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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 7 to 31 of 31. Go back in thread:
Posted by babbler20 on July 13, 2014, at 23:51:19
In reply to Intranasal ketamine - Anyone?, posted by SLS on July 12, 2014, at 21:44:50
Sorry you aren't doing well SLS. I know we have both been at this for a while. From what I've heard Ketamine works for some, but like with any other anesthetic there are only so many times you can use it before it becomes dangerous to continue using it. I don't think this is the answer for us, but one of the substances they are working on bringing to market that is derived from ketamine, could be our answer.
Posted by SLS on July 15, 2014, at 9:51:34
In reply to Re: Intranasal ketamine - Anyone? » SLS, posted by europerep on July 13, 2014, at 15:20:25
> Hi,
>
> What kind of information are you looking for?Basically, I would like to know if the stuff really works.
I understand that there is a test that can distinguish between responders and nonresponders, although it is probably still experimental.
> I'm sure you know the scientific stuff about it? There was an article in Biological Psychiatry recently, which can be found here:
> http://www.sciencedirect.com/science/article/pii/S0006322314002273 (abstract, unless you have access) Generally, as far as I know, the little research that exists is promising, and I don't think they have identified clear disadvantages compared to IV infusion. But I haven't been actively following ketamine news since a year or two ago, so I may well be wrong about some of this stuff.
Thanks for the citation.
> I tried it, and it didn't help me. But neither did intramuscular ketamine, which as a route of administration probably comes the closest to IV.I'm sorry that ketamine was without benefit for you.
Do you know of any risks involved with long-term use?
Thanks.
- Scott
Posted by SLS on July 15, 2014, at 10:00:04
In reply to Re: Intranasal ketamine - Anyone? » SLS, posted by phidippus on July 13, 2014, at 16:47:31
> Its weak.
What do you think of IV administration?
> What are you on now?Currently:
Panate 100 mg/day
desipramine 200 mg/day
Lamictal 200 mg/day
lithium 450 mg/day
prazosin 30 mg/day
I am not very optimistic about my chances to respond to treatment well enough to have a rewarding and productive life. I am haunted by the many years of pain and struggles of my past, and I feel doomed to die this way. My doctor keeps suggesting DBS (direct brain stimulation).I hate my life - past, present, and future. There is nothing for me.
Thanks, Eric.
- Scott
Posted by SLS on July 15, 2014, at 10:05:43
In reply to Re: Intranasal ketamine - Anyone?, posted by poser938 on July 13, 2014, at 21:18:48
> I had a psychiatrist who prescribed intranasal ketamine for me about 2 years ago. it did the same exact thing for me as over the counter Dextromethorphan (DXM). it simply just made me dizzy. BUT, if you remember my past posts on this site, you may remember many of my reactions on meds are different than normal.
Yes. You even described long-lasting negative effects of drugs that lasted well beyond drug discontinuation.
> currently, the past month or so, ive actually been doing Electroconvulsive Therapy. it has been no problem. just have been having some effects on my memory. besides that, it is the ONLY treatment that ive hade any benefit from in the past few years. and thank God it has been amazing. Things were getting rough for me and ECT arrived to help just in the nick of time.
That's a very bright and optimistic outcome. I hope you continue to improve. Will you go for maintenance treatments or add any medications?
> id recommend ECT to anyone.I had 15 treatments in 1991. The first 6 were unilateral left, the remainder were bilateral. It believe that the treatment you receive is more effective than that I received. I really cannot exclude modern ECT from consideration.
- Scott
Posted by SLS on July 15, 2014, at 10:10:52
In reply to Re: Intranasal ketamine - Anyone?, posted by tom2228 on July 13, 2014, at 21:54:45
> rTMS is currently (still) redefining "treatment resistance" for me...
Can you give me a brief description of your treatment resistance?
Have your doctors described the type of case for which rTMS is deemed ineffective?
Thanks.
> Had remission scores last week and this week no major pain except for a few dull moments here and there. Making a lot of growth since beginning a month-ish ago, especially socially.
Great!
> regarding intranasal ketamine being "weak"... don't write off something until you've tried it, especially something different from the standard slew of medications. being so pessimisitic is PART of having "treatment resistance". attitude plays a huge role in placbo effects guysIf I opt for intranasal ketamine, I would have to find another doctor. My current doctor refuses to use it.
- Scott
Posted by SLS on July 15, 2014, at 10:20:44
In reply to Re: Intranasal ketamine - Anyone?, posted by babbler20 on July 13, 2014, at 23:51:19
> Sorry you aren't doing well SLS.
Thanks, Babbler. My sense of hope and positive outlook are deteriorating.
> I know we have both been at this for a while. From what I've heard Ketamine works for some, but like with any other anesthetic there are only so many times you can use it before it becomes dangerous to continue using it.
