Post-Transplant Update: 09 January 2020

Happy New Year {and New Decade}, Everyone!

I cannot believe that another year has so speedily passed. I am now swiftly approaching three full years since my transplant!

Before I get started on this blog entry, it is time for me to remind my readers that this blog reflects my personal experiences with PCKD, dialysis, transplant and post-transplant life. My journey has been very atypical in how it has all unfolded, and it should never be inferred that anyone else going through this process will have the same issues regarding their pre and post-transplant progression. However, if this blog can help anyone better their experience in some way, then I am grateful to have been of service.
Remember, you should always consult your physicians and other healthcare personnel regarding your treatment, then follow their directions and advice at all times, and exactly as given. Only they can know what is best for you!

Alright, let's get going...

My little vacation went by too quickly, and I returned just in time to make my latest appointment with the Kidney Clinic.

The visit was actually much quicker than usual, and we made two changes to my meds in addition to ordering an additional test on my next monthly lab draw; which is coming up on 21 January.

First, the so-so news...

Although I was unable to do my vitals with any consistency during my vacation, the results I did get showed that additional tweaks in my meds were necessary. Since my previous visit and the increase of Hydralazine [to 75 mg 3x/day], my blood pressures remained elevated despite the routine usage of Clonidine (.05 mg morning, and .1 mg evening). The A.M. systolic readings averaged in the 130's, while the P.M. reading were in the 140's. While the readings were at least stable, and without wide swings, my blood pressure remains too high which, of course, stresses the kidney and inhibits it from working at the best possible efficiency.

Second, the good news...

Most of the edema caused by the Amlodipine has left my body. The greatest loss of the fluid happened within this past week. As a result, my feet almost look normal, my lower legs are thinner, and my face, which I had not realized was also affected, is less rounded; leaving me looking a bit healthier.

Third, the great news...

Since getting off of the Isosorbide and Amlodipine on 17 December (the date of my last Kidney Clinic appointment), I have now lost a total of 3.2 Kg's !
Do you remember how I was telling you that the Isosorbide can cause unremittent weight gain? Well apparently now that it (the Isosorbide) is out of my body, the weight is dropping...and I'm not even trying to lose any! Plus, as of this morning, I had dropped an additional 3/10's of a Kg from yesterday.
Also, the doctors are extremely pleased that my latest labs finally show great overall stability. We are hoping with the weight sloughing off that my next labs will look even better.

Now, following my Clinic visit, here's the latest approach...

All of my meds will stay the same aside from two differences. First, the Hydralazine has been increased once again; this time going from 75 mg 3x/day to 100 mg 3x/day.

Second, to help further eliminate additional fluids from my body, I have been placed on a temporary regimen of Torsemide 50 mg 1x/day in the morning.
Torosemide is a diuretic similar to Lasix, but its effect lasts longer; being effective from 6-8 hours after onset of diuresis. The hope is to eliminate as much extra water on my body as we can, thus helping to lower blood pressure on top of the increase of Hydralazine.
I will continue with the Torsemide for one month; at which time I will have another visit with the Kidney Clinic doctors, and my progress re-examined.

Lastly on the visit, I off-handedly remarked that it would be nice to stop being cold all of the time, and the doctor asked if I'd had a Thyroid test since the transplant. I did not recall having had that, so a test was ordered that will be included on my next lab draw. The reason for this test is to determine if the thyroid is producing enough of two chemicals that help regulate heat in the body. The Thyroid is stimulated by the Pituitary gland, which itself is regulated by the Hypothalamus; also known as the body's thermostat.
I do not yet understand the entire interaction between the three, but I am including a basic explanation at the end of this blog. As far as what will be done if the labs reflect an issue, I do not know. I will do some studying on the matter in the coming days.

So, for the next few weeks I am hoping to see additional weight loss, lowering BP's, increased energy and better overall progress. I'll keep you updated.

And with that I am going to go ahead and finish this entry. I will have a new one done next week that will keep you apprised of my progress.

Upcoming appointments: Lab draw and monthly Bletacept infusion on 21 January.

Until next week...

Good Health to All!

ScottW



*(Basic explanation of the Thyroid, Pituitary and Hypothalamus Interaction)

Your thyroid gland is a small gland, normally weighing less than one ounce, located in the front of the neck. It is made up of two halves, called lobes, that lie along the windpipe (trachea) and are joined together by a narrow band of thyroid tissue, known as the isthmus.

