Mets Day 501 – PET scan mighty for remote mets

Mets Day 501

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Dr. Apolo referred to as me slightly at the identical time as ago with the resultseasily of last Wednesday's PET scan. She said that the lymph node beneath my left clavicle that had shown up in my August 6 CT scan changed into "sizzling", strongly suggesting that I had  metastasis of my melanoma. She couldn't be one hundred% bound until eventually the node would smartly maybe be biopsied, however. She already had consulted with one interventional radiologist at NIH, who said that my node changed into too small and too complicated to get entry to to enable a biopsy at this point. Dr. Apolo said that she changed into going to consult with the leader of interventional radiology the subsequent day to find out if he can be willing to are attempting to find to do a biopsy. She said that she would call me the subsequent day with an replace.
So this can be terrible news, whether or no longer it changed into no longer extraordinary. After my three consultations indoors the beyond couple of weeks, I had come to the conclusion that I no doubt had a long manner-off metastatic sport. I failed to enjoy an atmosphere nice deal of shock or shock at the inside observe. I assume Jennifer took it a part tougher. She's made up our minds to positioned her grab's degree work on dangle indefinitely.

Because Dr. Apolo tacitly said that this scan would smartly also be a fake constructive, I did a a phase of analyzing about PET scans and the risk that my scan changed into a fake constructive. The May 2007 report of the National Comprehensive Cancer Network (NCCN) on PET and CT scans in detecting melanoma is ideal here, and means that, whether or no longer PET scans are very exquisite at detecting small quantities of a long manner-off metastatic sport, there is a few 10% menace of a fake constructive. The NCCN report defined that PET scans are very exquisite at detecting metabolic sport in which it does no longer belong. Cancer cells gradually have immoderate metabolic sport since they are turning out to be greater hastily than they deserve to. The affected person is injected with a sugar molecule containing radioactive Fluorine referred to as 18-Fluorodeoxyglucose or 18-FDG. A PET scan can see cells that are consuming that sugar for stress. The PET scan detects in which the radiation is accrued indoors the frame, and the radiologist turns out for abnormal metabolic sport (instead like lymph nodes) in puts in which it does no longer belong. But every characteristically – either ensuing from some weird sport indoors the frame, or an interpretive mistake, a fake constructive analyzing may even be made.

This December 2011 article discusses causes and imaging components of fake positives and fake negatives on 18-FDG PET and CT scans in oncologic imaging. It discusses particularly much of the rationale why there is most sincerely fake readings, none of which look like came upon in my case. (This 2010 put up on as smartly as discusses probable causes for a fake constructive PET scan, none of which look like accurate to me.) The 2011 article says that fake positives may even be minimized if a PET scan and a CT scan equally indicate that a lymph node has metastatic sport. Because I have already had a CT scan appearing an enlarged lymph node indoors the identical quarter, it turns out that the risk that equally scans have been falsely constructive is awfully no longer going.

Thus, the odds are immoderate that I have a long manner-off metastatic sport. In myblog entry of May 29, 2012, I summarized my meeting that day with Dr. Apolo, during which we cited a long manner-off metastatic melanoma at size. The highest imperative concerns keep equally genuine today:

There is hardly very any recognised medical care for Stage IV bladder melanoma. Nothing has been clinically shown to be helpful as a medical care, similar to any classification of chemotherapy, immunutherapy, radiation treatments, foodstuff regimen, or some thing. Anyone who says in but another method is ignoring the small print.
The lookup today is involved by attempting to find to slow the tempo of the melanoma. Even varied months of excess time is thought to be victorious. Each advance builds on beyond advances, and is how varied cancers have in the end realized helpful long time treatments.
Historically, 90% of all Stage IV bladder melanoma patients die inside 5 years of the Stage IV diagnosis. The 10% who reside on accomplish that on account that, for causes unknown, the melanoma does no longer develop in  quarter.
Virtually every bladder melanoma affected individual that has a long manner-off metastases develop will die from it. The typical (imply) size from diagnosis of the a long manner-off metastasis to loss of existence is prepared one year.

ADecember 2011 article says "metastatic urothelial carcinoma portends an fully poor long time prognosis, with 5-year survival at approximately 5%. The total survival of metastatic bladder melanoma has no longer greater compatible over the last two decades." ASeptember 2012 article adds that "the prognosis of patients with metastatic ailment stays poor with median survival being approximately 12-14 months . . . . No imperative advances have been completed indoors the fresh years indoors the medicine of urothelial carcinoma of the bladder. . . . Several focused brokers are lately beneath investigation, but no imperative breakthroughs have been completed with these drug treatments."
So what's in shop for me? This National Cancer Institute actuality sheet is a expert evaluation of metastatic melanoma. This entire article particulars the standard route of metastatic bladder melanoma, with the the will likely be puts for a long manner-off metastatic tumors happening indoors the liver, lungs, bones, and brain. The bone metastases can trigger off intense ache; the others do no longer look like as painful. Eventually, the organs fail, inflicting loss of existence. There are focused experimental treatments to slow the development of tumors in these a long manner-off puts, however the immoderate easiest quality of existence may even be degraded by the medicine. In the coming months, I'll be grappling with the ones business-offs.

Enough documents. Enough typing. I'm going to pass hug my wife.

Mets Day 495 PET experiment at NIH tomorow

Mets Day 495 PET experiment at NIH tomorow

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I'll be getting a PET scan the subsequent day at NIH. Dr. Aragon-Ching inside the muse had scheduled one at GW, then again then Dr. Apolo awarded to do it at NIH, that suggests that we do not should be troubled almost coverage approval. Plus, Dr. Apolo also had awarded to have the biopsy done at NIH, and having the PET there would possibly priceless resource whilst the time comes for the needle to be probing around my chest. The scan outcomes very likely will probably now not be obtainable an analogous day, so we'll be able to merely should wait and see what it tells us. I've already been warned that a damaging scan doesn't mean that there is rarely comparatively very any metastatic prepare, then again merely that it became now not detected through the scan. So the PET scan will probably now not deliver any additional one-of-a-kind data, merely horrible data or no data.
Last weekend Jennifer and I took Kirsten down to Newport News for her movement into faculty. It has been an notably long-time period coming, and I suppose about we all felt relieved to have handed that milestone. We then went to the lake apartment — the 1st time this yr we've been there — and positioned thigh-best possible grass and a a little musty apartment. To my shock, the boat started terrific up, then again it idles extra or less — I suspect that the carb would possibly need some goop fitted up from sitting for hence long. The jet ski and riding mower batteries crucial to be charged. I like going to the lake apartment, then again according to how little we've used it, and the approaching darkness, we'll be able to without doubt promote it next spring.

I have been impressive unperturbed through the wisdom that my cancer would possibly also additionally be metastasizing. I've had realise that-of-reality conversations with the entire childrens almost it. Jennifer and I also have had several calm conversations with regard to the other that I is almost in reality dead through the finish of 2014, and what we need to do in the period in-between. We're then again jogging out the particulars, then again we shall probably now not be doing a thing drastic inside the on the factor of destiny. I'm going to do a little extra paintings on the apartment, play with my soon-to-arrive granddaughter, and enjoy time with my circle of better half and toddlers. I've already go the wheels turning for updating our estate planning, and Jennifer is appearing extra consideration in gaining wisdom of almost our payments.

Last evening Spencer and I went to the Redskins preseason opener. I had discovered a bunch of tickets on Craigslist, and so they have been inside the decrease bowl almost 10 rows up from the sideline. We went early, ate some bratwursts, yelled and booed and cheered and stayed to the finish. It became a preferrred evening with my son.

Life is going on, shorter for some, longer for others, then again the day to day approach of residing forms a development this is laborious to disrupt, even inside the face of looming mortality. I have discovered how duties and commitments can govern my time, and too routinely I have allowed my agenda to usurp my college. Even now, once i in bigger section have been revealed from 25 years of practicing laws, I am shocked either through the toughness of my conduct, and the styles that I have fitted with my circle of better half and toddlers. I didn't all right respect how the ones styles, either additional one-of-a-kind and horrible, have been forming over time, then again now can see how they've have been given have been given etched into the stone of my soul.

Mets Day 489 – GW consultation

Mets Day 489 - GW consultation

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Today I met with Dr. Aragon-Ching, the oncologist with GW who supervised my chemotherapy ultimate yr. We reviewed the experiment outcomes from Fox Chase, and had a candid discussion approximately my clients. She admitted that, with as unfavourable as my put up-surgical medical care pathology had been ultimate May, she changed into stunned that it had taken 15 months for a CT experiment as an example enlarged lymph nodes. She also reported that, similtaneously there changed into a narrow opportunity that the nodes have been now not metastatic melanoma, I aren't be stunned if they have been.
Like Drs. Plimack and Apolo, she reported that much efficient time would nicely much possibly inform if this changed into metastatic melanoma. She explained that the nodes have been below my clavicle, next to the brachial plexus, and adjacent to the best possible correct of my lung. It's a nasty aspect to cross probing with a biopsy needle, particularly in case your objective is much efficient one cm all over the worldwide. I advised her that I would nicely much possibly like to renowned turbo as an exchange of later, because I in all opportunity would nicely much possibly ensure therapies as briefly as it changed into verified. She agreed to schedule a PET experiment for next week, even with the reality it essentially is by no performance certain that it's going to feature any additional statistics.

