Medical Varicella zoster virus in those over 50 ACK

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rhody

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Just when you thought I could breathe a sigh of relief and was feeling good for a couple of weeks, Blam, shingles, son of a .....
But more than half, and perhaps as many as 75 percent, of shingles patients beyond age 60 develop a condition called postherpetic neuralgia (PHN)-excruciating pain that persists long after the viral infection is over.

A Drama in Two Acts

Because shingles may start with nonspecific signs and symptoms, it can mimic conditions ranging from muscle strain to heart attack. The most common initial complaint is burning or shooting pain in the area served by the nerves infected by VZV, usually near the waist or on the head and face. Patients describe the pain as pulsating, stabbing, piercing, unbearable, and some experts have described it as second only to the pain produced by certain forms of cancer. (Some shingles victims have severe itching or aching rather than pain, and a blessed few, chiefly young patients, experience no discomfort at all.)

Within a couple of days, the pain or discomfort is accompanied by a rash--small, clear blisters (lesions) that form on inflamed skin in the painful area. New blisters continue to appear for about seven days. They gradually get larger, become cloudy, and form crusts that fall off with little or no scarring. The whole episode of pain, rash and healing is generally over in three to five weeks.

After VZV has entered the body and caused chickenpox, it doesn't go away, even after the patient recovers. Instead, the virus takes up residence in nerve cells next to the spinal cord and cranial nerves. Years later, for reasons that scientists don't fully understand, VZV again becomes active. It infects nerve fibers to their very ends, causing them to send impulses that the brain interprets as severe pain, burning or itching.
A quick call to my brother in law who is about ten years younger than me confirmed the symptoms. He said the best advice is to get on an antibiotic as quickly as possible to keep the spread of the virus from advancing along other nerves. It was weird too because the last few days I have been having pain above the area where my kidney stone was removed. I thought it was another one. I am glad it wasn't but this is no fun either. I have a call in to my Dr now, hopefully he will trust my symptom description, and I can get the antibiotic no later than tomorrow. My brother in law waited over a week and he got a pretty bad case and has had tingling and discomfort from time to time since then, it comes and goes. My personal belief is that stress can bring it on, but I have no absolute proof, but recent bout with kidney stones and recent work stress certainly didn't help the situation.

Funny I was feeling especially upbeat health wise, and will try to continue that feeling despite this. The Dr just called and is calling in the prescription now, so I won't have to wait until tomorrow, that is a good thing.

Rhody... :yuck:

P.S. I just had a thirty minute sneezing fit, until I remembered that old trick I learned awhile ago, grab your lower lip squeeze and shake, I did it for about five minutes and it worked, then the urge to sneeze returned, more squeezing and shaking and now it has subsided. Took a couple of benadryl too to address the itching.
 

Evo

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Just when you thought I could breathe a sigh of relief and was feeling good for a couple of weeks, Blam, shingles, son of a .....


A quick call to my brother in law who is about ten years younger than me confirmed the symptoms. He said the best advice is to get on an antibiotic as quickly as possible to keep the spread of the virus from advancing along other nerves. It was weird too because the last few days I have been having pain above the area where my kidney stone was removed. I thought it was another one. I am glad it wasn't but this is no fun either. I have a call in to my Dr now, hopefully he will trust my symptom description, and I can get the antibiotic no later than tomorrow. My brother in law waited over a week and he got a pretty bad case and has had tingling and discomfort from time to time since then, it comes and goes. My personal belief is that stress can bring it on, but I have no absolute proof, but recent bout with kidney stones and recent work stress certainly didn't help the situation.

Funny I was feeling especially upbeat health wise, and will try to continue that feeling despite this. The Dr just called and is calling in the prescription now, so I won't have to wait until tomorrow, that is a good thing.

