James Relph. PSNC is very concerned about the impact that current supply problems are having on pharmacy teams' workload and about the potential impact on their patients. Currently in Shortage. 23.4% Sodium Chloride Injection. The first part of the volume introduces general concepts of normal development, assessment, and treatment. This new edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5®), used by clinicians and researchers to diagnose and classify mental disorders, is the product of more than 10 years of effort by hundreds of international ... The number of security clearance approvals in 2019 — including both new clearances and renewals — increased by a solid . Concerta (methylphenidate) is a member of the CNS stimulants drug class and is commonly used for ADHD, and Narcolepsy. Please enable JavaScript and refresh the page in order to complete this form. 4 days ago. Updated May 10, 2011 12:01 am ET . Resolved Shortages. “The extended-release argument doesn’t hold water since the generics are produced and sold by generic manufacturers — not the manufacturers of the brand-name medications,” says Dodson. Our mission is to be your trusted advisor, an unwavering source of understanding and guidance along the path to wellness. Special education teacher shortage impacting 48 states. In some cases, drug companies manufacture both generic versions of ADHD drugs as . Adderall, Ritalin and similar drugs are used by an estimated 5.4 million children and 1.5 million adults who suffer from ADHD. Aug 16, 2021. Common or Proper name. If you have ADHD, then you're also at risk for developing an eating disorder. (Stacker) - Attention deficit hyperactivity disorder, or ADHD, affects about 7% of children and adolescents in the U.S. Update on the ADHD Medication Shortages. This should allow for a single-dose product that is consistent with the effect of a three times per day dose of immediate-release methylphenidate hydrochloride. Heller—which invalidated a law banning handguns in the nation’s capital—as a springboard, Winkler brilliantly weaves together the dramatic stories of gun-rights advocates and gun-control lobbyists, providing often unexpected insights ... How a “Sensory Diet” Helps My Child with Sensory Processing Disorder, ADHD in Children: Symptoms, Evaluations & Treatments. Research and development expenses were $1.8 million and $0.9 million for the . Within the past few years, the FDA has given the okay for generic manufacturers to market generic versions of brand name Concerta (methylphenidate ER).. PERTH, Australia - Tali Digital Ltd. inked a licensing deal worth A$51 million (US$37.5 million) for its new digital therapeutic that could be the first line in early intervention to treat the underlying conditions of attention deficit disorders. 9/5/2021 8:02:09 PM . The AICPA created this shortage by requiring 150 hours. Found insideA comprehensive and granular insight into the challenges of promoting rational medicine, this book serves as an essential resource for health policy makers and researchers interested in national medicines policies. Last . Meanwhile, patients unwittingly consume medicine with unpredictable and dangerous effects. The story of generic drugs is truly global. BH3406 05/2021 ADHD Screening and Follow-up Care for Children We appreciate your taking an active role in screening children with symptoms of attention deficit / hyperactivity disorder (ADHD). Drug Shortage Report for ACT METHYLPHENIDATE ER. However, you may or may not know that Concerta is the only ADHD medication with a very unique delivery system referred to as OROS (osmotic controlled-release oral delivery system).. Several manufacturers have been making generic . But schools nationwide can't find enough special education teachers to fill the vacancies. Alabama - can confirm all pharmacist claim a shortage on adderall (generic) in 20mg and 30mg. Acetylcysteine Oral and Inhalation Solution. If you have . Joker virus: Smartphone users urged to delete these 8 apps. 02330377. Jul 08, 2021. Academic freedom for teachers is as important as money. Effective June 1, 2021, the North Carolina Medicaid and NC Health Choice PDL will be updated to reflect changes made based on the March 25, 2021 PDL Panel meeting. Blake was diagnosed formally with ADHD when he was five years old. In ADHD and Me, he tells about the next twelve years as he learns to live with both the good and bad sides of life with ADHD. Alongside these findings, the Biden-Harris . New Preferred Drug List (Pdl) Begins 6/1/2021 . Adverse event reports in Australia. Published: Feb. 2, 2021 at 3:44 PM PST. Have you ever wondered about a friend, a partner, a mother, sister or daughter? Quillichew ER, a CNS stimulant, is also indicated for the treatment