The thyroid is situated just below your "Adams apple" or larynx. During development (inside the womb) the thyroid gland originates in the back of the tongue, but it normally migrates to the front of the neck before birth. Sometimes it fails to migrate properly and is located high in the neck or even in the back of the tongue (lingual thyroid). This is very rare. At other times it may migrate too far and ends up in the chest (this is also rare).

The function of the thyroid gland is to take iodine, found in many foods, and convert it into thyroid hormones: thyroxine (T4) and triiodothyronine (T3). Thyroid cells are the only cells in the body which can absorb iodine. These cells combine iodine and the amino acid tyrosine to make T3 and T4. T3 and T4 are then released into the blood stream and are transported throughout the body where they control metabolism (conversion of oxygen and calories to energy).

Every cell in the body depends upon thyroid hormones for regulation of their metabolism. The normal thyroid gland produces about 80% T4 and about 20% T3, however, T3 possesses about four times the hormone "strength" as T4.

The thyroid gland is under the control of the pituitary gland, a small gland the size of a peanut at the base of the brain (shown here in orange). When the level of thyroid hormones (T3 & T4) drops too low, the pituitary gland produces Thyroid Stimulating Hormone (TSH) which stimulates the thyroid gland to produce more hormones. Under the influence of TSH, the thyroid will manufacture and secrete T3 and T4 thereby raising their blood levels.

The pituitary senses this and responds by decreasing its TSH production. One can imagine the thyroid gland as a furnace and the pituitary gland as the thermostat.

Thyroid hormones are like heat. When the heat gets back to the thermostat, it turns the thermostat off. As the room cools (the thyroid hormone levels drop), the thermostat turns back on (TSH increases) and the furnace produces more heat (thyroid hormones).

The pituitary gland itself is regulated by another gland, known as the hypothalamus (shown in the picture above in light blue). The hypothalamus is part of the brain and produces TSH Releasing Hormone (TRH) which tells the pituitary gland to stimulate the thyroid gland (release TSH). One might imagine the hypothalamus as the person who regulates the thermostat since it tells the pituitary gland at what level the thyroid should be set.

Post-Transplant Update: 26 December 2019

(Because of Christmas, I am getting this started later than I had planned.)

This is my final entry for 2019...

Unlike I had stated in my last post, this entry will not be as abbreviated as I had intended simply because I want to tell you about my headaches and the edema in my feet and lower legs. First off though, are my latest labs...

23 Dec 19 Labs

*Creatinine:   2.54 (NC)

*Hematocrit:   37.7 (+1.1) IR

*Hemoglobin:   12.0 (+0.6) A touch High

*Lymphocytes:   14.1 (+7.3) Low

*Lymphocytes ABS:   1.0 (+0.6) IR

*Neutrophils:   76.1 (-0.4) High

*Neutrophils ABS:   5.4 (+1.4) IR

*Red Blood Cells:   4.26 (+0.13) Low  *Low end of range is 4.50

*White Blood Cells:   7.1 (+1.9) IR

*Blood Urea Nitrogen:   35 (-2) Very High

*Calcium:   9.5 (+0.7) IR

*Glomerular Filtration Rate:   27 (NC) Extremely Low

*Blood Glucose Level:   102

*Potassium:   4.1 (NC) IR

*Sodium:   141 (+4) IR

*Magnesium:   2.0 (-0.1) IR

*Phosphorous:   3.70 (+0.2) IR

     NC= No Change     IR= In Range

*Urinalysis

Color:  Normal
Glucose, UR:  Negative
Hgb, UR:  Negative
Ketones, UR:  Negative
Leuk Esterase:  Negative
Nitrite:  Negative
pH, Urine:  6.0 (Normal Range is 5.0-8.5)
Prot, UR:  Negative
Specific Gravity, Urine:  1.013 (Normal Range is  1.003-1.030)

The labs are looking steady, and decent. 

The Hematocrit rose nicely to solid In-Range territory for the first time since--I believe--my rejection episode in late March of 2018.
In conjunction, the RBC took another uptick, and at 4.26, am just 0.24 away from the bottom of the preferred range. This was a nice surprise!

The Calcium returned to its preferred range after that brief dip to 8.8.