She said chemotherapy and radiation undertaking probabilities, even so warned that none of them had been shown to be competent towards metastatic bladder melanoma. She reported that my bladder melanoma changed into without doubt platinum-resistant, because my tumors had back and spread to my lymph nodes in the path of chemotherapy. I advised her that I failed to are browsing to spoil my optimistic of existence suffering by approach of therapies that had marvelous level outcomes and little likelihood of accomplishment. She agreed with me. She will paintings with Drs. Plimack and Apolo to make school on the best possible similar path of solve, as briefly as the a equipment away mets are verified.

For now, I'm going to wait for that my melanoma has metastasized, and architecture my existence in this example. Maybe I'll be stunned in some time and imagine like I have a new rent on existence. But the realist in me says now not to cling my breath and on no account want for miracles.

Mets Day 487 – NIH consultation

Mets Day 487 - NIH consultation

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Today I met with Dr. Andrea Apolo, a clinical researcher at NIH who specializes in examining resolution information cures for bladder cancer. (A recent interview that she gave to BCAN is sweet here.) Coincidentally, this beyond weekend she was co-chairing BCAN's 2013 Bladder Cancer Think Tank, an invite-handiest convention that gathers probably the most and brightest medical authorities who're operating on locating a remedy for bladder cancer. She specializes in bladder cancer clinical trials, and is greater than likely the single optimum an skilled human being contained in the global on the subject of the optimum updated analysis and files cures for metastatic bladder cancer.
While I was sitting contained in the NIH waiting room, Dr. Steinberg, my surgeon from Chicago, acquainted as to claim that he had acquired my e-mail of ultimate Tuesday, and that he had sought out Drs. Plimack and Apolo on the BCAN Think Tank to debate about my case. Dr. Steinberg favourite that, given my history, I was marvelous to fret on the subject of the CT scan. He equally that the vicinity of the lymph nodes (a lot now not up to the clavicle, adjoining to a neighborhood of imperative arteries and nerves) and the stunning small dimension of the node (merely over 1 cm) would make it practically very unlikely to biopsy at this part. He also favourite that he agreed with my in the search for out Dr. Apolo, and situated that, among Drs. Plimack, Apolo, and Aragon-Ching, I was being situated by one of several most foremost bladder cancer oncologists contained in the scenario.

I had equally the disks with my FCCC scans for Dr. Apolo and her work force to assessment. After a practically two-hour wait and a lengthy screening by one of several NIH fellows, Dr. Apolo joined us, announcing she had spent a lengthy run reviewing my scans in point. She didn't upload notwithstanding what new approximately my existing prestige: the enlarged nodes have been worrisome, though they have been nonetheless gorgeous small, being merely over the edge of clinical value. She established that it indubitably is going to be practically very unlikely to biopsy the nodes at this part, announcing that inspite of an ultrasound-guided CT, the node is additionally on the very least 1.five cm to have a friendly option of luck, and 2 cm was more more greater than likely to be have a priceless biopsy. Of path, she favourite that if a bigger CT scan showed the node was 2 cm, then it was ninety nine% yes to be metastatic to boot.

I told her that I'd would like to realise quicker as opposed to later. Dr. Apolo bluntly responded that understanding in advance wouldn't make any alternate in either medication or the chances of survival: a long means-off metastatic bladder cancer is fatal. I concept, though didn't say, that understanding in advance would remove the uncertainty that I now enjoy. More on that later.

Dr. Apolo favourite that, until the a long means-off mets was established, it was too early to debate about clinical trials. She remembered that my BC was HER2 advantageous, and favourite that she knew of a vast choice of experimental cures that in some prerequisites had slowed the trend of HER2 advantageous BC. She also favourite that, if NIH did the biopsy, they would do a genetic sequence of my cancer. That would let them to larger select out equally the mutations that had brought on my cancer, and the optimum correct clinical trials to inspect if notwithstanding what may good also gradual the trend of the dysfunction. (Note to self: ask Dr. Aragon-Ching if GW can sequence my tumors that have been eliminated in my TURBT's.)

Dr. Apolo comparatively priceless that I have a seriously seem into up CT scan in three months. I told her that FCCC already had scheduled a seriously seem into-up for October, and she or he concept that was competitive, though when FCCC would do it that early, then that was terrific. She favourite that she would seriously seem into-up with Dr. Plimack to boot Dr. Aragon-Ching of GW, who I will see on Wednesday.

After leaving, I concept more approximately why I sought after to realise even after i now had a long means-off mets. I bear in mind that even after i know if the nodes are advantageous will now not extend my existence. I at ultimate made a decision that the the rationale why I would are in search of out to realise now, as opposed to two months from now, is that I greater than likely would enchancment the urgency of my existence if I knew with certainty that my most correct days have been drawing close. I would greater than likely retire from my ideas trade; get transferring on updating my will and trusts; sift through and convey in combination my journals, emails, and the different writings that doc primary chunks of my existence; sell our ruin condo; are making an strive to get full the renovations on our ordinary home so Jennifer do now not should deal with it; eradicate one of several most detritus of existence; confer with lengthy relations; set up my instantaneous relations for existence with no me; and speeded up set up myself for eternity. Other than that, I wouldn't alternate something.

After operating through this intellectual checklist, I asked myself why I'm now not doing those matters now. (In all fairness, I have been performing a type of those matters.) The answer, I think, is a mixture of exhaustion, inertia, and indubitably now not inclined to handle it. Maybe this ambiguous scan is the kick contained in the butt I've necessary to once another time refocus my like on what basically problems.

Mets Day 483 – mulling over Tuesday’s CT take a look at

Mets Day 483 - mulling over Tuesday's CT take a look at

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Since receiving the tense experiment effects on Tuesday, I've spent your time analyzing a half-dozen articles revealed this 12 months reporting on the treatment of metastatic bladder optimal cancers. Unfortunately, there turned into style of most no growth since I greatly researched this in early 2012. BC that spreads to far-off puts inevitably is deadly, and researchers were unable to recognise the physiology or mechanisms of how and why it spreads. There is not commonly really very any treatment, and coverings are palliative. Average survival time after far-off mets are detected is approximately nine months.
We do no longer know if that is what I've obtained yet, having recounted that. On Tuesday, I emailed my DC-primarily dependent oncologist the next:

"Dr. Aragon-Ching:

I hope all is absolutely with you. Yesterday I had a CT experiment at Fox Chase. Comparing it to my prior experiment in March 2013, the radiologist detected several somewhat enlarged lymph nodes (10.2 mm) through my left clavicle. Dr. Plimack pronounced taking a wait and spot technique. My next CT at FCCC shall be on Oct. 8. I'd love to recognize  in assignment of later if my BC has spread to far-off destinations. I'm also leery of the accuracy of CT scans, since my April 12, 2012 CT after chemo confirmed three enlarged nodes (approximately 1 cm), and the surgical pathology after my May 2, 2012 RC revealed 12 constructive nodes.

I would get joy from your concepts on the next:

1. How can I uncover out no matter if these nodes are mets constructive? Would you recommend a applicable kind away PET? Can I have the nodes biopsied now? Who would do the biopsy? I count on it desires to be CT or ultrasound-guided.

2. Assuming the nodes are constructive, what are my treatment opportunities? I'd love to recognize the gamut, from tremendously aggressive to conservative, together with your perspectives on effectiveness, facet effects, and size. Should we factor in chemo with taxenes? I'd also welcome your concepts on the optimal advantageous scientific trials to factor in.

three. What is the odd timing and progression if that is mets? I know there isn't commonly really very any treatment and my diagnosis is grim, having recounted that it desires to be very helpful to my making plans if I had a miles extra advantageous concept of my course, e.g., be awaiting to have especially commonplace causes for a 12 months or so, then 6-twelve months of sliding downhill with palliative care.

I'd get joy from your concepts through e mail, cellphone, or an appointment."

She replied with the next:

"Hi Mr. Brothers,
I may neatly have Meghan add you with out guard up to my agenda for next week Wednesday if that works for you.
There are cases after we see these non-descript lymph nodes namely in no longer so ordinary puts (as in the clavicular puts) and although spread to these puts are through and big attainable, remoted findings resembling this may also no longer be attached with optimal cancers in the least. I suppose repeating the experiment would be in your finances for the motive why that unfortunately the serve as of chemotherapy in true, verified, recurrent/metastatic affliction is palliative, in assignment of recuperation. Given there aren't a very effectively style of chemotherapy regimens obtainable for metastatic bladder optimal cancers, the stance is necessarily allow's treat it if and as quickly as we've to.
As nerve-wracking this may also sound, waiting till this evolves to such that it also may also neatly be safely biopsied is in your finances (the percentages of luck of biopsying is restricted at the same time the node is small – and 1 cm would nonetheless be really applicable small except for it be miles clearly palpable). Obtaining a PET experiment is an alternative, even at the same time as quickly as extra its price is restricted in 1 cm or most less lesions in which a extensive style of occasions, it desires to be beneath limits of detection through PET.
I would no longer be too hasty in calling it metastatic at this part and imagine Dr. Plimack's evaluation of obtaining an alternate experiment in heaps of months. I suppose we've to appearance at scientific trials have to there be unequivocal recurrence/metastatic affliction.
I'd be chuffed to level of hobby on added with you next week…Dr. Apolo at NIH would even be a official resource adult to consult. Do you have the disc for this trendy experiment? it desires to be intelligent to ship it with you.
take care,
I've confirmed the appointment on Wednesday, August 14. As she pronounced, I also reached out to Dr. Apolo, whose accomplished level of hobby is bladder optimal cancers learn. Her assistant speedily replied, indicating that Dr. Apolo had some concepts re attainable scientific trials and would be chuffed to level of hobby on the modern files attached to BC approaches, and I have an appointment with her on Monday, August 12. Both medical authorities also essential to exercise session the bodily experiment details, so I arranged for FCCC to in a single day the disks to my condo.
I'm thankful for the commitment of the ones medical authorities, and hope that there they'll ship me some intelligent information. The optimal advantageous information would be that the nodes through and big are no longer constructive for optimal cancers in the least, having recounted that that in all likelihood shall be confirmed most efficient through a biopsy. It's practically improbable to biopsy nodes which are most efficient one cm in size, so I may also have little determination having recounted that to attend and spot what occurs.

