Topic: Mum just been diagnosed Ninewells

Hello,

I am new to the forum and my Mum has recently  been DX at Ninewells hospital in Dundee Scotland.It took one month of tests and four procedures before they managed to fit an internal  metal stent in her duct to relieve jaundice.They had to make a hole in her side (percutaneous).

She has been returned for palliative care at the local hospital,and she and my Dad have been told that it is terminal.I used to nurse so I had guessed as much ,due to her symptoms and research on the internet.

She is too weak at the moment to manage the stairs at home,but we are to try to get a stairlift fitted ASAP and hopefully get her home in the near future.

I don't have good health myself,with CFS/Fibromyalgia and Dad is nearly 82 now ,so we will probably need a lot of help down the line.Luckily I stay nearby,but I feel that we are probably in for the ride of our lives,and not in a good way if she does get home.Just cannot imagine her staying for weeks to months in the Infirmary ,good as they are.

My folks are such a close couple and will be married 60 years this year.
I realize she has had a full and happy life up to this illness,and many younger people are cheated with this Cancer,but she is still my Mum,and I would do anything to spare her from any suffering.

I know I will find friends and support on this forum as I have for my own health problems on the FMS/UK forums in the past,it is good to get your feelings and worries out.

I will post again soon.

A hard journey means a joyful arrival

Re: Mum just been diagnosed Ninewells

Hello ScottsMum....and welcome to our site.  You are right in that you will find tons of support and friends here.  By the way, our Gavin also is from Dundee and I am sure that he will post real soon.
The percutanous drain should make your Mom feel lot's better and she should be gaining some strengths by eating calorie-rich foods assuming; she is able to digest it. 
I think that most of us are overwhelmed when given the diagnoses of CC.  You are not alone.  We wish for no one having to deal with this cancer.   However, disease progression varies from person to person and is something we adjust to as time goes on.  Unforeseen strengths and determination seem to evolve from the patients and caregiver alike.  You will be no different.
I am sending all my best wishes your way,
Marion

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER

Re: Mum just been diagnosed Ninewells

Hello Marion and thanks,

They did have a percutaneous drain in Mum for about a week,but luckily on a fourth attempt they got the metal stent in using the side route.Now she does not have to cope with the bile bag,things will be better and life will appear more normal as she does not have the visual reminder of her cancer there at all times.Bless her heart,she will feel so scared just now till she adjusts to the diagnosis.

ScottsMum

A hard journey means a joyful arrival

Re: Mum just been diagnosed Ninewells

Yes, these stents can be difficult to place.  I am happy to hear that your Mum feels better now.  No one can predict the progression of this cancer.  There is still plenty of time to go about life in a normal way.  I hope that she can come home real soon.  Kudos to you for being such a great daughter.
Best wishes,
Marion

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER

Re: Mum just been diagnosed Ninewells

Hi Scottsmum,

Welcome to the site, although I am sorry that you had to join us all. But I am glad that you joined as you are right, you will find a ton of support from us all and find friendship as well.

As Marion has said to you, I am from Dundee, born and bred and still live here. My dad was dignosed in the summer of 2008 at Ninewells and his DX was inoperable. His specialist was Mr Iain Tait. Is that who is treating your mum? My dad also had the metal stent inserted and this helped a lot in relieving the jaundice and everything that goes with that. It was also Mr Tait that my dad saw on a 3 month basis.

Was your mum offered the services of a Macmillan Nurse? She should have been and I have nothing but good things to say about the work that Mac nurses do. I think the Mac nurse would be able to assist you in getting a stairlift organised for your mum. My dad also had to go to the hospital up in Brechin for a scan once and I know that Mr Tait also sees patients there as well as in Dundee at Ninewells.

Marion is right when she talks about being overwhelmed when given the diagnosis of CC. I can still remember sitting there with my dad and hearing from Mr Tait that dads CC was inoperable. Felt like I'd just been hit with a cricket bat and I was stunned. You are doing the right thing here in reaching out and looking for information and I came here back in 2008 after my dad was diagnosed.

I know that you will have a load of questions, so please feel free to ask them all and I know that someone will be able to help. And you are right in that it is good to get your feelings out and vent if need be. So keep coming back here as I know that it will help you.