And the best news was the unexpected jump of both my Lymphocytes and the Lymph ABS. A 7.1 jump puts me just below the minimum that I need to be at. Coupled with the Lymph ABS' jump to 1.0, which is actually where it needs to be, my immune system has taken a welcomed turn for the better! So, no more masks (in most circumstances),and I can ease up a bit with my overall precautions.

Lastly, the Urinalyses is steady once more, having only slight variations on the pH, and the Specific Gravity.

Headaches
Without the Isosorbide and Protonix influences, my headaches remain down from their previous, unrelenting low-grade pain. With only TMD now causing the headaches, I have seen old, familiar patterns to them from day to day. Since last week, I have had three days with minimal top no headache pain that was easily controlled with Excedrin.
However, Christmas day, I had a full-blown TMD headache for the first time in about two months. It took strong meds just to get comfortable, and the NTI devices proved of little benefit as the TMD went a bit wild. As of this morning, the muscles in my jaw had relaxed a bit, and I awoke with my headache around a not-too-bad 6 out of ten. 
So far today, the headache pain is under control.

Now, I know that it seems like my headaches have not improved whatsoever. On that thought, I remind you that uncontrolled TMD causes me to have terrible headaches for weeks and months on end without relief. To have one day out of the last two months be a little tough is a monstrous difference from what I know it has the potential to be. Having one rough day is nothing!

Peripheral Edema
Next, the peripheral edema caused by the Amlodipine is slowly retreating. I have not taken any more Lasix since last week, and every day that goes by sees both feet looking progressively better. I have read that ridding the body of the Amlodipine-caused edma can take up to two months; so seeing such a difference already is terrific!

Lastly, I read last week that an uncommon side effect of the Isosorbide is weight gain. This would explain why I saw significant weight gain ever since my rejection episode.
 I had been on the Isosorbide ever since that point, and saw my weight go from 114.5 Kg to 118 Kg, to 122 Kg, and then up to as high as 128 Kg. This happened despite my efforts to limit food, fluids and the use of Lasix to help my body shed excess water.
Anyhow, since I stopped using the Isosorbide, my weight has dropped from 126.5 Kg to 123.3 Kg as of this morning.
I hope that this downward trend continues the longer I am off of that med.

So, there you are...my final 2019 entry. My next one will be not only in a new year, but a new decade, as well.

I hope that you all had a wonderful Christmas! 
May you also have a fun, festive New Year celebration as you ring in 2020.

See you next year!

ScottW

Post-Transplant Update: 19 December 2019

As scheduled, I went to both of my appointments on Tuesday with 1) My Nephrologist and 2) The Kidney Clinic. Here's what is happening...

My Nephrologist is pleased with my overall progress. 
We also discussed the Amlodipine, and he agreed that getting rid of it would be for the best. He also agreed that the Kidney Clinic overseeing this change of meds was the best option as they are most familiar with my complete medical history.  
One thing that I greatly appreciated on this visit was that the doctor wore a mask [this time], stating that he was feeling just a little off, and with my immune system lowered right now, he thought it best to be extra cautious around me.

My next visit will be in mid-March.

Next, I went to my appointment at the Kidney Clinic. After seeing my feet and lower legs, looking at my daily vitals and asking how I was doing, the two doctors [that saw me] readily stated that the Amolodipine had to go immediately. (YAY!!)

So, here's the new approach...

The rest of my current meds will stay the same expect for one thing: I will increase my Hydralazine from 50 mg AM, 50 Mg Afternoon and 75 mg PM, to 75 mg each of the three times per day that I usually take that med. That's it. Again, this is in hopes of having a sustained BP in the proper range. I will continue using the Clonidine booster should I need with BP over 140 systolic.

The current regimen will stay in place for three weeks, and then I'll have another appointment at the Kidney Clinic. Any changes will be made at that time.

In the meantime, I took yesterday (Thursday) to see if the edema in my legs would reduce on its own, which it did not. So, I took a 40 mg Lasix this morning in order to help get rid of the extra water buildup. By this afternoon, the edema was still quite evident, so I took one more Lasix.
I am hoping that I'll only need a few doses of the diuretic; but I will continue using it until my feet and legs look much better.

As far as my vitals since stopping the Amlodipine, they remain a bit high, but with the extra fluid that I'm carrying, this is really not a surprise. Once that edema has reduced, I'll have a better indicator of where my BP has settled. Of course, I will keep you apprised of my progress.