Mentally, I'm getting all set myself for the affirmation that the optimal cancers has spread. Maybe it hasn't, and all this will likely be for naught. But I've identified the percentages for ages, and have had a 12 months and a half to get all set myself for the time that I revealed out that the optimal cancers is spreading. Maybe that is it. Maybe no longer.

I be mindful that I have no longer any administration over no matter if the optimal cancers spreads or no longer, and there's no treatment that science also may also neatly be delivering. I am no longer anxious as regards to the troubles I can not administration. What I uncover optimal engaging is that, to the volume I revel in any frustration or nervousness in the least, it be miles at needing to recognize no matter if or no longer the ones infected nodes are mets constructive. I've mulled why that is the case — my understanding may neatly no longer distinction my diagnosis in the least — and concluded that I've spent a whole lot my existence obtaining files. Learning and understanding the repute of my optimal cancers progression is not commonly really very any exclusively the several. Whether I'm losing my time making an take a look into to uncover that out is an alternate question. The optimal practical thing which might neatly come of that files is a somewhat extra advantageous knowledgeable wager of how long I will reside.

I don't are having a look to be clutching to existence with grasping fingers, doing each and every thing attainable to shop for an alternate day of mortality, despite how undesirable the advantageous of existence. Some of the approaches for most-off optimal cancers tumors may also buy an added week or two, having recounted that at a horrible can price. I'm no longer attracted to destroying my existence so one can delay it. On an additional hand, if there are treatment opportunities that can stay the mets at bay with out turning me into a creature of distress, then I'd love to recognize approximately them. That's what I hope to be trained from next week's appointments.

Kruger National Park recap

Kruger National Park recap

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Sunday, July 26
Our flight to Johannesburg on SA 208 left Dulles International Airport at 5:20 pm, and turned into scheduled it land at JNB at 5:15 pm a smarter day. I had booked these tickets by collecting miles on United Airlines from historic commercial enterprise commute, plus beginning some credit rating playing cards and piling up the award points. One way economic climate seats were 40,000 miles each single; the associated fee to shop for an equivalent seats turned into $2800 each single. There were more cheap flights attainable, nevertheless all went by means of Europe and lots of were cut down back to chop down back redeyes.

I've flown from DC to Korea, together with DC to Tokyo, a number of times, and this flight to JNB turned into certainly one of a number of longest aircraft rides I've experienced: sixteen.5 hours on the air, plus an hour on the floor in Dakar, Senegal for refueling and a crew modification, with by means of passengers not authorized to get off the aircraft. Jennifer, Kirsten, Garrett, and I shared a middle row; Spencer had an aisle two rows ahead of us. There in no such element as sleeping without a trouble in an economic climate airline seat, nevertheless Kirsten and I amused ourselves watching Garrett's head nod, bob, sag, and weave. In Dakar, members of the Senegal males's basketball crew boarded, and the 7'2" middle sat behind me. I then stumbled on my loss of legroom turned into not so bad, nevertheless his knees unavoidably massaged my cut down back.

While on the flight, Spencer had left his glasses hanging out of the seat pocket. At some part, girl sitting next to him knocked them out and snapped off the body on the temple. Spencer observed his damaged glasses beneath her chair, and she or he sheepishly admitted to breaking them. She made no be offering to settle for fiscal responsibility, and what may probably smartly Spencer do about it? Unfortunately, they were his simplest pair, nevertheless happily, he also had additional his contacts.

Monday, July 27

Upon arrival in Johannesburg at 5:15 pm, everyone turned into required to fill out a kind bearing on qualifications Ebola publicity. The varieties were gathered with barely a glance by harried officials, so it turned into not an drastically confident formula of self-reporting. Passport control required us to give an authentic get started certificate for Garrett – a new legislations designed to preclude child trafficking – and fortuitously we had come prepared. We observed a number of little ones being dragged faraway from screaming oldsters who were not conscious about the brand new legislations. (No we didn't – nevertheless I wondered what got applicable here about to tourists that did not convey their kid's get started certificates. Were they enormously denied entry and made to fly cut down back to their homestead kingdom?)

We gathered our bags, and developing into the terminal we observed a Sunglass Hut kiosk. Maybe they could be able to probably smartly fix Spencer's glasses! No such luck, nevertheless the girl stated that there turned into a within sight mall with a number of optical department outlets. We also picked up a porter who turned into totally happy to end up us where to fulfill the resort shuttle (tip, please), which jogged my reminiscence that I vital to find an ATM. The South African Rand currently is terribly weak in assessment with the dollar, buying and selling at 12.5:1, which makes most things a relative cut down cost.

We rolled into the Protea Hotel O.R. Tamboro at about 7 pm, and we were tired. I had three rooms by the use of Marriott Reward points, so we dropped our bags, went to the buffet dinner, then fell into bed.

Tuesday, July 28

Spencer turned into the most effective one who got up early for a workout. The relaxation of us slugged our way down for breakfast, then packed up and checked out. Bearded Heron Safaris had organized for a motive strength with a minibus to fulfill us at 9 am and power us to Kruger National Park. We persuaded the motive strength to first give up on the within sight mall to work out if Spencer's glasses can be repaired. The optician stated that the frames were unrepairable, nevertheless that the lenses can be re-sized and fixed applicable into a new pair for frames. That would take 3 days, nevertheless. I figured that we would be cut down back in Johannesburg next Monday for our flight to Zambia, so we agreed. The frames and resizing cost simplest $eighty five!

We made our way east each single of ways by means of the veld and throughout the hilly Mpalangna sector, coming into Kruger National Park (KNP or, as locals pick it, "The Kruger") at Malelane Gate. We got out of the van since the motive strength received our allow, and observed a troop of vervent monkeys in a tree, beneath which a herd of impala were grazing. Our first photograph option! Smiles all around. We passed some baboon, then stopped to observe a mother elephant scratching its cut down back, rear, and ears on a tree, intently observed by a feminine calf. Cool stuff.

We arrived in Berg-en-Dal relaxation camp, where our van motive strength handed us off to Neil Heron, proprietor and sole advertising consultant for Bearded Heron Safaris. Our motive strength turned around to power cut down back to Joburg (I hope my tip of R100 turned into high-excellent caliber), and we met our host. Neil Heron turned into raised throughout the bush, went to university in Great Britain, returned to South Africa to work for and at last run the South African division of Penguin Publishing, before figuring out to get started his safari agency in 1993. His compatriot and prepare dinner, Alister, turned into also an ink stained wretch at Penguin before coming aboard the safari gig. Neil's wife, Tina, does each single of the booking and logistics, and Neil spends 220 days of the yr in The Kruger. Neil has saved Beaded Heron small so he can personally advertising consultant all of his valued clientele. We are totally happy to be his simplest fear for a smarter six days.

After a short snack of fruit cocktail, we headed out on our first recreation power. It turned into simplest a 4 km power on a dust road very swiftly open air the gate of the camp, nevertheless what selection! We observed 5 giraffe, dozens of impala, a number of elephants, a intensive kudu buck who combined in totally with the bush, and later the comfort of the kudu clan, a mother and calf white rhino close to a watering gap, and most impressively, the dominant rhino marking his territory throughout the midden circle, then walking each single of ways by means of the street between our safari truck and the line of vehicles behind us. Wow! All the even as, Neil turned into telling us about the routine of every single of these creatures, and how they were interdependent upon each single different.

Neil taught us about the birds throughout the Kruger, introducing us to the Grey Go Away hen (its actual pick, as a influence of its distinctive pick), and the dove with the pick that sounded adore it turned into declaring "work more challenging." We observed this kind of lot of lilac-breasted rollers, whose coloring feels adore it turned into made by a five yr historic with a intensive container of crayons. Over the six days we were throughout the Kruger, Neil outlined birds quicker than I may probably smartly fail to remember about them. This place is loaded with them – our advertising consultant book has 172 pages of birds and 44 pages of mammals, and I suppose that we've seen at least half of the hen species indexed. It's too bad I'm not this kind of lot of an ornithologist. We returned after our 90 minute recreation power, considering that if they all were going to be this cool, then this turned into going to be an potent journey.

While we were having enjoyable with our first publicity to the Kruger, Alister (Neil's long-suffering assistant) turned into preparing dinner. He had the charcoal going, and Neil tossed seven considerable steaks (4 hundred g, or about sixteen oz.) onto the grill. Neil explained that a "braai" – cooking meat over an open air fireplace – turned into a major South African lifestyle. Each evening even as throughout the Kruger, we were going to have a braai with varied classification of meat, prepared by our hosts. I remarked to my circle of possess family that, after i turned into first exploring possibilities for this journey, I had viewed renting a vehicle, self-driving by means of the park, and being liable for all of our possess cooking. I stated that I turned into very glad that I didn't comply with by means of on that idea, nevertheless it turned into some distance this kind of lot less pricey than having Neil as our advertising consultant and host.