And for those of you who don't know where Brechin is, probably most of you, it is just 30 miles or so up the road from me! So know we are neighbours ScottsMum!!!

My best wishes to you and your mum,

Gavin

Any advice or comments I give are based on personal experiences and knowledge and are my opinions only, they are not to be substituted for professional medical advice. Please seek professional advice from a qualified doctor or medical professional.

Re: Mum just been diagnosed Ninewells

Hi Gavin ,

Thanks for the welcome post and I am sorry that I have had to join this Forum ,but glad for the outlet.Friendship and information will also be vital in the coming days.

My Mum's case was headed by doctor Elaine Hendry apparently,although I only spoke to a dr.Siddhi myself.He said weeks /months to me.Terminal.

Apparently the GPs have talked to my parents at Brechin Infirmary and have told them up to 18 months,which I feel is probably optimistic with Mum's state of general frailty and the fact she is already starting with the swelling of the ankles.

The hospital your Dad attended was Stracathro if he was there for a scan,and they have a Macmillan Centre recently opened there with a Day Centre which I will encourage my parents to utilise.

The big deal was that up till Tuesday ,my Dad was in Big time DENIAL and refused to discuss her illness in any way shape or form and as such I don't think he has much of a grasp of the reality of the situation.

Since the GP talked to them it is a bit of a wake up call for him and we have at least got round to talking stairlift.Unfortunately ,my Mum's successful attempt at stairs during Physio (don't get me wrong, great!) means he thinks that can go on the backburner for now.She may not manage them next week,for God's sake ,we just don't know!

If he is to have her home for the long term he will need that lift big time!

Also I have it from the horses mouth that they have refused all help at this time.He needs to get some help in place NOW ,so that it can be increased as needed.If he gets out of his depth it takes time to organise these things
and she will end up back in the infirmary.I get the impression he thinks that when he gets her home it will somehow all just go away.

Please drive the thirty or so miles to Brechin Gavin and stop me from strangling the stubborn old B.

Of course I will be helping to the best of my ability, but I don't keep that well myself.It doesn't help that no-one seems to listen to me.My background is in nursing and social care when I worked,( but  am now retired due to ill health),so I know what I am about.

I feel I am going to have to go over his head on this one ,I don't want to fall out at a time like this ,but he must listen to reason.He will be 82 soon and has sciatica.He cannot be caring for Mum 24/7 without at least the potential for help in place.(Besides me)

They are talking of exercise classes when she gets home and dancing at their Diamond Wedding in October.She is on a zimmer to go to the toilet and can't get up from the chair without assistance at the moment.I know we have to be hopeful( that it is not just weeks) and they have some decent amount of quality time left, but we must be realistic as well.

I don't want to frighten them with the stark reality of what this beast can do as it will become apparent soon enough.

What do you or anyone else reading this advise I do ?(besides strangling Dad which wouldn't help much for sure)

ScottsMum.

A hard journey means a joyful arrival

Re: Mum just been diagnosed Ninewells

Hi ScottsMum,

Yes I know how frustrating it can get sometimes being the carer. I am my mums carer and have been since 2003, she has COPD and was also my dads carer during his battle with CC. I know it's not easy sometimes, especially if someone doesn't want to discuss the situation. Have you been able to speak with your dad about your mum since Tuesday? And I agree with you that it would be good now to get the ball rolling regarding future care needs for your mum.

I know I mentioned it before, but the services of a Macmillan nurse would I think be a big help to you all as they do seem to carry a lot of clout when it comes to getting things done in a hurry. My dads Mac nurse was excellent and did an amazing job for dad. She used to come visit dad every few weeks and would come round the same day if dad needed to see her. She was also great at just talking with dad and all of us about everything and anything really. If your mum was not offered their services, then your mums GP would be able to refer her to Macmillan straight away.

Yes you are right that it was Stracathro that dad had a scan at. And I am happy to hear that they have a Macmillan day care centre there. They have a Mac day care centre in one of the hospitals here in Dundee and dad used to go twice a week, and he absolutely loved it there! Perhaps that is also something that your mum would like? I took my dad up the first time to see if he would like it, nothing ventured nothing gained and all that, and he loved it from the start! They take great care of the patients there and have lots of activities such as crafts, quizes, music etc, and at the Dundee centre they all got fed very well indeed! And if your mum was to need transport to get there then they would come and pick her up. My dad spent many happy days there indeed.