I wasn't aware of that. What are some of the dangers attendant with the long-term use of ketamine?
> I don't think this is the answer for us, but one of the substances they are working on bringing to market that is derived from ketamine, could be our answer.
You are probably right. It is proposed by some that one of the major metabolites of ketamine, known as HNK, is capable of exerting an antidepressant effect without the complications of the anesthetic and psychotomimetic effects of ketamine. It works via nicotinic alpha-7 receptors and doesn't affect the NMDA receptor at all. Unfortunately, it might take many years before such a compound could be developed and marketed.
Thank you for your concern. Good thoughts heading your way...
- Scott
Posted by tom2228 on July 15, 2014, at 11:53:50
In reply to Re: Intranasal ketamine - Anyone? » tom2228, posted by SLS on July 15, 2014, at 10:10:52
> > rTMS is currently (still) redefining "treatment resistance" for me...
>
> Can you give me a brief description of your treatment resistance?over 45 meds, combinations including MAOIs + TCA + stimulant + others...
>
> Have your doctors described the type of case for which rTMS is deemed ineffective?No. It's trial and error. I would suggest stopping theorizing about why you can rule out a certain potentially helpful treatment and just go for it. Depression kills.
>
> Thanks.
>
> > Had remission scores last week and this week no major pain except for a few dull moments here and there. Making a lot of growth since beginning a month-ish ago, especially socially.
>
> Great!
>
> > regarding intranasal ketamine being "weak"... don't write off something until you've tried it, especially something different from the standard slew of medications. being so pessimisitic is PART of having "treatment resistance". attitude plays a huge role in placbo effects guys
>
> If I opt for intranasal ketamine, I would have to find another doctor. My current doctor refuses to use it.
>
>
> - ScottI understand the difficulty finding a new doctor given the complexity and risk of your drug combination. Fortunately if you do TMS you can see the TMS provider and keep your old doc if you need to.
Posted by babbler20 on July 15, 2014, at 12:53:24
In reply to Re: Intranasal ketamine - Anyone? » babbler20, posted by SLS on July 15, 2014, at 10:20:44
I read about HNK as well. There are other drugs in the pipeline that work on glutamate receptors as well. The thing that has helped me more than anything is long-term exercise. I don't know if you read my post about this, but after 16 weeks of the Northwestern University exercise study protocol, I went from a very depressed, very sleep-deprived person to a mildly depressed person that sleeps normally 5 days a week. It was really a miracle for me. It doesn't have an effect for 16 weeks, but once it starts to work, your life will change. Check this out; http://articles.chicagotribune.com/2013-09-11/health/ct-x-0911-expert-insomnia-20130911_1_better-sleep-sleep-problem-better-night. I hope you feel better.
Posted by phidippus on July 15, 2014, at 13:50:06
In reply to Re: Intranasal ketamine - Anyone? » phidippus, posted by SLS on July 15, 2014, at 10:00:04
>What do you think of IV administration?
The effects are strong initially, but wear off in 2-3 days. I got pronounced side effects as well-mostly dissociative.
>My doctor keeps suggesting DBS
This may be a viable option. Have you looked into it?
>I am not very optimistic about my chances to respond to treatment well enough to have a rewarding and productive life.
New treatments are devised all the time, which gives you many chances to treat your illness. Advances are made all the time which afford you the opportunity to better treat your illness. I guess the key is finding a current treatment that makes you feel comfortable enough to wait for that breakthrough that works for you.
>I am haunted by the many years of pain and struggles of my past
Would you say there's a bit of PTSD you are contending with?
Do you dwell on these thoughts?
Can you think of anything you've gained from your struggles?
When I think of past breakdowns and the pain of mental illness I've suffered throughout the years I recognize how much stronger I am for it. I sometimes laugh about craziness I've experienced-like the one time I thought my heart had stopped beating. I was walking around like a zombie and thinking of myself that way is somehow hilarious to me.
>I feel doomed to die this way.
What is 'this way'? How do you feel everyday and what kind of thoughts do you have?
>There is nothing for me.
Some malfunctioning part of your brain is saying this.
You also have me.
>Panate 100 mg/day
desipramine 200 mg/day
Lamictal 200 mg/day
lithium 450 mg/day
prazosin 30 mg/dayHave you tried switching to another MAOI?
Have you tried Imipramine?
What happens if you raise the Lamictal to 400 mg and drop the Lithium?
Have you tried Opioids?
Eric
Posted by europerep on July 15, 2014, at 15:39:45
In reply to Re: Intranasal ketamine - Anyone? » europerep, posted by SLS on July 15, 2014, at 9:51:34
> I understand that there is a test that can distinguish between responders and nonresponders, although it is probably still experimental.