Our lodgings throughout the Berg-En-Dal camp consisted of a brick stricture with a thatched roof, containing one considerable bedroom with three twin beds, a kitchen, and a rest room with a delightfully hot shower. I joined the men in a single unit, and Jennifer and Kirsten had a added one within sight. After our dinner and cups of hot chocolate, we turned in and by 9 pm were all asleep.

Wednesday, July 29

Wednesday morning we aroused from sleep at 5:20 am (Spencer had awoken at 3 am and went for a run, then stayed up) and met at a table on the porch of Neil and Alister's unit for hot chocolate and rusks – a type of crusty bread for dunking. The gates of the camp opened at 6 am, and we were off for our first morning recreation power. The temperature turned into about 6 phases C (low 40s F), and we were riding in an open-sided safari truck. It turned into a chunk chilly, specifically as we were driving around. We had packed and were dressed in layers of clothing and gloves, and Neil supplied each single of us with a intensive woolen blanket that we sat on and wrapped around ourselves. As the day warmed and temperature rose to above eighty phases, we stripped off layers and basked.

We drove east out of the camp and drove alongside the Crocodile River. As the sunlight rose, the kids started singing the beginning track from Lion King. From time to time each single of ways by means of our safari, one do the kids would get started humming "The Circle of Life." I had pretty lots of songs tumbling by means of my head from Paul Simon's Graceland, or Toto's Africa. It's challenging to be on safari and not hear music on your head.

Soon after we turned off the oiled road (S114), we observed a mother rhino and calf about 20 ft off the street, intently adopted by a intensive bull rhino. The bull turned into drawn to making a social pick to the mother, nevertheless she turned into having none of it. As he approached, she unexpectedly turned and crashed into him. He gave a roar of alarm and beat a hasty retreat. The mother and calf then crossed the street very swiftly throughout the front of our vehicle, even as the bull sulked in a grove of trees.

We oscillated down a dust road badly washboarded throughout the dry season. Neil infrequently would give up and view tracks throughout the dust, explaining that he turned into making an strive to to find manufacturer new footprints from lion and leopards. He explained how he may probably smartly judge the age of a track by how crisp the edges were, and the age and repeatedly the sex of the cat by the length and shape of the print.

He also explained about tracking by analyzing the freshness and composition of the spoor – the feces – of pretty lots of animals. As we drove alongside the Crocodile River, we may probably smartly see that the south part of the river, only open air the park limitations, were lined with intensive homes that Neil stated were owned by celebrities and captains of trade, who not repeatedly ever visited them. We were extra targeting the class of nature in place of the hubris of guy, nevertheless.
We didn't see any cats on the morning power, nevertheless. We did encounter a constant of a half-dozen young grownup male elephants that were making a ruckus even as feeding, pushing down trees, spraying urine on bushes, tipping over buffalo, and conducting conduct conventional of sexually pissed off adolescent males. Neil stated that it turned into very strange to work out this kind of constant of males together – usually grownup elephant males, as soon as they reach sexual maturity, are kicked out of their circle of possess family network and roam as solitary bulls till they kind their possess circle of possess family. Sometimes they agree to an older male around who acts as a mentor. But to have all young grownup males roaming together turned into atypical. To me, their booming music and occasional-slung pants explained their organization, nevertheless Neil wasn't acquiring it.

We got cut down back to camp at eleven am for a full English breakfast prepared by Alister – scrambled eggs, baked beans, sausage, bacon, potatoes, onions, tomatoes, juice, and hot chocolate. We took a short relaxation, then were off as soon as extra at 1:30 pm for a added recreation power. We observed many rhino, antelope, kudu, giraffe, and elephant, nevertheless the highlight turned into coming upon a constant of five lions – sincerely 4 lionesses and one younger male. We parked about 15 ft away, and watched 4 of them were sleeping throughout the afternoon sunlight. A lionesses saved watch over them, infrequently circling the space, then laying down and grooming with the others.

The male throughout the tip rolled over on its cut down back, gave a tremendous stretch, then fell asleep in an utterly undignified pose, fore and hind legs splayed, and head upside down resting on certainly one of a number of lionesses. Neil idea that these five were detail of a bigger delight of about 25 lions known to be throughout the space, and guessed that the comfort of the lions were sleeping in a within sight dry riverbed. They most likely had just lately polished off a kill, and were sleeping it off. Neil informed us that lions progressively sleep 18 of every 24 hours, nevertheless their prey never knew which 18 hours which may probably smartly be, since they were constantly searching throughout some different 6 hours.

We returned to camp at 5:30 pm, and at 6 sat applicable down to a nice braai of fowl and squash, in conjunction with rice and salad. The youngsters fell into bed by 8 pm, and Jennifer and I stayed up till 9:30 visiting with Neil and Alister. Our body clocks had principally achieved the six hour shift in time zones, nevertheless we were feeling it by the time we stated respectable night. One element about safaris – you arise before the sunlight rises, and do not stay up too long after it sets.
Thursday, July 30

This turned into the most effective morning with an not obligatory sunrise recreation power. Kirsten, Jennifer and I were all in, nevertheless Spencer and Garrett elected to sleep in. The three of us were to fulfill Neil at 5:30 am for hot chocolate and rusks, nevertheless I mis-set my alarm for 6:20 am. At 5:40 am Kirsten knocked on the door to our hut and woke me out of a sound sleep. I hurriedly dressed and left the sleeping boys, apologizing to Neil and the women for my being late. I ought to still have been in deep REM, since it took extra than an hour for me to sense utterly awake. Perhaps by explanation why of this, the recreation power seemed this kind of lot less eventful than normal – we observed some critters, nevertheless nothing that specifically stood out.

We returned to camp at 8:20 am to find breakfast waiting, and the men still in bed. I roused them with the promise of bacon, and we polished off an potent volume of delicacies. We returned to pack our bags, as we were moving camp as of late: Alister would take our bags and the Bearded Heron supply trailer to Skukuza camp and setting up, even as we would be out on a 6 hour recreation power.
The highlight of contemporary day power turned into being surrounded by elephants. As we approached a single lane concrete roadway each single of ways by means of the nearly dry Biyamiti river, we observed some elephants walking on the downriver part of the street. Neil stopped midway each single of ways by means of the causeway and we started taking images. Soon a added network of elephants approached us from the upriver part and got applicable here within 20 ft of the vehicle. They paused at a smartly gap throughout the river bed that different elephants had dug, and proceeded to drink and spray themselves.

Neil slowly pulled the truck ahead so we wouldn't be so getting able to the elephants, simplest to work out a added network of elephants crossing throughout the front of us since the street climbed out of the riverbed. He started to chop down back up when a added network of elephants starts offevolved crossing behind us. We had elephants all around us! In the network behind us turned into a mother with a wholly young calf – Neil estimated it turned into simplest a few months historic – and the calf didn't desire to leave the small water gap. We watched since the mother stomped impatiently, then went cut down back and pushed apart some juveniles, and wrapped her trunk around her calf to drag it away. The calf bawled, slipped out of its mothers draw close, and went cut down back to the watering gap. The mother stood within sight, rocking impatiently, spreading her ears wide in a threatening gesture, and bobbing her head. Neil idea that her anger turned into directed towards her calf, nevertheless she got applicable here about to be dealing with us. There turned into a guess that she turned into showing anger towards us. Neil stated we ought to still have the possible to attract back right away, nevertheless there have been still elephants throughout the front of us. Eventually, the calf got applicable here alongside, and the mother led her calf alongside, adopted by two different juveniles – Neil stated they most likely were her different little ones – and in order that they crossed behind us and went on their way.

During this time there have been over 50 elephants that passed between 20 and one hundred ft from our vehicle. I captured 20 minutes of this encounter on my iPhone, and presumably will publish it if I work out how.
We rolled into Skukuza camp at 4 pm. Skukuza turned into certainly one of a number of authentic Kruger camps, located next to a rail line and on the Sabie river. It now is certainly one of a number of finest camps throughout the park, with extra than 200 circular resorts units, known as rondavels, each single with three twin beds, a rest room, and a kitchenette with a small fridge and hot plate, and in assertion a braai open air. As Neil and Alister setting up camp, we walked by the river and prefer iron shavings adjoining to a magnet were pulled into the current store. Of course the full factor turned into gloriously overpriced, and in assertion we purchased furthermore to.

At Skakuza Camp

The adjoining restaurant had a signal promising unfastened WiFi, so we pulled out our iPhones like empty canteens hoping to be stuffed, nevertheless alas! No signal. An worker stated that maybe it is going to be working later, and I noticed a personal seated within sight who turned into having a look forlornly at his phone and sadly shook his head. I took that as a demonstration that we are not are anticipating to attach with the area even as throughout the Kruger. Jennifer would say that's an average element.
Alister prepared a added culinary masterpiece for dinner: Cape Malay Curry, a type of venison in a sweet sauce, served over rice. We achieved the pot and licked it easy. We turned in to bed at 7:30, nevertheless I later ventured out and observed the WiFi turned into working at 14.4 Mb dial-up speed. I looked at my emails, skimmed the headlines, and observed that the area turned into carrying on with to spin without my ongoing consideration.