Rhody... :yuck:

P.S. I just had a thirty minute sneezing fit, until I remembered that old trick I learned awhile ago, grab your lower lip squeeze and shake, I did it for about five minutes and it worked, then the urge to sneeze returned, more squeezing and shaking and now it has subsided. Took a couple of benadryl too to address the itching.
I'm really sorry to hear this, I hope that you are still going to the doctor to confirm what is wrong. My doctor would never agree to call in anything without an examination first, I'm surprised your doctor didn't insist that you be seen by a physician first.

Hope you feel better soon.
 

rhody

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I'm really sorry to hear this, I hope that you are still going to the doctor to confirm what is wrong. My doctor would never agree to call in anything without an examination first, I'm surprised your doctor didn't insist that you be seen by a physician first.

Hope you feel better soon.
Evo,

I have known my Doc for fifteen years, in all my visits I would say 95% of the time I would tell him what I thought was wrong with me and was proven correct. This is one of those circumstances where waiting would be foolish. I could suffer long term effects not pleasant for years to come by waiting. I will make an apt on Monday to confirm I was correct. I saw my brother in laws rash and mine matches it exactly. I checked online google images of it as well, same thing.

I find it curious that the breakout site is on my right side almost parallel to my right kidney. Coincidence ? Remember my right kidney and ureter had a stinking stent in it for 9 days. Less than two weeks later, shingles.

Rhody... :bugeye:
 

turbo

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Sorry to hear that rhody. My wife's uncle suffered debilitating bouts of shingles when he was in his 60's. I hope you can get it under control. I had chicken pox (bad!) when I was a kid, and I am praying that my stressed immune system doesn't lay me open to shingles. I wouldn't wish that crap on anybody. He was a cranky old guy, and the cousins used to tell their kids to call him "uncle agony" instead of "Anthony" for all his complaining, but he really did have something to complain about when the shingles kicked in.

When someone lives on a pristine pond and loves fishing and he is in too much pain to walk out on the dock and make a few casts now and then to try to pick up a smallmouth or a brookie for supper, you know that the suffering is real. You don't give up some dearly-loved activity like that without a reason.
 

Evo

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Evo,

I have known my Doc for fifteen years, in all my visits I would say 95% of the time I would tell him what I thought was wrong with me and was proven correct. This is one of those circumstances where waiting would be foolish. I could suffer long term effects not pleasant for years to come by waiting. I will make an apt on Monday to confirm I was correct. I saw my brother in laws rash and mine matches it exactly. I checked online google images of it as well, same thing.

I find it curious that the breakout site is on my right side almost parallel to my right kidney. Coincidence ? Remember my right kidney and ureter had a stinking stent in it for 9 days. Less than two weeks later, shingles.

Rhody... :bugeye:
Rhody, you can't treat a virus with antibiotics. Aside from the fact that it won't help, it's irresponsible for your doctor to prescribe an antibiotic for anything without seeing you first. Do you mean you requested anti-viral medication?

http://www.webmd.com/skin-problems-and-treatments/shingles/shingles-treatment-overview
 

rhody

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Rhody, you can't treat a virus with antibiotics. Aside from the fact that it won't help, it's irresponsible for your doctor to prescribe an antibiotic for anything without seeing you first. Do you mean you requested anti-viral medication?

http://www.webmd.com/skin-problems-and-treatments/shingles/shingles-treatment-overview
Evo,

I didn't tell him what to prescribe. He didn't ask, he knew. He just wanted to know how long I had the rash. I have valacyclovir, 1 gram, 3 times daily, 7 days. I checked your link, he prescribed one of the recommended meds, listed above.

Rhody...
 

rhody

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Has anyone had a bout of shingles shortly after surgery, stress or trauma ?

Rhody... :yuck:
 

bobze

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Has anyone had a bout of shingles shortly after surgery, stress or trauma ?

Rhody... :yuck:
Shingles, like you pointed out is caused by the Varicella-Zoster virus (or VZV). As Evo points out antibiotics don't work against viruses. VZV is a herpes virus (human herpes virus 3) and like other herpes viruses (in deed like most DNA viruses) they establish latent infections.