Next week I have my December Labs and Infusion of Belatacept. I will post those numbers probably Monday afternoon or Tuesday morning in an abbreviated post. Other than that, I will be going out of town post-Christmas, so my next full entry will not be until after January 7th.

May you have a safe Holiday Season!

I wish you all a Very Merry Christmas!

ScottW

Post-Transplant Update: 12 December 2019

Just a quick update today regard the ongoing side effects of the Amlodipine.

My feet have actually gotten worse , in regards to edema.

Here's a photo I just took:

(Peripheral Edema from Amlodipine Usage, 12 Dec 19)

I haven't seen peripheral edema this bad since I was pre-dialysis when my kidneys were dying, and I had no way to get rid of the fluid buildup.

At first, the edema was contained to just my feet, and was relatively moderate. Over the last four or five days it has not only become severe, but has slowly migrated upward; now including both ankles and extending about halfway up the lower legs. Plus, my feet are becoming more and more uncomfortable as each day passes.

So...Amlodipine seems to be a definite "No!" 

My return appointment with the Kidney Clinic is next Tuesday. In a way, I am glad it has taken so long to have that follow-up visit because I have very concrete proof (excessive and worsening edema, consistent diarrhea, elevated BP's) that this med is not the way to go.

Anyhow, that's my update. Of course, I will let you know how my appointment goes, and how we next proceed to unravel the puzzle that is my post-transplant body.

Have a great weekend!

Good Health to All!

ScottW

Post-Transplant Update: 05 December 2019

I finally have time to get this update done, so lets get going.

First, I was unable to get to my appointment with the Kidney Clinic yesterday because of a scheduling conflict that arose with my wifes' job. So, I have rescheduled it for the 17th (the soonest I could get in), and will continue with the current regimen of Amlodipine.

Before I get into that, let's cover my latest lab work...

26 Nov 19 Labs

*Creat:   2.54

*HCT:   36.8 (NC) IR

*Hemo:   11.4 (-0.4) IR

*Lymph:   6.8 (-4.0) Very Low

*Lymph ABS:   0.4 (-0.4) Extremely Low

*Neut:   76.5 (-4.5) High

*Neut ABS:   4.0 (-2.2) IR

*RBC:   4.13 (-0.02) Very Low

*WBC:   5.2 (-2.5) IR

*BUN:   37 (+4) Very High

*CA:   8.8 (-0.5) [A Touch] Low

*GFR:   27 (-2) Extremely Low

*Gluc:   96

*K+:   4.1 (-0.4) IR

*NA+:   137 (-2) IR

*MG:   2.1 (NC) IR

*Phos:   3.5 (+0.2) IR
     NC= No Change     IR= In Range

*Urinalysis

Color:  Normal
Glucose, UR:  Negative
Hgb, UR:  Negative
Ketones, UR:  Negative
Leuk Esterase:  Negative
Nitrite:  Negative
pH, Urine:  5.0 (Normal Range is 5.0-8.5)
Prot, UR:  Negative
Specific Gravity, Urine:  1.016 (Normal Range is  1.003-1.030)

The Lymphocytes are the glaring issue on my labs. I had expected them to rebound after the drop to 10.8 in October, so seeing a further sharp decline was surprising. In conjunction, the Lymph ABS also dropped by half, which is also a problem. And with my White Count lower, I must again take precautions whenever I am out and about around people. These primarily are a mask, and using hand sanitizer frequently--especially after touching doors, shopping carts, common goods, etc--and by being sure to avoid touching my face or ears until I can sanitize once again.
So, no big changes; just extra caution.

My Calcium was only a touch lower than the minimum looked for by my doctors, dropping just 0.2 below that point. I am not worried by this at all as the number is so close to the desired range.

On the Urinalysis, there is only one difference from the previous four months. 
The pH dropped a full point from 6.0 to 5.0. This drop is likely due to my eliminating the Sodium Bicarb from my daily intake (via meds), and my body is probably still adjusting to no longer having that large, constant supply in my blood. Next month should be a better indicator of this lab value.