I didn't know that. Seems much easier to test it by just giving it to people, rather than developing a test for that. Ketamine has been used in human medicine for decades, it's not like people will all of a sudden go crazy after one tiny dose of it.
> Do you know of any risks involved with long-term use?
Long-term daily (or frequent) use of recreational doses of ketamine has risks. Besides all the issues associated with it being a psychoactive drug, at least one of the main concerns would be bladder issues. But the doses used in depression are much lower, and the frequency of administration would be considerably lower as well. It's all about weighing risks. But I would venture that the risk of a single dose, to find out whether it works for you, is practically zero...
Personally, I think it would be a good idea for you to give it a try.
ER
Posted by baseball55 on July 15, 2014, at 19:17:34
In reply to Re: Intranasal ketamine - Anyone? » phidippus, posted by SLS on July 15, 2014, at 10:00:04
> I hate my life - past, present, and future. There is nothing for me.
> - ScottScott - I am so sorry to read this and see that you are feeling so low. I know that feeling of despair so well and hope you can find some hope to hold on to. Have you tried therapy, especially mindfulness therapy/DBT? That helped me a lot when I felt I had exhausted all medical solutions. It takes time and requires a very patient and committed therapist. I hope you will consider this.
Posted by Phillipa on July 16, 2014, at 10:06:34
In reply to Re: Intranasal ketamine - Anyone? » SLS, posted by baseball55 on July 15, 2014, at 19:17:34
Scott Bryn did IV ketamine. It didn't work long term. I think she is doing well on regular meds now used to be Lexapro and a benzo maybe one other med also. Remember JR Becker he also tried IV ketamine. Might want to contact him. Phillipa
Posted by Bob on July 18, 2014, at 11:32:22
In reply to Re: Intranasal ketamine - Anyone? » phidippus, posted by SLS on July 15, 2014, at 10:00:04
> > What are you on now?
>
> Currently:
>
> Panate 100 mg/day
> desipramine 200 mg/day
> Lamictal 200 mg/day
> lithium 450 mg/day
> prazosin 30 mg/day
>
>
> I am not very optimistic about my chances to respond to treatment well enough to have a rewarding and productive life. I am haunted by the many years of pain and struggles of my past, and I feel doomed to die this way. My doctor keeps suggesting DBS (direct brain stimulation).
>
> - Scott
Scott -I've gone through the DBS process and might be able to help you if you have questions. It was not a cure for me and was turned off a few years ago but I'm not ready to have it taken out. I still hold out hope that another try might be different or that they may discover something new about their methods and techniques.
- Bob
Posted by Bob on July 18, 2014, at 11:36:22
In reply to Re: Intranasal ketamine - Anyone? » phidippus, posted by SLS on July 15, 2014, at 10:00:04
> > What are you on now?
>
> Currently:
>
> Panate 100 mg/day
> desipramine 200 mg/day
> Lamictal 200 mg/day
> lithium 450 mg/day
> prazosin 30 mg/day
>
> - Scott
Scott -I noticed that you switched out nortriptyline for desipramine as well as discontinuing Abilify. How recently did you make these changes? Do you these changes may be contributing to some of your deterioration? I know for me and some others the discontinuation of Abilify can lead to some serious problems and an insidious, delayed deterioration, even weeks after stopping.
What are your impressions of the desipramine in place of the nortriptyline? Do you think it has accomplished what you wanted?
- Bob
Posted by Bob on July 18, 2014, at 12:53:13
In reply to Re: Intranasal ketamine - Anyone? » phidippus, posted by SLS on July 15, 2014, at 10:00:04
> I am not very optimistic about my chances to respond to treatment well enough to have a rewarding and productive life. I am haunted by the many years of pain and struggles of my past, and I feel doomed to die this way. My doctor keeps suggesting DBS (direct brain stimulation).
>
> I hate my life - past, present, and future. There is nothing for me.> - Scott
Scott -I can empathize deeply with you concerning your statement about what you've been through haunting you. When I'm feeling my worst the burden of what I've been through looms large and there is zero hope for the present or future. In fact, my mind starts to kind of take inventory of all the pain and suffering I've endured. At the least I can say that this burden becomes lighter if the meds are helping at all.
- Bob
Posted by SLS on July 18, 2014, at 13:01:05
In reply to Re: Intranasal ketamine - Anyone? » SLS, posted by Bob on July 18, 2014, at 11:32:22
>
> > > What are you on now?
> >
> > Currently:
> >
> > Panate 100 mg/day
> > desipramine 200 mg/day
> > Lamictal 200 mg/day
> > lithium 450 mg/day
> > prazosin 30 mg/day
> >
> >
> > I am not very optimistic about my chances to respond to treatment well enough to have a rewarding and productive life. I am haunted by the many years of pain and struggles of my past, and I feel doomed to die this way. My doctor keeps suggesting DBS (direct brain stimulation).