VZV, the first time around, causes chickenpox. HSV 1-3 have a predilection for neurons. With VZV this predilection is for dorsal root ganglia neurons. When you become immunosuppressed it is possible for the virus to reactivate and spread down the dermatome that sensory nerve innervates. This leads to that painful rash isolated to one "stretch" of your body that VZV causes.

[Strike]The chance of developing post-shingles neuropathy is low and the exact circumstances that lead to it are not fully understood. I don't believe the number is as high as your OP states IIRC. Possibly in the elderly it is more common, but in the general population with shingles I believe it is actually pretty low. So I would try not to worry over it too much. [/Strike]

Edit again; apparently there is not strikethrough, you'll have to use your imagination! :redface:

Edit: Nevermind. It appears to be a pretty common complication :(. I was thinking of transverse myelitis which develops in <1% of patients post shingles. If it makes you feel any better with some anecdotal evidence: I actually had shingles while in undergrad (dirty living conditions, post-bronchitits, not eating healthy, partying a lot etc) and didn't develop it. Referring back to some of our literature from micro, less severe reactivations of the virus generally tend to have less post-shingles neuropathy complications. So here is to hoping you only had a small outbreak!

Having just come through surgery and being older (?I'm guessing?), its not really surprising. There is (of course of little help to you now) a shingles vaccine. It doesn't actually prevent you from getting the virus (remember you acquired it when you got chickenpox--the little bastard has just been laying dormant in your neurons all this time), but will prevent reactivation of virus.


The meds your doctor gave you are actually herpes anti-virals. Valacyclovir (VACV) is actually just the L-valyl ester of acyclovir (that popular herpes med you see commercials for on TV). Since VZV is a herpes virus and is closely related to other herpes viruses (HSV1/2, EBV, CMV, etc) valacyclovir works on it. The doses needed to treat non herpes simplex viruses are higher however, which is why we use valacyclovir a lot for non-life threatening herpes infections. It has much better oral bioavailablity than does acyclovir (same deal with ganciclovir/valganciclovir as well). Compared with the original drug, you have it easy you should be happy :P. You could be taking 5 or 6 pills a day! VACV has less side effects as well.
 
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atyy

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He just wanted to know how long I had the rash.
Do they still say it's only worth taking if you've had the rash for less than ~48 hours?
 

rhody

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Do they still say it's only worth taking if you've had the rash for less than ~48 hours?
Yes, atty he did, and it was just about at the limit so I said yes.
this predilection is for dorsal root ganglia neurons. When you become immunosuppressed
I'll give you a dorsal root ganglia, would love to arm those structures with nano punji sticks, lol. Seriously, though, don't you both find it odd that the stress of living through kidney stone treatment, combined with work stress, and a short time later < 2 weeks then boom, here we go with shingles, and almost in the exact place of the right kidney and ureter which had to endure a stent for nine freaking days !!??

I know we aren't getting into dispensing medical advice here, (Ryan is watching, hehe, thread lock gun is loaded, finger is on the trigger, lol), but the Doc has got me on one gram Valacyclovir three times a day for the next seven days. With such a large dose, this is a yes or no question, does that weaken me if I need this type of medication in the future ?

I wanted to say thanks for your support bobze, atty, it is appreciated. I will post a picture of the biggest area if you wish. It feels like someone hit that area with a scrub brush from a grill. One more factor I didn't mention that me or may not be relevant. I took my beast of a motorcycle out for a twenty minute ride in 30 degree Fahrenheit weather with heated gloves that barely helped. It felt good when I got back, but chilled, then an uncontrolled sneezing fit started. I swear I must have sneezed at least two hundred times. My nose wouldn't stop running either. That couldn't have helped the situation. :redface:

Rhody...
 

lisab

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Since there's a chickenpox vaccine now, kids rarely get it anymore. So they won't have the virus in their system. Does this mean they can't get shingles as an old person? Does the chickenpox vaccine last a lifetime? Will they need a booster as they approach old age?