Friday, July 31

I turned into up at 5 am for a tub, then awakened the men and packed up. Today turned into an all-day power from Skakuza camp north to Lebata camp, throughout the central detail of the Kruger. Soon after we crossed the Sabie and Sand rivers, we chanced on a searching social gathering of five lionesses, trotting alongside part the street. We stopped and watched as they crossed throughout the front of us, and slowly crept to a couple bushes and crouched down. The oldest lioness got applicable here last, scanning ahead for prey. They had their ears cocked toward, and took turns slowly moving ahead.

We debated whether to stay for a even as, nevertheless Neil stated that there didn't seem to be prey within sight. We pulled ahead and observed some waterbuck about 300 yards away. It might take a number of hours for them to make a kill, Neil stated, so we drove on.

Further up the street, we pulled over at a intensive waiting gap. Ten hippos were submerged throughout the foreground. Behind the watering gap a herd of over 200 wildebeest approached from the south, even as seven African buffalo approached from the north. A dozen zebra milled throughout the documents. We watched as they all converged on the water, with the buffalo wading each single of ways into the river, and the wildebeest and zebra ingesting on the sting. Several wildebeest seemed to get a intellect freeze from the water, bucking and spinning after their drink. One started pawing and digging is hooves into the floor, then rolling over throughout the mud. All the even as, a intensive crocodile turned into sunning itself about one hundred yards away. We watched for nearly an hour as this spectacular pure film played before us, and ought to still have stayed all day, nevertheless there turned into so even extra to work out.
Up the street, we got applicable here to a cluster of motors blocking the street. One of the drivers reported that a leopard turned into crouching in a thicket. Neil tried to work his truck into place, and at last I in brief spotted (get it?) the cat. No one may probably smartly get a easy snapshot, nevertheless, and Neil turned into getting very pissed off by different motors boxing us in. He wanted to retain a obvious line of get away ought to still the leopard come toward us, and at last decided our defense turned into extra crucial than battling for a miles bigger visual allure on the beast.

A half hour later, we were in a added lion traffic jam. This time it turned into a intensive male lion and a lioness, probably a mating couple. Neil explained that after a lioness turned into in warmth, the dominant male would take her faraway from the delight and in order that they would mate each quarter-hour or so for two days straight. King of the jungle certainly! We stuck temporary glimpses of the lion as he turned into taking a holiday from his (ahem) challenging existence, then he leaped up and pursued his mate into the bushes for circular forty seven, or whatever.

At an equivalent time, a herd of elephants turned into crossing the street within sight. There were a number of toddler and juvenile elephants dutifully following their mother toward the water. But each single of different folks in some different motors were drawn to turned into the lion. It grew to extend applicable into a working comic story for us as vehicle after vehicle pulled up to Neil and requested, "Seen any lion?" We stated we'd get started telling different folks, "No, nevertheless there are some tigers up the street!" (There do not seem to be any tigers in Africa.) Neil informed how, some years in advance of now, he guided a pair who had come from a stopover at throughout the Arctic, and had photographs of polar bear on their cameras. The next time someone requested whether he had seen any lion, he stated no, nevertheless visual allure what we only observed, and showed him the electronic camera reveal of the polar bear. "Where, where?" they known as as he drove away with a laugh.

We met Alister at Satara relaxation camp, where he had constant a added certainly one of his full breakfasts. We were famished and prefer locusts on wheat we fell upon the eggs, sausage, bacon, beans, garlic toast, and juice, leaving nothing behind.

With scarcely a pause to catch our breath, we saddled cut down back up and rolled out of Satura and north on the H1-4. Fortunately, most of contemporary day power turned into on oiled roads, and we were spared the jostling and ruts from the dry washboarded roads of the day gone by. We are visiting the Kruger throughout the procedure winter, which is the dry season, and loads of the plain is bone dry, brown, and dusty. The southern and central quantities of the park are savanna, which Neil defined since the grassland at war with the forest. Scattered mature thorn trees are surrounded by shorter bushes of which the leaves are eaten by giraffe, and the whole trees routinely are destroyed by elephants. The roots and seeds of those bushes are excreted throughout the elephant dung and begin turning into as soon as extra to repeat the cycle. Surrounding those bushes and trees are pretty lots of grasses, each single of which is most smartly-liked by the dozens of hoofed mammals, adding buffalo, wildebeest, kudu, zebra, impala (by some distance the most famous), bushbuck, waterbuck (with a categorical rest room seat circle on the rear), steenbok, and duiker.

Rhino are also herbivores, and over the 1st three days we observed dozens grazing. Rhino grew to extend into this kind of lot less famous as we went north; poaching unfortunately is famous. According to Neil, poachers from Mozambique mainly enter the park, shoot a rhino, observed off the horn, and leave the carcass. Powdered rhino horn is viewed an aphrodisiac by many idiots in Asia (all male, in assertion), and a single horn will also be sold for 1000 money or extra on the black industry. This afternoon we passed a closely armed two guy army patrol making an strive to to find poachers. Neil believes that summary execution of poachers is only too kind; they first ought to still have their noses sawed off, then shot and left for the vultures.
We stopped on the bridge over the Oliphants River, and were authorized to get out of the truck and stretch our legs. It is against the legislations (and threatening) to get from your vehicle in 99% of the Kruger. Only throughout the fenced in camps, or in some designated (and patrolled) relaxation regions is the famous public authorized to wander from their motors without escort. The Oliphants River bridge is almost a kilometer long, and few animals will willingly go on this kind of persistent walkway with this kind of constrained ability of get away.

After crossing the river, Neil pulled off the street and drove down close to the water's edge. We watched hippos sunning themselves on the bank, then developing up, yawning, and slowly submerging themselves beneath water. We counted the crocodiles basking on the banks, estimating that the perfect one turned into over 12 ft long. We watched the kingfishers, cormorants, and Egyptian geese on the water. It turned into a added place that one may probably smartly watch for hours.

After 10 hours throughout the truck, we rolled into Lebata camp. It turned into a persistent day's power, and felt respectable to give up moving. We explored the camp, which is located on a considerable curve of the Lebata River. During the dry season the river is little extra than a trickle. A signal marked the high water mark of the flood in 2000 where the river turned into extra than a mile wide, washed out bridges and buildings, and carved new paths by means of the savanna. The camp is fascinating and peaceful. Several bushbuck wandered by means of the grounds, safe inside the fence from predators. Vervent monkeys patrolled the grounds: a signal warned friends to snug their housing unit towards monkeys are making an strive to to find delicacies and breaking into units by means of reflects and doorways left ajar. A signal next to the girl's unit warned of falling sausage fruit, which seemingly can give a personal a concussion.

Alister constant a added tasty dinner of a type of fowl stir fry over rice. I additional in all probability the most medium Nando sauce and enjoyed a nice glow with my meal. I am so glad that we didn't are seeking to to try this ourselves. It is terribly nice to have the full factor looked after. During dinner, we admired the blue moon – the 2nd full moon in a month – as it shone by means of the trees and over the Lebata River.

Saturday, August 1

This morning Neil had made advance reservations for us to go on a recreation stroll, led by two South African National (SAN) Park rangers, armed with rifles. We were required to signal a waiver acknowledging that wild animals might kill or maim us on the stroll, and that we or our survivors wouldn't publish ugly photographs on social media.

At 5:forty five am, we walked to the reception building and met our two applications, John and Oscar. An Indian couple joined us as we loaded into the SAN Parks safari vehicle. An armed guard opened the major gate for us, and we drove into the pre-sunrise gloom. A couple of kilometers down the street, John pulled off to end up us a hyena guarding a den of cubs in a culvert beneath the street. John explained that the comfort of the pack turned into out searching, and one grownup had been left behind to babysit the cubs younger than 8 months. The babysitter moved some paces faraway from the vehicle and watched us intently. I haven't got any doubt that had any private someone gotten out and moved toward the culvert den, that someone would have been met by an angry hyena.

John turned around and drove off the paved road preceding a "road closed" marker, and we bounced some km then parked. John explained the laws of the stroll: retain quiet, stroll single file, do not leave the network, comply with the rangers' concepts, and if anything else got applicable here about to attack us, stay behind the rangers and DON'T RUN. Runners are people who get picked off, he explained. In the bush, there's defense throughout the pack.

John and Oscar took the part, and the comfort of us adopted. The blue moon turned into life like throughout the sky as sunrise slowly broke each single of ways by means of the savanna. Walking gave a this kind of lot varied perspective: I cherished why it turned into known as "the bush", in view that that's all you may probably smartly see. During the dry season that we were in, we may probably smartly at least see by means of a host of bushes; throughout the wet season, visibility most likely is constrained to a smarter bush. We adopted recreation trails around to a dry river. There turned into a deep water gap that contained a submerged hippo. It sensed our presence and as our cameras snapped away, gave a loud snort, lumbered out of the water and ran faraway from us into the bush with surprising speed. John made us stay in place till he may probably smartly verify the trail of the hippo. He explained that the most damaging animal throughout the bush turned into a hippo out of water. It has deficient eyesight and if threatened will cost with little warning. Once convinced that the hippo turned into effectively away, we saved walking. I exhibits that our path turned into at a correct perspective from the trail of the hippo.
John paused one or more minutes later to listen, and whispered that the snapping of branches intended that an elephant turned into within sight. We slowly made our way till John unexpectedly stopped, motioned for us to get behind him, and outlined a intensive bull elephant with its cut down back to us about 60 yards away. The elephant turned into upwind and seemed to take no notice of us. John moved our network around just so we may probably smartly see the part of the bull. Suddenly it jerked up its head, turned towards us, and shook its head – a obvious warning signal. John and Oscar no doubt pushed us backwards about 30 yards. The bull saved having a look at us, then started to advance towards us, shaking its head and flapping its ears. I wasn't that in contact till I heard Oscar quietly work the bolt of his .458 rifle and chamber a circular. John and Oscar endured to push us farther away, with the two of them staying between us and the elephant. I turned into keenly mindful at how very small I felt when faced by an disillusioned animal weighing over 5 tons and with considerable tusks. Eventually the bull stopped moving. John and Oscar watched till they were bound that he turned into no long fascinated about charging, and we turned away.