Next, I am fully off the Isosorbide and Sodium Bicrab tablets, which I stopped the morning after the med switch. My getting started on the Amlodipine has gone a bit worse than I expected.
My blood pressures have all been elevated, both morning and evening. As a result, I have had to take Clonidine both A.M. and P.M, and I am still getting systolic readings in the 130's (morning) and 140's (evening).
The swelling in my feet that I was warned about is definitely more than moderate. Sleeping helps the edema to reduce, but as soon as I am up and moving, it just comes right back. There is no additional edema in my arms or hands; only in my feet.
Plus, my feet become a bit painful at night from what I am guessing to be further nerve irritation from the fluid shifts caused by the edema. My feet are not intolerable in either edema or pain...just uncomfortable; so much so that even if I could stand to have shoes on, my feet would not fit right now.

Other evident side effects I am seeing are daily diarrhea or loose watery stools. and  restless and poor sleep (more than usual, at least) which has caused a general malaise during the day. I can often fight through the tiredness, but it is always there; even after taking two and three hour naps.
So, sticking with the Amlodipine may not be the best thing, when considering the extent of these side effects. I will discuss the side effects I am experiencing at my upcoming Kidney Clinic visit. 

Also, the drawdown of the Protonix has gone well. I have just one more single dose to take in a few days, and then that med will be eliminated. I stuck with the drawdown  schedule I noted, and without the Isosorbide present, I have had zero nausea, acid reflux or gastric burps! (YAY!!)



The cold I was getting has abated almost entirely. Thanks to the rejection med-friendly combination of Mucinex and Delsym, I was able to keep the cold from exploding. It has taken almost two weeks to tamp it down, but with my immune system lower, I am not surprised that has taken so long to overcome.

Despite the peripheral edema [in my feet], my weight has remained consistent. I am currently at 124.5 Kg's as of this morning; where it has stayed within 3/10's on either side for the past week plus. So, despite the edema, my kidney continues to process all fluids properly; it just so happens that fluid is collecting in my feet [because of the Amlodipine] instead of other places throughout my body.

My appetite is good, my dreams are completely controlled, and without the Isosorbide and Protonix, my headaches are fewer! The constant low-grade headache is completely gone...finally!
The TMD is still ever present, but I can now concentrate on only the TMD, and address that from day to day.
If fact, I have had several days--despite the cold--that I took only Excedrin for a mild headache...and it took the headache away! This development is incredibly encouraging! 
It tells me that my TMD is a bit better than I had thought, and that I am closer to getting it under control than since the headaches started back up a few months after the kidney disease really kicked in back in early 2010.
I am hoping that within a few months, I can get the TMD to settle down so much that my T3 use is down to few, if any. Knowing how severe my TMD is, that timeline may not be possible; but I'll try anyhow. I look forward to having zero uncontrollable headaches once again, and now, I am closer than ever to achieving that!

With that piece of good news, I will close this entry.

Upcoming appointments are Nephrology (17 Dec) and Kidney Clinic (also on 17 Dec).

I may or may not get an entry written before that. If not, you'll have a full report on both appointments within a couple of days afterward.

Good Health to All!

ScottW

Post-Transplant Update: 20 November 2019

...and now to finish up.

I just returned from my visit with doctors at the Kidney Clinic. They agreed that I needed to be off of the Protonix simply because it is so hard on the kidney. It was also agreed that it was time to lose the Isosorbide, and replace that with a better BP med, Amlodipine (trade name Norvasc, common name Amlodipine Besylate). The dosage will be 10 mg 1x/day, and with my morning meds.

(from Drugs.com)

"Amlodipine is a calcium channel blocker that dilates (widens) blood vessels and improves blood flow.

Amlodipine is used to treat chest pain (angina) and other conditions caused by coronary artery disease.

Amlodipine is also used to treat high blood pressure (hypertension). Lowering blood pressure may lower your risk of a stroke or heart attack.

Amlodipine is for use in adults and children who are at least 6 years old."

As for side effects, the most commonly reported is that of peripheral edema of the feet. Though this does not always occur, the best way to treat that edema is by raising your feet above the level of your heart when you sleep...if you can tolerate doing this.
IF this med creates too much edema, we will try another.

Also, I can discontinue the Isosorbide immediately, and begin the Amlodipine tomorrow (Thursday) morning.

As far as the Protonix, I cannot just get rid of it. I must do a slow draw-down off the med over a period of about three weeks. So--as discussed with the doctor-- starting tomorrow, I will take one Protonix every other day for one week. On week two, I will reduce that to every three days. In week three, I will take one Protonix every four days, then be completely done with it.