You are right in that strangling Dad will not help! I'm not too sure what to say really that would help as I never went through the denial with my mum and dad. They seemed to accept what dad had and what the doctors were going to do to deal with it. Perhaps others who have been through this type of situation will have better advice than I. Something that may help you with this is talking to a Macmillan nurse straight away. I called them twice on this number 0808 808 00 00 regarding a couple of issue about my dad and they were a great help. Maybe that is something that would help you and how to handle this with your dad?

And keep coming back here, as I know how much it helped me to come here and I am sure that it will help you as well. You are not alone in this.

My best wishes to you, your mum and your dad,

Gavin

Any advice or comments I give are based on personal experiences and knowledge and are my opinions only, they are not to be substituted for professional medical advice. Please seek professional advice from a qualified doctor or medical professional.

Re: Mum just been diagnosed Ninewells

Dear ScottsMum, I am thinking you are going to have to pull rank on your Dad now. I know how hard it is for me at 70 taking care of Teddy at 78. You are so right about preparing for what you know will be. It will make things easier on your Mum and you. You do have a trump card if you want to play it
I don't know your housing situation but you could perhaps tell Dad that you are moving Mum to your house and he will have to stay at their house so that you have the freedom there to do what needs to be done with Mum. Another suggestion is for you to have a talk with the doctor with Dad in attendance. I know its hard to over ride a parent at anytime but if you do, this is the time. Maybe he doesn't want to acknowledge anything as in his mind at 82 he feels, well, if she gets sick, who will take care of me. Those are my feeble opinions. Once you can get him to cooperate your life will be much easier. Please keep us posted, we care.

Teddy ~In our hearts forever~ATTITUDE is EVERYTHING
Any suggestion I offer is intended as friendly advice based solely on my own experience. Please consult your doctor for professional guidance.

Re: Mum just been diagnosed Ninewells

Scotsmum,
I too have a "difficult" dad and can only imagine what you must be going through. I am the patient in my situation and we always try to talk about what is happening and what it means. It was very difficult at the start, but now we can talk about most things (even if at least one of us still cries).

I am an American and live in Sweden (though I was first diagnosed and had surgery in Scotland...lived there 7 years) and I was immediately teamed up with a psychologist. My husband and I have both joint and individual sessions and my wonderful psychologist will even include my parents when they visit. We meet sometimes every 2 weeks, sometimes every 6 weeks depending on our needs. This has been one of the most helpful things in my cancer journey. Perhaps you could talk to either the Mac nurses or the family gp to organise something like this for both your mom and dad and even you.

Be careful about remembering to take time for yourself and to deal with your feelings and emotions. You cant kick your dad in the pants, but you can tell him that he is making things more difficult for everyone. Perhaps he just needs some help coming to terms with reality.

Hugs,
Kris

Cancer is a word, not a sentence.

36 year old patient with buckets of hope

Re: Mum just been diagnosed Ninewells

Thanking everyone for their input,

My Mum returned home from hospital today ,but Dad has refused help"at this time"and I quote, despite all the family's wishes. He wants to look after her himself,but the progress of this disease will ultimately wear down his resolve I fear.Also there is the Stair which she is barely managing with assistance.A downstairs commode is in situ.Not great, but better than nothing.

The family is hoping to help with Mummy-sitting and maybe some help with the garden as the need arises .He has said that they will seek help in the future if need be ,and we are going to have to leave it at that for the moment to save feuds and my sanity!

Unfortunately there is only myself and my husband and one of my sons who live locally,so our pool of family helpers is awfully small.

I will be keeping a close eye on their progress and helping out when I can.My first day of Mummy-sitting is in two days time as Dad has a hospital outpatient procedure to attend in Ninewells Hospital.

This will give me all day to spend with Mum who for some reason seems to be detached and a little sad to be home from hospital.Maybe she will open up to me a little when Dad is not there and we can have a good chat.