Less than 200 yards away, we got applicable here each single of ways by means of a constant of elephants grazing. John quietly explained that, as soon as certainly one of a number of matriarchs sensed our presence, she would flip towards us and experiment out to work out if we were a threat. Once she verified that we were not a threat, she would shake her head in mild inflammation and go cut down back to her breakfast. Almost very swiftly after he achieved speaking, she did precisely that, as if she had research John's script.
We moved off and walked for a couple of km to a rocky space. John stated we would take a ten-15 minute holiday, and Oscar allotted juice boxes, cheese and crackers, peanuts, and a "lunch bar" – some factor that we throughout the States would pick a sweet bar. By this time the sunlight turned into utterly up and it turned into foundation to warm up. In the central Kruger savanna throughout the winter the temperature right away rises from the 50s to the 80s with the holiday of sunrise, and falls equally right away after sundown. We haven't seen a drop of rain the whole time, and little most likely will fall throughout the month of August.

John moved our network towards a spring. He stated that the space bore signs of human workout for a persistent time, and that historic human maintains to be had been exposed (and reburied) close to the spring. As we approached, we observed a steenbok and zebra, and John quietly known as us ahead, "cameras ready." We crested over the bank and observed a dozen or so zebra ingesting on the spring. After some seconds they noticed us and very swiftly bolted away, hooves thudding as they surged up the bank and into the bush. Jennifer gave me certainly one of her triumphal grins, and I knew she turned into proud of her photographs.

From time to time, John would give up our network and determine varied hen calls. He had us listen to the sound of the bush, quietly naming each single of the sounds – hen pick and reaction, hyena laugh, elephant snort, and so on.

After 5 km or so, we returned to the truck. There turned into a buffalo skull within sight which everyone with cameras photographed as if they were a CSI crew. We took network images and, all to soon, were cut down back at camp, where we observed Alister waiting with a breakfast of omelets, bacon, sausage, potatoes, tomatoes, beans, juice, and hot chocolate. As soon as Alister additional out the delicacies, a number of birds gathered, hoping for scraps. Neil saved shooing them off with his monopod, and as soon as he turned his cut down back, one would land behind him and advance on our plates. When one roller perched on the part of the pan of baked beans, we knew that our obligation turned into to be bound there have been no leftovers, and we fulfilled our obligation.

Neil gave us the more than a few of going out on a recreation power on every occasion we wanted. We had not had this kind of lot down time, so we voted to chill out for some hours then have a leisurely afternoon power. After a tub and a sleep, we all felt refreshed. Spencer went for a run and a dip throughout the camp pool – "nice, nevertheless chilly" – and we had a light-weight snack of butternut squash soup with toast to amplify us for our next expedition of the beasties.

We rolled out of the camp gate at 1:30 and headed north alongside the Lebata River on H1-5. The water turned into packed with hippos and crocs, and each single extra or less waterfowl fluttered amongst the many trees. We crossed the river and turned east on S62. Neil turned into hoping to catch a glimpse of a leopard, nevertheless the comfort of us were only having enjoyable with the journey. We arrived at Matembeni Hide, located on the north bank of the Letaba River, walked by means of the heavy gate and down a path lined with 8 foot high wooden fences on each single part, to arrive at a hid seating space overlooking a considerable swath of the river. Below us a number of bushbuck rested, and three considerable terrapins basked throughout the afternoon sunlight. Skinny mongoose scampered and chattered within sight since the birds raised the alarm. On the opposite part of the river there have been extra than 30 hippos lying on the seashore. Nearby were five crocodiles, and down river were a constant of elephants. We were clearly in Africa! Hippos throughout the water were snorting and calling to each single different. Soon one, then two, then three of the beached hippos waddled towards the river. As soon as their ft were wet, each single hippo surged in with a intensive splash. After some extra minutes, and for no visible explanation why, each single of the comfort of the hippos on shore – save one – jumped up and ran into the water with a tremendous ruckus. All of the Oxpecker birds that had been resting on some different hippos took flight and soon alighted on the simplest remaining hippo, who then resembled a moveable aviary. The hen-laden hippo slowly moved towards the water, pausing no extra than five ft faraway from a intensive crocodile. I wondered if it turned into a type of hippo double dare, and were we were going to work out a National Geographic moment. Sadly for us, nevertheless not the hippopotamus, the croc didn't move, and after assembly the instances of the dare, the hippo splashed into the river with his cargo taking wing on the last moment.

Reluctantly we heeded Neil's pick to retain on, and we drove to an overlook above the Englehard Dam. Looking southeast, the savanna stretched to the horizon with barely any modification in elevation. It's staggering to suppose that so some distance since the eye may probably smartly see turned into protected parkland, without a fences to incorporate the animals from going wherever they wanted.

We dropped cut down backtrack the hill and stopped on the dam, spotting extra hippos and crocs. We observed a intensive African fish eagle, which resembles the American bald eagle, as it swooped down and stuck a fish. Soon a circle of possess family of elephants approached, and we watched as they fed and shepherded their calves.

On the return power, Kirsten spotted what appeared like a raccoon. Neil backed up and we observed a civit lying throughout the grass having a look at us. As soon as Neil stopped, it jumped up to end up its spotted coat, and ran into the bush. We all advised Kirsten for her sharp eye. As we returned to camp, the sunlight seemed to plummet below the horizon, transitioning to nighttime with surprising speed. We pulled into the Letaba camp gate with simplest minutes to spare before it turned into locked for the night.

For our ultimate dinner in Kruger, Alister served a conventional South Afrikaans dinner (piuke?), named after the three legged pot where it turned into prepared. It consisted of five layers of delicacies – impala, purple meat, potatoes, carrots, and onions. The meat turned into nicely seasoned with ginger, coriander, clove, and a few different spices. It had simmered for extra than 5 hours without being stirred. It turned into served over a bed of rice and accompanied by salad. We all agreed it turned into pretty tasty, and even Jennifer, who doesn't look after wild recreation, had seconds. After our meal we sat across the hearth ingesting hot chocolate and toasting marshmallows. Alister tried to lead us in a circular of KumBiYa, nevertheless even I idea that turned into going too some distance. Instead we visited for hours, listening to varied tales of adventures throughout the bush from Neil, speaking of preceding travels, existence at homestead, and pretty lots of world problems important and small.

Sunday, August 2

On our last day in The Kruger, we got to sleep in till 6:30 am or so. Breakfast turned into at 7, and soon thereafter we left on our mix recreation power and park exit. Alister achieved breaking camp and adopted with our luggage. Neil had organized for us to be met by a transit van on the Phalaborwa gate located on the west part of the central Kruger at 10 am, so we had 2.5 hours to meander about 50 km. We didn't see as this kind of lot recreation as we observed on our prior drives, nevertheless what we did see turned into very swiftly adjoining to the street: a giraffe with considerable calcium growths around her the front ankles; a intensive water buffalo bull staring intently at our truck; a constant of zebra nibbling on the grass on the shoulder; a tawny eagle feeding on a Franklin foul clutched in its left talon. On certainly one of a number of "low maintenance" (that means very bumpy) dust roads that we took, Neil spotted manufacturer new lion and hyena tracks, nevertheless unfortunately they were getting into the opposite path. We observed vultures throughout the gap circling over what may probably wish been a manufacturer new kill, nevertheless in an potent loss of foresight, SAN Parks hadn't evolved a road which may probably smartly take us there.

As we neared the Phalaborwa gate, we observed miles of termite mounds on either sides of the street, stretching so some distance since the eye may probably smartly see. Every 50-one hundred ft a added mound arose, each single over 6 ft high, some extra than 15 ft tall. Neil explained the soil applicable here turned into specifically favorable to termite colonies, and for hundred if not thousands of years, that they had been doing their element. The mounds were as challenging as concrete, and each single rain made them a little more challenging. Occasionally we may probably smartly spot a gap that had been dug throughout the base, presumably by aardvark, or porcupine, or maybe a warthog, the latter two that may probably also share a den with each single different.

At the Phalaborwa gate we stated our goodbyes to Neil and Alister – one last photograph op – and transferred to a van with a small trailer for our luggage, pushed by Hector. We had come north an average deal, and the journey cut down back to Joburg would take extra than 6 hours. Jennifer rode shotgun and I sat throughout the cut down back pecking away on my iPad seeking to convey together my memories before they dissipated and fragmented throughout the haze of my dotage. Our route took us west on the R71 by means of Tzaneen, a principally two lane road with many give up signs, small villages, and hitchhikers. We climbed by means of the mountains and forests as our elevation rose from 200 ft above sea degree to extra than a mile high. At Polokwane we headed southwest on the R16 before joining with N1 dual carriageway south by means of Pretoria and Joburg. We arrived on the Protea Hotel by nightfall, our South African technological recognize-how nearly full.