of ADHD in patients aged 6 years and older. Experts recommend you keep an emergency supply of prescription medications on hand, with some suggesting you obtain 90-day supplies. This action is related to steps the FDA took in November 2014. Achievement Gap (9) Adams (5) ADHD (18) . This forced parents to speed-dial doctors and dozens of pharmacies to find the medication their child depends on to manage symptoms. The site is secure. The total number of clearances is about the same as it was a decade ago, but well below the reported peak of 5.1 million cleared persons in FY 2013. FDA included the authorized generic in its analysis and found it to be bioequivalent to, and substitutable for, Concerta. A report revealed frozen chips are likely to be particularly affected - with a warning of steep price rises. In some cases, drug companies manufacture both generic versions of ADHD drugs as . In context. 14.6% Sodium Chloride Concentrated Solution for Injection. From Distress to DE-STRESS. The following article is a part of conference coverage from the 2021 American Association of Nurse Practitioners National Conference (AANP 2021), held virtually from June 15 to June 20, 2021. Details. Slicing up the Pie: New dashboard launched to track drugmaker market share. BT. They expect the supply of the VYVANSE 70mg will return to normal in February 2020. bteufaula 14 Feb 2019. For most people who include ADHD medication in their treatment plans this can be difficult because of legal requirements regarding Schedule II medications. Shop owner sent customer free gift - but it brutally backfired. Since 1998, millions of parents and adults have trusted ADDitude's expert guidance and support for living better with ADHD and its related mental health conditions. An Associated Press report found that at Hurley Medical Center in Flint, Michigan, the nurse-to-patient ratio went from its . JAXPORT / Flickr cc. Some local daycares are facing staffing shortages. 31-44-87. Second quarter 2021 total revenues of $141.3 million, a 12% increase compared to 2020Qelbree™ launched in the U.S. for pediatric ADHD at the end of May 2021Qelbree sNDA for adult ADHD submitted . The .gov means it’s official.Federal government websites often end in .gov or .mil. For a brief period in early 2012, the sky was falling in for parents of children with attention deficit disorder. This book draws on scientific research on procrastination conducted over more than twenty years by the author and his colleagues, to help you learn what stops you from getting things done so that you can find the solutions that will really ... Methylphenidate Hydrochloride ER Capsules/Tablets Many people claim it helps with anxiety, concentration and even depression. The Mallinckrodt UCB/Kremers Urban products are still approved and can be prescribed, but they are not recommended as automatically substitutable for Concerta. Learn about our editorial process. Who will teach our grandchildren.and their children. This is a mixed-method study that Ipsos MORI has carried out on behalf of the Department for Digital, Culture, Media and Sport (DCMS). If a new prescription is written for a child, ask the doctor or nurse to call the pharmacy to see what’s in stock before walking out of the office. It appears JavaScript is disabled in your browser. Ciba's Ritalin (methylphenidate), prescribed for hyperactive children, is expected to continue to be…. Addressing Suicidal Ideation in Patients with Schizophrenia. News; Tassie families distraught in dire speech pathology shortage. Methylphenidate hydrochloride extended-release products approved as generics for Concerta are intended to release the drug in the body over a period of 10 to 12 hours. 5% Lidocaine and 7.5% Dextrose Injection. Discontinuations Listed by Generic Name or Active Ingredient. This has resulted in a shortage within Australia of this 70mg dosage strength only. NOW PLAYING . UP NEXT. APO-METHYLPHENIDATE ER. At that time, the FDA changed the Orange Book therapeutic equivalence code for these two products from AB (indicating therapeutic equivalence) to BX (data are insufficient to determine therapeutic equivalence). Found insideThese drugs have been prescribed routinely, especially for the treatment of attention deficit hyperactivity disorder. Aug 18, 2016. The driving force behind the shortage is a U.S. Drug Enforcement Administration (DEA) policy that sets limits on the manufacturing of ADHD drugs, to limit the supply of these drugs to people who might use them illegally, according to a report by The New York Times. The book is a valuable resource for scientists who work in the pharmaceutical industry, regulatory agencies, and academia as well as undergraduate and graduate students looking to expand their