I will let you know how things go with both meds.

Next, the doctor wants me to stop taking Sodium Bicarb tablets (2-25 mg tabs 2x/day) entirely. It was explained to me that the Sodium Bicarb (aka Baking Soda..literally) helps the blood maintain the proper pH balance. As my pH has been looking great, the elimination of the Sodium Bicarb should not affect my labs. IF it does, then I can always go back on these benign tablets once again.

I have a follow-up appointment at the Kidney Clinic in two weeks (04 Dec 19). We will go over my latest labs, and discuss my progress on the Amlodipine, the Sodium Bicarb and the Protonix draw-down. If we need to adjust anything, we will do it then.

In the meantime, as per usual, if I have any untoward side effects from the new med--including excessive peripheral edema--then I am to call my Clinic Coordinator.

So, I lose two meds, but pick up one. However, without the Sodium Bicarb, I am taking 28 fewer pills each week! I'll take that!

Overall, the Clinic doctors are very pleased with my progress, and hope, like I do, that the new med will help me get moving forward in my healing and strengthening once again.

Next week I have both my monthly lab draw, and my next Belatacept infusion. With the Thanksgiving holiday next week (and extended family in town), I may not get to updating my blog until later in the week; but I will try to get to it as soon as possible.

For my U.S. readers, I wish you all a Happy and enjoyable Thanksgiving!

For my international readers, I hope that you have a terrific week, and are safe in all that you do!

Good Health to All!

ScottW

Post-Transplant Update: 19 November 2019

Despite there being a sixteen day gap between blog entries, I am going to start this blog today (the 19th), but finish tomorrow afternoon for reasons I will explain. 
Let's get started...

I thought that I'd start with a bit of good news. My headaches have been on a definite down-cycle over the past week. In fact, there have been three or four days that I have only taken Excedrin, and the rest of the week I have only had to take one, maybe two T3's, and the rest of the day just OTC meds. There was even one day that I took one dose of Excedrin in the morning, and then nothing for the rest of the day!
As always, I don't ask why...I just enjoy [fairly] headache free days. And though I know it won't last long, the past week has been another indicator that the TMD will be under control once again in the near future.

The reason I have taken so long to get this update written is because my wife and I have been in the beginning stages of getting a home-based business up and running; and all of my time is either spent on that project, recuperating from my efforts and/or getting housework and cooking done. 
We decided to start this business because it is highly probable that my ability to find profitable work after a ten plus year gap in my employment, coupled with my ongoing recovery and in addition to my age, will be difficult, to say the least.

Next, my urinary output remains consistent, and my weight continues hovering between 125-126 Kgs. And as I had reported earlier, my daytime output still lags behind the evening and nighttime output. I've had three nights in a row now that have seen output totals of 1300cc's, 1700cc's and 1600cc's. So long as I get rid of all the fluid I take in each day (about 3.25-3.5 Liters), I am a happy camper!

With getting up two or three times each night, my sleep has been pretty good, overall. There are nights that I have a difficult time getting back to sleep, while other nights I am asleep almost as soon as my head hits the pillow. And my dreams remain completely under my control, so I am pretty sure that those bad looping dreams, and the ones in which I have zero control over what is happening, are now a thing of the past; and my conscious control of the subconscious has been firmly reestablished.
Just now, I realized that the further away I get from all of the tests, uncertainty, surgeries, dialysis treatments, vomiting, horrible nausea, etc, the greater control I gained over my dreams. Personally, I found that thought extremely interesting!

My energy level continues its agonizingly slow progress. However, I recently started having a strong desire to start working out again. Granted, I still cannot do much towards that; but having that desire rekindled is a fantastic sign that things are moving in the right direction, and that I am farther along in my recovery than I had thought.


Now, the reason I am starting this today and finishing tomorrow is because the doctors at the Kidney [Transplant] Clinic agreed with my Cardiologist that they should oversee my changing meds from the Isosorbide (and Protonix) to another BP med(s); and that appointment is tomorrow, 20 November. 
I will let you know how that discussion goes, and what the plan is so that I can start moving forward, physically, once again, and stop being so tired all of the time; as well as likely helping to reduce my non-TMD headaches.

And with that, I am going to end for today...