Is the chickenpox vaccine identical to the shingles vaccine, since it's the same virus?
 

atyy

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Since there's a chickenpox vaccine now, kids rarely get it anymore. So they won't have the virus in their system. Does this mean they can't get shingles as an old person? Does the chickenpox vaccine last a lifetime? Will they need a booster as they approach old age?

Is the chickenpox vaccine identical to the shingles vaccine, since it's the same virus?
Wow, it's getting harder to be a kid - one less excuse to skip school!
 
There is now a vaccine for this virus that you can get while you are older to boost your memory b cell population with ig's to VZV. You should look into it.
 

rhody

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There is now a vaccine for this virus that you can get while you are older to boost your memory b cell population with ig's to VZV. You should look into it.
What about a poor soul like myself, is it fruitless to have a booster shot now that I have had an outbreak of shingles ?

Rhody...
 
What about a poor soul like myself, is it fruitless to have a booster shot now that I have had an outbreak of shingles ?

Rhody...
It is not fruitless because as you get older your memory b cells (immune cell that remembers Zoster) die. The Center for Disease Control is generally a reliable source of evidence based medicine and they recommend it for anyone 60 or older. Here's the paragraph from their report:

CDC Morbidity and Mortality Report said:
ACIP recommends routine vaccination of all persons aged
>60 years with 1 dose of zoster vaccine. Persons who report
a previous episode of zoster and persons with chronic medical
conditions (e.g., chronic renal failure, diabetes mellitus,
rheumatoid arthritis, and chronic pulmonary disease) can
be vaccinated unless those conditions are contraindications
or precautions. Zoster vaccination is not indicated to treat
acute zoster, to prevent persons with acute zoster from
developing PHN, or to treat ongoing PHN. Before routine
administration of zoster vaccine, it is not necessary to ask
patients about their history of varicella (chickenpox) or to
conduct serologic testing for varicella immunity.
And here is the full report:

http://www.cdc.gov/mmwr/PDF/rr/rr57e0515.pdf
 

bobze

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Since there's a chickenpox vaccine now, kids rarely get it anymore. So they won't have the virus in their system. Does this mean they can't get shingles as an old person? Does the chickenpox vaccine last a lifetime? Will they need a booster as they approach old age?

Is the chickenpox vaccine identical to the shingles vaccine, since it's the same virus?
Correct, if you are vaccinated against chickenpox--In theory you should never need the shingles vaccine or be able to get shingles. The populations of memory immune cells does tend to decrease over time--With some vaccines more than others.

However, the chickenpox vaccine is a live attenuated virus so life-long immunity is generally very good (I think their numbers are somewhere around 80-90%). Of course people can always get a low dose or have a sub-par immune response and still get a very mild form of chickenpox though. If that were the case, in theory they could get shingles as well.

The shingles vaccine (Zostavax) is the same strain of attenuated virus as the chickenpox vaccine (Varivax), just delivered at a much, much higher dose. Since someone getting the Zostavax has had chickenpox and has an immune response in place against VZV already, then the large dose is okay and just ramps up the production of immune response to VZV, such that it will suppress shingles. You cannot use the shingles vaccine in someone who is not immunocompetent to VZV already and you cannot use the chickenpox vaccine to create a large enough response to suppress shingles in someone with VZV latency.

What about a poor soul like myself, is it fruitless to have a booster shot now that I have had an outbreak of shingles ?

Rhody...
Rhody, the CDC recommends that all persons over the age of 60, regardless of having had shingles before or not, get Zostavax. Most people only ever have one bout of shingles in their lives, baring other immunosuppression complications.

It is possible however to get shingles more than one time and having it once doesn't necessarily protect from getting again. There is no formal evidence to show having one out break is sufficient to protect against others, however that is "formal evidence". The fact that clinically, most people only ever deal with one (or less than one) outbreak of shingles suggests it obviously provides some protection against subsequent outbreaks (at least in immunocompetent individuals).