knowledge about bioequivalence standards. Becker and his colleagues conducted a study in which they recruited 300 students, half with ADHD, half without. After nearly 10 months, the nationwide shortage of ADHD drugs has taken a toll on Kate Skinn. This book is designed to help parents address their child’s Attention Deficit Disorder (ADD) or Attention Deficit Hyperactive Disorder (ADHD) in 7 simple steps. Below is a summary of the changes: ANTICONVULSANTS . All rights reserved. The inflation-driven seafood price spike is a growing concern in our industry, affecting operations across the entire chain—from suppliers to retail and restaurants. Found insideDesigned to accompany Lehne's Pharmacology for Nursing Care, 9th Edition, this robust workbook features critical thinking study questions, case studies, and patient teaching scenarios that help you connect pharmacology concepts with their ... Growing number of parents seeking ADHD diagnosis for children to manage remote learning . Doctors can tailor the dose and number of pills based on what’s in stock. An official website of the United States government, : At this time, there have not been reports of ADHD medication shortages because… Copyright © 1998 - 2021 New Hope Media LLC. At that time, the FDA requested that Mallinckrodt and Kudco either (1) voluntarily withdraw their products from the market and request that FDA withdraw approval of their product’s Abbreviated New Drug Applications (ANDAs) or (2) within six months, provide data to confirm that their products are bioequivalent to Concerta consistent with the revised draft guidance for industry for bioequivalence testing for these products. As a result, the FDA has changed the therapeutic equivalence (TE) rating for the Mallinckrodt and Kudco products from AB to BX. As part of this process, the FDA is publishing Notices of Opportunity for Hearing (NOOHs) on its Proposals to Withdraw Marketing Approval in the Federal Register. If you're looking for advice, […] No date available The . Psy-Q: Stimulant Misuse, Overdose, and ADHD Prescribing. Learn key reasons why the supply of cardiologists is falling behind demand, and what it means for patients. METHYLPREDNISOLONE. The American Academy for Child and Adolescent Psychiatry and the American Psychiatric Association affirm thorough Found inside"A groundbreaking and definitive account of the widespread misdiagnosis of Attention Deficit Hyperactivity Disorder--and its serious effects on children, adults, and society"-- 12:30 PM - 2:00 PM EDT. This is why there is a national shortage of people who want to go into education. FDA has asked that within six months, Mallinckrodt and Kudco confirm the bioequivalence of their products using the revised bioequivalence standards, or voluntarily withdraw their products from the market. Found insideSide Effects of Drugs Annual: A Worldwide Yearly Survey of New Data in Adverse Drug Reactions, Volume 41, first published in 1977, and continually published as a yearly update to the voluminous encyclopedia Meyler's Side Effects of Drugs, ... Parenting When the Parent Has ADHD — a chat with Patricia Quinn, MD. Found insideThis book documents the history and development of drug safety systems, pharmacovigilance centers and activities in developing countries, describing their current situation and achievements of drug safety practice. How parents can proactively prepare for the next ADHD medication shortage. Drugs in short supply often include sterile injectables and potentially life-saving oncology (cancer) treatments. This reply was modified 6 months, 1 week ago by WaveOffTheCoast . Presents a guide to maintaining a relationship with an adult diagnosed with the disorder, with information on the basics, challenges, and options for treatment. Theresa Cerulli is a neuropsychiatrist specializing in ADHD through her practice and position on the staff at Beth Israel Deaconess Medical Center in Boston. February 25, 2021 at 4:48 am #195261 Drug company marketing strategies are behind much of the shortages, says Gary Boggs, agent for the federal Drug Enforcement Agency. Now in its 8th edition, this classic text continues to offer in-depth coverage of all areas relevant to the contemporary science and practice of pediatric dentistry. Psy-Q: ADHD and Cultural Sensitivities SOLU-MEDROL 1000 mg powder and solvent for solution for injection. ADHD is a very complex neurodivergence, so even with the challenges I face managing symptoms, the camaraderie I've found with other people with ADHD has been comforting for me as I manage all of . While some in the media blamed the ADHD medication . This excessive education requirement is the real reason behind the CPA shortage.
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