I get the impression she is not happy with the fact that Dad is going to make her go out in public ,taking little walks and going for coffee etc.
She is embarrassed by her frail appearance and swollen feet,She feels those who know her will be speaking about her and how she has "come down",She was a woman always concerned with her appearance and is experiencing loss of self.

Hopefully they will soon have the services of a Macmillan Nurse who will try to allay her worries on this and other aspects of her journey through her illness.

We have been told weeks/months by one Doctor and 18 months by another, so I have no idea how this is going to play out.As long as she has quality of life , then longer will be better,but if things go awry quickly and she is bedbound or in pain,I'll be praying for the shorter option for her own sake.

I still want to wake up and find this is all a nightmare.We all would like a long healthy life and peaceful passing to the next for our loved ones and ourselves when the time comes.Why do bad things happen to good people,you ask yourself?

ScottsMum.

A hard journey means a joyful arrival

Re: Mum just been diagnosed Ninewells

This is such a hard time for you, ScottsMum.  I'm thinking of you & sending my very best wishes.

Julia

"Time may be a great healer, but it's a lousy beautician."

Re: Mum just been diagnosed Ninewells

Sad to report that Mum's stay at home only lasted three days .

She has taken another stroke yesterday and Dad had to phone for the emergency services as she was paralysed down the left side .So traumatic for him.

She has been re-admitted to hospital and some movement returning but not a lot.

I know that I was extremely worried about Dad coping at home with her,but this is a real Monkey's Paw.The reality of the situation has now hit him like a truck and I thought at one point today he was going to need medical attention himself.

It is just such a downer for everyone as she was making some worthwhile progress and even managing the stairs with some assistance.Even if she'd only managed a few weeks at home they would have had quality time together.

I have a posting under" CC connection with strokes"under General topics
re- her stroke 18 months ago.Almost as if I'd a premonition of this.

ScottsMum

A hard journey means a joyful arrival

Re: Mum just been diagnosed Ninewells

After a week in the stroke unit at Ninewells,my Mum has been moved nearer home to the Stroke Rehab Unit in Stracathro Hospital which is good for visiting as it's just 10 mins away.

She has been there for two weeks but has little return of movement and physio has had to be halted as she has developed multiple DVT clots in her groin.Her poorly leg is very swollen.They have started Heparin and are to put her on Warfarin tomorrow.

She also has developed an ESBL infection in her urine.I had never heard of this ,but it is basically a super-bug .Hospital acquired and due to indwelling catheterisation.

So everything seems to be going wrong for her.She has no appetite and is starting to refuse food and fortified drinks. She has been vomiting  sometimes after eating what little she takes,and is complaining of nausea and is miserable.Maybe they can give her something for the nausea.

She says she feels like she did when the jaundice was creeping up on her before , so I am wondering if the stent is still functioning properly. These things are known to block up ,even the metal ones,which is what she is fitted with about six weeks ago.Maybe it is disease progression of her CC.

She continues to lose weight gradually and is now very frail looking.
I am a bit concerned that due to being in the stroke unit ,they will not be all that genned -up on the CC,as it is an uncommon cancer.

However, we want to keep her nearer home than Ninewells as the daily journey there was killing my father.

He is taking her illness very hard and is aging before our eyes.I don't think he feels there will be any reason for him to go on if Mum goes.His doctor has him on Beta-blockers, but they don't seem to be helping very much.

I am resigned to the fact that ultimately Mum is not going to survive this, but it pains me that she is having to endure so much ,and it is hard to see her so ill and now dependent as well .She is also nearly blind from the stroke,and can hardly see what's in front of her.

It is such a trying time for all the family and the constant trips to hospital are getting so depressing with every day a new problem.We are not likely to ever get her home now,she needs intensive nursing care .So sad.