Whether you get the shingles vaccine or not will be up to you and your doctor. I would bet that if you are normally healthy though (aside from your stone bout) and not 60 yet, then he'll recommend you just follow the guidelines for getting the vaccine (single dose at 60).
 

Moonbear

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Since there's a chickenpox vaccine now, kids rarely get it anymore. So they won't have the virus in their system. Does this mean they can't get shingles as an old person? Does the chickenpox vaccine last a lifetime? Will they need a booster as they approach old age?

Is the chickenpox vaccine identical to the shingles vaccine, since it's the same virus?
This is an excellent reason to get the vaccination instead of the "chicken pox parties" some parents ignorantly use as an alternative to vaccination.

Valacyclovir, acycolovir, etc. are antiviral medications. That's the correct thing for shingles/chicken pox, not an antibiotic. However, a doctor prescribing an antibiotic is not necessarily wrong either. The lesions produced by the virus are susceptible to secondary bacterial infection. Back before antivirals were developed, antibiotics were still prescribed simply to prevent skin infections from so many open sores.

What I've always thought was interesting about shingles is that it doesn't affect all nerve endings, but will pick just one spinal nerve somehow and affect all areas of skin supplied by that single nerve. That's why the most common shingles symptoms occur in a "belt" of skin around the torso; that's just the area affected by one spinal nerve. I've always wondered why not all of them, or at least more than one?
 

bobze

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It is not fruitless because as you get older your memory b cells (immune cell that remembers Zoster) die. The Center for Disease Control is generally a reliable source of evidence based medicine and they recommend it for anyone 60 or older. Here's the paragraph from their report:



And here is the full report:

http://www.cdc.gov/mmwr/PDF/rr/rr57e0515.pdf
Not that I really see any difference between the two, so more just an fyi thing;


Its probably best to use the Vaccines: Home from CDC for your most up-to-date vaccine information. They adjust and change the recommendations almost yearly. The recommendations for VZV were updated in Sep. 2011; CDC VZV recommendations, which are "more current" than the 2008 MMRW original recommendation you provided Phys. Though again, I don't think they changed much.
 
Thanks to bobze, I found the new recommendation which includes ages 50 - 59 based on a 70% reduced risk of getting zoster.

Herpes Zoster Vaccination for Health Care Professionals said:
In 2011, FDA expanded the age indication for Zostavax® to include adults 50 through 59 years old for preventing herpes zoster. This decision was based on a large study showing that the vaccine reduced the risk of herpes zoster by approximately 70 percent.
http://www.cdc.gov/vaccines/vpd-vac/shingles/hcp-vaccination.htm#recommendations [Broken]
 
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rhody

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Thanks for the heads up, bobze and PhysiPhile, why does the FDA recommend this and not the AMA ? I printed your post PhysiPhile and will show it to my Doc when I see him.

Rhody... :smile:
 

bobze

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What I've always thought was interesting about shingles is that it doesn't affect all nerve endings, but will pick just one spinal nerve somehow and affect all areas of skin supplied by that single nerve. That's why the most common shingles symptoms occur in a "belt" of skin around the torso; that's just the area affected by one spinal nerve. I've always wondered why not all of them, or at least more than one?
Moonbear, good question. Unlike other HSV viruses (well at least 1 and 2), VZV is active while it is latent--producing lots of nuclear and cytoplasmic viral proteins. These proteins accumulate in the DRG neurons which spread all the way (single neurons! they can be long!) to a single dermatome they innervate. It seems that when the protein count gets high enough (like in times of immunosuppression, when antiviral properties in the cell would be active) the virus starts actively budding again an can infect other uninfected cells in the DRG and nerves and the overlaying cutaneous cells (lytically though) as well.

It seems that there is differential expression of VZV genes during latency and that some proteins are more important for determining reactivation than others. Likely by "monitoring mechanisms" of their local (read; DRG) environment. Its also worthy to note that VZV does appear to remain latent in supporting cells as well as the neurons themselves.