Next: Zambia, Zimbabwe, and Victoria Falls

Join me for the 2017 BCAN Walk May 6, 2017

Join me for the 2017 BCAN Walk May 6, 2017

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The 2017 fundraising walk backed through the Bladder Cancer Awareness Network is on Saturday, May 6, at 9 am, origin on the Jefferson Memorial. Here is a link to the Team KBros fundraising internet website online. Please make a donation and, within of the get mutually you are within of the DC location, confidence joining me and my domestic and associates for the walk. See you there!

Infusion forty 8; CT experiment showns smart dysfunction

Infusion forty 8; CT experiment showns smart dysfunction

Image source:

On Thursday, June 14, I had my labs accomplished prematurely of my next Opdivo infusion. My labs have been unexceptional, to boot for continued will enhance in my liver enzymes (alanine aminotransferase, or ALT, 84 U/L, and aspartate aminotransferase, or AST, fifty six U/L). Both have been creeping upward as my new tumor has grown. The ranges don't appear to be so excessive as to the touch off fast main issue, nonetheless its something to search at, like an inexorably emerging river for the time of excessive rains. My prior CT scans have proven small nodules in my liver, nothing marvelous enough to be definitive, nonetheless something to be mindful about. If I had to guess, Id guess that my liver ought to a lot likely also be the most organ with the intention to have metastatic game. Ill cross that bridge after i come to it.
On Friday (June 15) I had nivolumab infusion #48 on the Kaiser Tysons Corner workplace. It changed into the 0.33 since Ive resumed my healing procedures with Opdivo, and changed into so actions that I fell asleep. The nurse reported that I changed into noisily loud night breathing. Clearly Im now now not drinking enough Diet Coke.
On Monday (June 18) I had an trade CT scan. There have been 20 americans contained in the waiting room and I resigned myself for a protracted wait, nonetheless the skills of being a day to day scanner is precedence boarding. I changed into rapidly is named in by the tech who remembered me attributable to my generous feedback and changed into rewarded with just one blown vein. Maybe 15% of nothing critically is now now not very enough? As basic, after the scan I changed into told to drink such loads of fluids to flush out the barium and iodine. As basic, I went to McDonalds for two sausage and egg McMuffins and 4 liters of Diet Coke. And as basic, Kaiser had the CD of my scans organized after my check with to the Golden Arches.
Today (June 19) I acquired the consequences of yesterdays scans. The headline is that the mandatory tumor in my neck has now now not grown in dimension. Stable disorder is multiplied than packed with existence boom. The scan literally measured the tumor to be constitution of smaller, nonetheless that may be real attributable to how the tumor changed into sliced by the scanner. Heres the fitting kind text from the neck scan:
The preceding enlarged left degree 3/four junction lymph node constitution of more cutting-edge to peer attributable to beam hardening artifact from adjacent contrast bolus nonetheless turns out to degree about 1.four x 1 cm that is borderline enlarged, though smaller than the preceding dimension of 1.7 x 1.four cm. Otherwise no enlarged or pathologic-acting lymph nodes are observed across the neck.
For my chest, abdomen, and pelvis there changed into no priceless lymphadenopathy or evidence of metastatic disorder. So yay for no tumor boom.
Later contained in the day, I went to Johns Hopkins for my a lot indisputable check with in reference to my participation contained in the Bristol-Myers Squibb-backed clinical trial that brought about the FDA approval of Opdivo for metastatic bladder cancer. Because of the FDAs approval a lot indisputable 12 months, I can get nivolumab from any oncologist with out my being in a clinical trial. I expressed my deep appreciation to Dr. Noah Hahn, and to senior clinical trial nurse Brad Wilt, and to all of the Hopkins institution of employees, for his or her occupation, compassionate, and protracted work at prolonging my existence.
I also acknowledged with Dr. Hahn his directions going forward. He steered that I wish to doubtless continue with nivolumab unless either all my tumors have been lengthy preceding, or they have been actively remodeling into. In the even that my tumors continue to develop, Dr. Hahn steered that there have been such loads of new therapies being validated on patients who had disorder pattern following immunotherapy. He acknowledged huge amounts of them a variety of which Ive prior to now blogged about and invited me to achieve out to him to speak if and when that point came. He also stimulated me to hinder with my weblog, saying what broad kind of of his patients had acknowledged to him how they have been readers of my weblog. More than a variety of had sought him out in many times dependent upon my authentic experiences with him and Hopkins.
Dr. Hahn knew that I changed into planning on relocating to Utah at some element, and steered that one of his fellows,Dr. Ben Maughan, now practices with the HuntsmanCancer Center in Utah. Dr. Maughan in general will swap into my new oncologist after i at a lot indisputable transfer my care plausible contained in the market.
Life, meanwhile, has taken an bizarre turn with my wifes bizarre prognosis of early onset dementia. Jennifers cognitive decline grew to swap into pronounced a lot indisputable October, and for the beyond 9 months we've struggled to solve the challenge. Four hospitals, eleven medical doctors, and 13 exclusively the varied drug regimens later, she retains to compliment the aid of from every body day confusion, uncertainty, disorientation, and wandering. This disorder is terrible for everybody, nonetheless turns out real merciless to strike my sincere spouse at age fifty four. After her a lot indisputable hospitalization, the medical doctors cautioned that she be transferred to an assisted dwelling facility that focuses on reminiscence care. Shes at present day residing at a reminiscence care center in Northern Virginia. After consultations with medical doctors and domestic, weve made the determination to relocate Jennifer to an trade reminiscence care facility in Northern Utah on July 2. There she ought to a lot likely also be closer to our oldest daughter, a practising physician, and her prolonged domestic.
This determination changed into educated by the very true opportunity that my disorder will enchancment and that I wont be around that lots longer to be Jennifers priceless caregiver. There is now now not very any posted knowledge to tell me of what occurs to americans with metastatic bladder cancer who've had a partial or whole response to nivolumab. Looking at knowledge for mets BC patients who've had the varied forms of immunotherapy, an editorial posted previously this 12 months tested very lengthy time in basic terms for americans with metastatic urothelial cancer who've been handled with atezolizumab. A as regards to analyzing of the information and evaluation of the charts advocate that, as quickly as there is a recurrence, a lot patients die within a 12 months.

A main limitation of this newsletter is that the information set closed in December 2016, turbo than a lot of the a lot refreshing aggregate drug therapies have been even being validated. Also, the information set is small, the age of the patients skews lots older than me, and in order that they've got more co-morbidities than do I. Plus, my refreshing scan tells me that, for now I have steady disorder. But nonetheless. I am real searching about my horrific prognosis. I have now now not any use for rose-coloured glasses, real when planning for the care of my spouse after I am lifeless.
Well get Jennifer settled into the Utah reminiscence care facility in early July. Garrett will whole his two 12 months mission for our church on July 10. Spencer and Kirsten will connect us in Utah for a variety of days, and smartly have a Brothers domestic reunion the most time the full varied persons ought to a lot likely also be collectively since March of 2016. Garrett could have solely a variety of weeks to transition into traditional existence turbo than he matriculates at Carnegie Mellon University in Pittsburgh, so at some element he and I will fly to get back to DC to rearrange for institution.
Im scheduled for infusions with the aid of Kaiser on June 29, July 16, and July 30. Ill ask to have a PET scan in late July or early August, which ought to a lot likely also smartly also furnish multiplied notion into regardless of whether the nivolumab is strolling. Notwithstanding the consequences of yesterdays scan, I have now now not been protecting out wish that Opdivo will work as smartly this time, for three functions. First, Dr. Hahn prior to now told me that, in principle, the nivolumab wish to have taught my immune machine to kill each cellphone that had a PD-L1 enzyme, so any new tumor boom is doubtless an trade mutation of my mutation-rich metastatic bladder cancer. Second, my unique mets lit up on CT scans heaps multiplied than this tumor, a lot fascinating me to wonder regardless of whether its a such loads of category of mutation. Third, projecting wish takes such loads of calories, and my calories has been directed in such loads of components in up to this point years. Given that I have now now not any regulate over my cancer, I have came across that I deplete a long way lots less emotional calories by accepting the small print of my prognosis as it be, versus scenery myself up for a dissonance between what ought to a lot likely also smartly also be pretend expectations and reality. Plus, Id moderately be pleasantly bowled over than bitterly disenchanted.
If and after i in finding that nivolumab isnt strolling, Ill appearance at my next alternatives. That ought to a lot likely also be Plan F. Ill attain out to Dr. Hahn and Dr. Apolo, amongst others. For some traditional rationale, there are more clinical trials accessible contained in the DC sector than in Utah. Go determine. So a lot likely Ill retailer in DC longer, or return and forth to get backward and forward between Utah and DC as priceless. I knew there changed into a rationale we hadnt bought our condominium but.
If, notwithstanding the indeniable truth that, I be told in August that the Opdivo is causing my tumors to cut back, then Ill in general relocate to Utah after I bring Garrett to Carnegie Mellon. Ill hire a sector someplace between Jennifers assisted dwelling sector and my grandchildren and appearance for goodness and pride every body day.