ScottsMum

A hard journey means a joyful arrival

Re: Mum just been diagnosed Ninewells

Scottsmum,

I am very sorry to here what your mum is going through right now and I know how hard this is for you to deal with. And you are right in that your mum having been moved to Stracathro will be so much easier for you and your dad when it comes to visiting. And I do understand your concerns about your mum being treated in the stroke ward at Stracathro and how they might not have the experience in dealing with CC patients. My dads specialist when he was being treated at Ninewells was Iain Tait, and I know that he also treats patients and runs clinics up at Stracathro. Perhaps it may be worth contacting him to see if he can see your mum up at Stracathro? Here is a link with his contact details.

http://www.dundee.ac.uk/surgery/onestaff2.php?ID=60

As to your mums nausea, has she been given anything to deal with this as there are lots of meds that can be used here. My dad went through a range of meds and combinations of these meds when he had nausea troubles. Some worked better than others and he was eventually put on a syringe driver to give him a constant dose of medication over a 24 hour period.

I hope that the warferin works for your mum and her blood clots. My mum was on Warferin for 6 months and they helped a lot with her blood clots. I know that this is a trying time for you and your family, and we know what you are going through here. Please feel free to come back here as much as you want to and we will all be here for you.

Best wishes,

Gavin

Any advice or comments I give are based on personal experiences and knowledge and are my opinions only, they are not to be substituted for professional medical advice. Please seek professional advice from a qualified doctor or medical professional.

Re: Mum just been diagnosed Ninewells

Thanks Gavin for your post,

The past couple days have been pretty horrible for my Mum,the nausea has worsened despite injections of anti-nausea meds.and nothing has been staying down,not even sips of water.

Dad and I are meeting with one of her doctors tomorrow afternoon,but I think things are getting quite serious now myself, I'm wondering what more can come.

If they can't control the vomiting and it doesn't abate she is going to go through hell as she is spitting up every few minutes when awake.She goes off to sleep for a little while and seems comfortable ,but the minute she wakes up she vomits again.

So despondent seeing her struggle with this.Can the CC be taking over already,they gave her up to a year from her scan results.Maybe the blood tests will give us a clearer picture of what is happening.

Warfarin treatment could not be initiated due to vomiting up the tablets.The clots will still be a potential problem .

Feeling tearful tonight.

ScottsMum

A hard journey means a joyful arrival

Re: Mum just been diagnosed Ninewells

Hi ScottsMum,

Thank you for the update on your mum and I am very sorry to hear that she is going through such a tough time right now. How is your mum doing today? And how did your metting with your mums doctors go today? Have the doctors talked about the possibility of trying different anti-nausea meds? I saw what my dad went through with his vomitting and I so hope that your mums medical team can get a grip on this and deal with it.

I know you say that your mum can't take the Warferin tablets due to vomitting them back up, but would they be able to give them or some other type of blood thinners by injection? I know when my mum was in the hospital she was getting injections to help with her blood clots.

I know how hard this is for you to deal with and watch as I went through it with my dad. So please know that I am thinking of you and keep coming back here.

My best wishes to you, your mum and your dad,

Gavin

Any advice or comments I give are based on personal experiences and knowledge and are my opinions only, they are not to be substituted for professional medical advice. Please seek professional advice from a qualified doctor or medical professional.

Re: Mum just been diagnosed Ninewells

Hi Gavin,

We had a good meeting with the doctor on Wed. and it seems that her bloods have come back A OK and they are blaming the antibiotics they administered for her super -bug  urine infection  for her vomiting.

They have given her some IV fluids and stronger anti-nausea drugs and she has perked up a good bit.The vomiting has moderated to a bit of reflux today and she is smiling again to see us all.

Her prognosis is for months rather than just weeks ,so we were very alarmed at the vomiting .It was quite intense and I would hope that if it returns during the course of her illness ,that they can do something to control it.

She has been having Heparin injections for her clots, so the warfarin will not be started till she is over the sickness a day or two,in case they unsettle her again.

Typical case of the cure being worse than the illness.She was being big time sick (as if she was on chemo.)Very distressing to see.

Dad has had a first visit from the Macmillan nurse and she is popping in to see Mum tomorrow, I believe.So this is all very positive and I am relieved the latest crisis seems past for the time being.

The doctors at the stroke unit have been swotting up about CC and are in contact with the GI consultants at Ninewells.We are very happy to leave her at Stracathro  as the unit has a ratio of four staff to seven patients at the moment.Where else would you get that kind of attention,certainly not at Ninewells !They are starting her physio again too as this is all in situ on the unit. It really is 5*,we will have to have a collection for the unit sometime in the future ,for all their good work.