Part of the current hypothesis of why only a single dermatome at time is; that reactivation in group of neurons innervating a dermatome (then breaking through to epithelial cells, resulting in shingles) also prompts a swift immune response (remember you've dealt with the virus since that first time you got chickenpox) that upregulates intrinsic antiviral actions (increasing RNAse etc) and extrinsic (Abs, CTLs, NKs, etc) ones and suppresses viron release and/or maturity in other DRGs.
 

bobze

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Thanks for the heads up, bobze and PhysiPhile, why does the FDA recommend this and not the AMA ? I printed your post PhysiPhile and will show it to my Doc when I see him.

Rhody... :smile:
That's actually CDC (Center for Disease Control) that makes vaccination recommendations. They are the governmental agency probably most concerned with these type of public health issues--particularly those regarding infectious disease. As Physi points out they put a lot of work into their publications on recommendations for medical professionals with evidence-based-medicine.

The AMA does issue some recommendations, but they are a professional peer organization. The National Guideline Clearinghouse (NGC) also maintains health guidelines and standards of care. For instance you can find their guidelines for prevention of herpes-zoster here .

You'll note that both the CDC and NGC use the Advisory Committee on Immunization Practices (ACIP) (and probably most other medical organizations that provide vaccination recommendations) for their recommendations. A little about the ACIP;

"The Advisory Committee on Immunization Practices (ACIP) consists of 15 experts in fields associated with immunization, who have been selected by the Secretary of the U. S. Department of Health and Human Services to provide advice and guidance to the Secretary, the Assistant Secretary for Health, and the Centers for Disease Control and Prevention (CDC) on the control of vaccine-preventable diseases. In addition to the 15 voting members, ACIP includes 8 ex officio members who represent other federal agencies with responsibility for immunization programs in the United States, and 30 non-voting representatives of liaison organizations that bring related immunization expertise.

The role of the ACIP is to provide advice that will lead to a reduction in the incidence of vaccine preventable diseases in the United States, and an increase in the safe use of vaccines and related biological products.

The Committee develops written recommendations for the routine administration of vaccines to children and adults in the civilian population; recommendations include age for vaccine administration, number of doses and dosing interval, and precautions and contraindications. The ACIP is the only entity in the federal government that makes such recommendations. "

Link
 
Part of the current hypothesis of why only a single dermatome at time is; that reactivation in group of neurons innervating a dermatome (then breaking through to epithelial cells, resulting in shingles) also prompts a swift immune response (remember you've dealt with the virus since that first time you got chickenpox) that upregulates intrinsic antiviral actions (increasing RNAse etc) and extrinsic (Abs, CTLs, NKs, etc) ones and suppresses viron release and/or maturity in other DRGs.
I wonder if temperature and stress work through interfering with intrinsic antiviral molecular pathways leading to an outbreak. The 70% risk reduction found was due to increase membrane bound IgG's, so that may fit into the intrinsic antiviral pathway as well.
 

rhody

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I tried to capture most of it with being embarrassing, it started below right armpit, one branch toward my back ending before it got half way,
and the other branching down the right side of the abdomen.
If you want a high res picture PM me and I will send it to you via e-mail. I got the bottom image off the internet have no idea who it belongs to, notice the cluster
of welts below his armpit, very similar, mine haven't broke open yet either, and yes, I know I could get a bacterial infection.

As soon as they do I will treat accordingly, remember, NO ADVISE in this thread, I don't want it locked. This may help other people in my age group know what symptoms to look for. Rhody, out for the night. Will let you know what the Doc says after I see him.

http://img24.imageshack.us/img24/1480/rashr.jpg [Broken]

http://img14.imageshack.us/img14/1707/rash1f.jpg [Broken]

Rhody... :grumpy: :mad:
 
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lisab

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This thread is very interesting and informative. Thanks for starting it, Rhody, and I sure hope you're better soon!
 

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