Infusion 51 reports of my CR are untimely

Infusion 51 reports of my CR are untimely

Image source:!!-:strip_icc-!!-/2014/07/08/758/n/1922195/fa6c975d05cb7e70_451849220.jpg

Last week Garrett and I flew from SLC to IAD, and spent a smartly appropriate choice of days prepping him for origin to Carnegie Mellon. He admitted that he became a part extra frightened style of starting college than he became starting a 2 12 months job for the church, for this cause of the declaration his time table became extra set on his job. I told him that, of all of his siblings, he became the highest arranged and highest mature to attend college. I helped him pass into his dorm room, gave him a hug, and talked about Id see him at graduation. Dad! he talked about. I spoke back that I hoped that I would, alternatively who understands what is going to turn up in four years. But Id also see him at the father or mother weekend in October, maybe for Thanksgiving, and in focused for Winter Break. And he became introduced.
Om Tuesday, August 21, went in for blood paintings. The first tech managed to blow two veins before I requested for each and every different tech, who had no disorders with the draw. My labs are totally unremarkable. My ALT and AST degrees, which had been creeping up prior in the 12 months, are again in the frequent kind, indicating my liver is happier. I met with Dr. Ferreira, my Kaiser oncologist. She mentioned that she became basically somewhat taken aback by the radiologists conclusion from last months PET scan that there became no small print of sickness, and Id had a entire response. She took a complicated appearance at the scan pix and detected a part of metastatic uptake in the neighborhood of my primary tumor in my neck. She showed them to me, and shes correct there's a part of uptake no longer a total lot, alternatively no longer nothing. So it feels just like the file of a CR became untimely. But Im no longer complaining. Its although a especially the contrary beautiful consequence! More than ninety% low cost in tumor size is engaging. It basically exhibits that I deserve to sustain it up taking Opdivo for your time, and proceed getting scans. We scheduled every and every different check out with and a CT for October, after the folks weekend at Carnegie Mellon.
After visiting with Dr. Ferreira, I drove as much as Baltimore for my last meeting at Johns Hopkins with Dr. Hahn underneath the aegis of the medical trial. Brad Witt, the medical trial nurse, talked about that I became the last Hopkins affected consumer in the shaped Opdivo medical trial who became although viewed to be contained in the trial. The 40 or so different genitourinary mets sufferers at Hopkins in the trial had lengthy since stopped taking the drug. Those although living have been although being accompanied, alternatively have been no longer viewed to be a component to the trial. Id all commenced the trial in early 2015, taken the drug for with connection with 2 years, then took a trip for about 18 months before resuming medical care. Hopkins will although proceed to email or call every and every 12 weeks or as a approach to be made a decision on Im no longer yet on the cart (no longer amount of pointless yet), alternatively my responsibilities to check out with Hopkins as a component to that medical trial is carried out. Im profoundly grateful to have been a component to that medical trial; to Dr. Andrea Apolo at NIH for assisting to coach for my participation; for the clinicians at Hopkins who furnished my care; and to Bristol Myers Squibb for coming up Opdivo and imparting the drug at no charge. Opdivo has kept my lifestyles no longer as quickly as, alternatively two times. It could smartly just maybe also additionally no longer paintings for all folks, alternatively its keeps to paintings for me.
Dr. Hahn and I spoke style of actually one of his former fellows, Dr. Ben Maughan, who now's with Huntsman Cancer Center in Utah. Dr. Hahn thinks that, as quickly as I officially relocate my care to Utah, my transitioning to Dr. Maughans care is a especially the contrary beautiful principle. Ive all commenced vetting the Medicaid Advantage plan associated with the Huntsman Cancer Center. SO a methods the reps haven't acquired any principle whether or not Opdivo will be a stable drug. Thats as a rule a especially the contrary sumptuous query (as much as $50,000 per 12 months, as a rule). I wont modification my care from Kaiser apart from Ive acquired that drawback worked out. I shook Dr. Hahns hand and thanked him for saving my lifestyles. Our paths are highest likely to proceed to as quickly as extra at masses of BCAN or NIH/NCI initiatives.
Today (Wednesday), I went again to Kaiser for Opdivo infusion #51. Utterly pursuits. So a methods the priority consequence of the four week infusions of nivolumab has been no great from both week infusions an occasional rash proper here and there, and a part looser bowels. Nothing to stress style of. I respect having to come back in exactly as quickly as every and every four weeks. Im flying again to Utah this night time. Chelsea is due to this of origin any day now, and Im flawlessly glad to help with the significant kiddies. And it'll also be beautiful to work out Jennifer.
Ive been investigating my wellness care possibilities in Utah. Since the federal govt considers me to be as totally and permanently disabled for this cause of my metastatic bladder highest cancers, Ive been Medicare-eligible since I became 50 years vintage. I all commenced on Medicare in January 2016, after my formal retirement from my regulation business undertaking left me with no paintings-sponsored wellness security. Beginning in January 2016, Ive been with Kaiser Permanentes Medicare Advantage plan. Ive broaden into spoiled, since its been the highest wellness care Ive obtained in my anyone lifestyles. I became already on my medical trial thru Hopkins when i joined Kaiser, and Kaiser no longer just agreed to proceed supporting my care thru Hopkins, alternatively the plan enrolled me into their added offer thru the Kaiser Family Foundation, which meant that I haven't mandatory to have any added premiums style of like deductibles or copays. I haven't mandatory to stress concerning the charge of Opdivo, or my scans, or in spite of what else.
In Utah, even if, Medicare plans do no longer look to be as generous. Ive discovered that for this cause of the declaration Opdivo is given by infusion, it's categorised as a Medicare Part B drug that will be zone to a 20% copay as much as the annual plan deductible (around $5000). Im told that non of the Utah Medicare Advantage plans conceal the Part B copay. I dont yet perceive how a lot the plans charge Medicare for my month-to-month 480mg dose of Opdivo, so I dont know the quantity of my copay. Im doing added studies, so I know my premiums up the front. Until I get that worked out proper here, Ill fly again out proper here for my remedies. Ive already purchased my tickets for September and October.

Infusion 50 and a PET check, and a entire reaction

Infusion 50 and a PET check, and a entire reaction

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It's tough to have religion practically four weeks has surpassed taking lower than consideration that my last infusion. Since then, Chelsea flew to DC, joined Jennifer and I as we attended a farewell reception at a chums condo, then then next day grew to grow into spherical and flew cut down back to SLC with Jennifer and me. We received Jennifer settled into her new specialised reminiscence care assisted living facility, then I went with Chelsea to her condo in Huntsville. The following couple of days had been a blur of vacationing Jennifer and taking her to her clinical appointments, spending time with Chelsea, Josh, and the grandchildren, and readjusting to the slower rhythms of small-the city existence.
On July 9, Garrett completed his two-12 months venture for the Church of Jesus Christ of Latter-day Saints. Jennifer and I met him at the venture domestic in Salt Lake City, and had been organized to wait the departing missionary fireside. Garrett sang "Be Still My Soul" acapella, then bore his testimony. It changed into a shifting day out. When he completed, I moved and allow Garrett take my seat next to his mother. Jennifer laid her head on his shoulder and wept tears of joy.

The next day, Spencer and Kirsten joined us in Utah. It changed into the 1st time our completed very own family had been collectively taking lower than consideration that March 2016. I had questioned regardless of whether I might maybe keep to go looking out out that day. We went boating, played video games, and ate collectively, absorbing each and every single other's presence. We met with a social employee who guided the children by way of a discussion just about their mother's cognitive decline, and mind on sorting by way of their feelings. We furthermore had a very own family council the place we discussed the estate planning steps that Jennifer and I had taken, and made some judgements just about very own family dollars.

After with regards to in retaining with week of very own family time, Kirsten and Spencer drove to Denver, the place Spencer embarked on mountaineering the Colorado Trail from Denver to Durango (weblog hyperlink proper sort here). It's "solely" 487 miles, so in contrast to his through-mountaineering the Appalachian Trail last 12 months, he'll knock this out in a month or so. I deal with telling him there's remedy which might assistance remedy his mountaineering disorder, having noted that he declines my sage counsel. The optimal advantageous pills, I've came across, is offered at Krispy Kreme.

On July 20, Garrett and I flew cut down back to DC. On Sunday, July 22, Garrett gave his missionary homecoming rfile to his domestic congregation in Great Falls. He left a boy and came domestic a guy. I furthermore spoke.

Yesterday, I went to Kaiser and had infusion #50. The solely element resultseasily I've noticed so received rid of from my greater dosage of nivolumab is a few scalp itching and maybe an inclination for my gums to bleed practically a little after brushing my tooth. No huge deal. I'll proceed to pocket book personal computer exhibit any element resultseasily.

Last evening I battled traffic for with regards to two hours to get to Kaiser's Capitol Hill serve as for a PET scan. That's a pressure that takes maybe 30 mins while it be miles not likely rush hour. I am not going to forget DC traffic. My Kaiser oncologist agreed to my request for the take a look at a bunch of days in the beyond, so I changed into added to the finish of the day for the finish of the day. The nurse practically called and noted the scan confirmed no evidence of metastatic infirmity — an whole response! Woo hoo! Dr. Ferrera recommends deal with going with Opdivo for now. Based upon this news, I'm extra extra without doubt to in the stop shift my ongoing care to the Huntsman Center in Salt Lake.

Southwest cancelled our flight to SLC this afternoon, because of the heavy weather that will be forecast to hit the theme later at the present time. So we're no scheduled to come back to Utah on Saturday. We'll keep for a bunch of weeks, then return to DC on August 14. I'll present Garrett to institution on August 18, then have an additional infusion at Kaiser the ensuing week. I'll furthermore be meeting with similarly Dr. Hahn at Hopkins and Dr. Ferrera at Kaiser, and without doubt will worth my determination to switch my care to Utah. For now, no subject the indisputable truth that, I'm practically relieved to be cut down back in remission.