Thanks for your ongoing concern,

Scottsmum.

A hard journey means a joyful arrival

Re: Mum just been diagnosed Ninewells

Went this evening to the hospital to see my Mum and she has been running a bit of a a temperature for a couple days ,but last night and today it is officially a fever.Over 39 degrees .She is flushed and looks poorly.

They are blaming the super-bug in her urine ,but there are no indications of discomfort.She had an X-Ray today to rule out a chest infection,and that came back clear.

I hope her stent is not infected. I know this can happen sometimes to people ,but she was fitted with a metal one which is supposed to be the more permanent option?

Anyone have experience of fever and stent blockage/infection themselves?

She just seems to have one setback after another.Discouraging for her and us as well.

A hard journey means a joyful arrival

Re: Mum just been diagnosed Ninewells

ScottsMum....  From what we have seen on this board stents can become infected however, a blood culture will determine the exact cause of the infection.  I am wishing for your Mom to respond to the antibiotics and for the smile on her face to return tomorrow.
All my best wishes are coming your way,
Marion

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER

Re: Mum just been diagnosed Ninewells

ScottsMum,

Metal stents can become clogged/infected.  Mine did within 5 months.  They were able to unclog it pretty easily and I had a shorter recovery time than my other planned plastic stent changes. 

I think my "total bilirubin" lab work was the main indication it was blocking (which showed the bile was in my blood stream) but I was also very sick.

Kathy

Re: Mum just been diagnosed Ninewells

Hi ScottsMum,

Sorry to hear that your mum is having yet another issue to deal with. As Marion and Kathy have said, stents both etal and plastic can get clogged and cause infections. Hopefully if it is an infection then the antibiotics will do the job and this will clear up, and if there are clogging issues then these can also be dealt with.

Please let us know how your mum gets on with this and I hope that she is feeling a bit better today.

Best wishes to you and your mum,

Gavin

Any advice or comments I give are based on personal experiences and knowledge and are my opinions only, they are not to be substituted for professional medical advice. Please seek professional advice from a qualified doctor or medical professional.

Re: Mum just been diagnosed Ninewells

Hi again and thanks to all who posted.

Mum has been receiving IV anti-biotic since yesterday and her temp. has thankfully dropped to just about normal today,and she had a better night last night,sleeping well.Urine and bloods have been sent away,so hopefully they will not find it is the stent.The ESBL is probably the cause.Superbugs!!

She is more comfortable today,but having some pain from the blood clots in her groin,which are being slow to resolve.

Such a frail old lady now ,my Dad looks like he could be her son,she is aging so rapidly before our eyes.Starting to look like a baby bird.

ScottsMum

A hard journey means a joyful arrival

Re: Mum just been diagnosed Ninewells

Hi ScottsMum,

Glad to hear that your mums temp is just about back to normal now and that she got some sleep and had a better night last night. Hopefully tonight she will get some more sleep. My dad had a bout of MRSA when he was in Ninewells and that was the last thing that he needed then!

Hoping that your mum has another comfortable day tomorrow.

Best wishes,

Gavin

Any advice or comments I give are based on personal experiences and knowledge and are my opinions only, they are not to be substituted for professional medical advice. Please seek professional advice from a qualified doctor or medical professional.

Re: Mum just been diagnosed Ninewells

Hello all,
Just to report that Mum is a good bit better and feeling well enough to complain about the food/nurses etc. More like herself!

She is not making great headway with the stroke recovery ,but it seems she is over the hump with her other health problems for the time being and the stent is working well.

Her appetite has returned somewhat and she is enjoying small seasonal treats of fruit we are taking in.

So quiet times and we are thankful.

Scott'sMum

A hard journey means a joyful arrival

Re: Mum just been diagnosed Ninewells

Dear Scott's Mum, we are so happy to hear your Mum is better. Enjoy this quiet time now and we are hoping for her to get better in all respects.

Teddy ~In our hearts forever~ATTITUDE is EVERYTHING
Any suggestion I offer is intended as friendly advice based solely on my own experience. Please consult your doctor for professional guidance.