> >
> > - Scott
>
>
> Scott -
>
> I've gone through the DBS process and might be able to help you if you have questions. It was not a cure for me and was turned off a few years ago but I'm not ready to have it taken out. I still hold out hope that another try might be different or that they may discover something new about their methods and techniques.I'm sorry that DBS did not produce the results your were hoping for. I would be pretty angry. What site in the brain were the electrodes implanted - Brodman 25 or nucleus accumbens? How do they decide between the two? Can the outcome of DBS be predicted based upon symptom profile? Who makes the best and worst candidates for treatment?
Thanks, Bob.
- Scott
Posted by SLS on July 18, 2014, at 13:40:37
In reply to Re: Intranasal ketamine - Anyone? » SLS, posted by Bob on July 18, 2014, at 11:36:22
>
> > > What are you on now?
> >
> > Currently:
> >
> > Panate 100 mg/day
> > desipramine 200 mg/day
> > Lamictal 200 mg/day
> > lithium 450 mg/day
> > prazosin 30 mg/day
> >
> > - Scott
>
>
> Scott -
>
> I noticed that you switched out nortriptyline for desipramine as well as discontinuing Abilify. How recently did you make these changes?I discontinued Abilify months ago. I did not experience any deterioration in my condition until I discontinued nortriptyline.
> I know for me and some others the discontinuation of Abilify can lead to some serious problems and an insidious, delayed deterioration, even weeks after stopping.
Exactly! This is not an uncommon scenario. I experienced this delayed deterioration after attempting to discontinue Abilify in 2010. It took about 3 weeks for me to relapse. I was not taking lithium or prazosin at the time, though. I suspect that the prazosin allowed me to discontinue Abilify.
> What are your impressions of the desipramine in place of the nortriptyline?
My doctor wanted me to attempt to discontinue nortriptyline. His hope was that I could do without a TCA. I deteriorated within 5 days of reducing the dosage of nortriptyline from 150 mg/day to 100 mg/day. However, I discovered that nortriptyline caused me to become passive and lazy. It suppressed some of my personality and took away my drive to accomplish things. I was getting nothing done. Because of this, I asked my doctor to switch me to desipramine. He said okay, but wanted me to titrate more gradually than the last time he treated me with 300 mg/day. He wanted me to pause at 150 mg/day, saying that he didn't want to "overshoot". He was also uncomfortable with using desipramine with the dosage of Parnate being at 100 mg/day. I went through hell during the time I was coming off of nortriptyline and titrating desipramine beginning at a dosage of 25 mg/day. I was impatient to bring the dosage of desipramine higher than 150 mg/day, even though I allowed only 6 days to see an improvement. My doctor allowed me to continue to increasing the dosage, even though his inclination was to have me give 150 mg/day more time. I wish I had listened to him. I spent 6 weeks experimenting with dosages between 200 - 300 mg/day. My reaction to these dosages of desipramine were uncharacteristic for me. I did worse as the dosage was increased, despite feeling better for a day or two immediately after each adjustment. It was very confusing. I decided to reduce the dosage of desipramine back down to 150 mg/day in the hope that something nice will happen. It has only been 3 days, but I am feeling better. This could just be another one of my transient improvements that occur upon dosage changes, though. I am trying not to become too optimistic.
> Do you think it has accomplished what you wanted?
It is too early to tell. If I continue to improve steadily over the next 1 - 2 weeks, I will be satisfied with my decision and will continue with my present treatment.
I forgot to ask... Were you allowed to take any psychotropic drugs while your DBS was enabled? Are you taking any now?
Thanks.
- Scott
Posted by ed_uk2010 on July 18, 2014, at 13:42:31
In reply to Re: Intranasal ketamine - Anyone? » Bob, posted by SLS on July 18, 2014, at 13:01:05
Hi Scott,
I didn't know you'd switched from nortriptyline to desipramine. I've not checked p-babble for a while though. Why did you change?
Intranasal ketamine doesn't sound as pleasant as oral. Ketamine is occasionally formulated as an oral solution for analgesia, mainly in palliative care. Psychotomimetic adverse effects, if they occur, are normally treated with benzodiazepines (not antipsychotics).
Would your psychiatrist give I/M ketamine? Low dose I/M ketamine is not especially unsafe eg. the risk of respiratory depression is extremely low, less than I/M benzos which are used very frequently in inpatient psychiatry. The main risk is a bad psychiatric reaction. And the drug may be difficult to obtain if it's not usually stocked by the hospital. If the hospital is part of a general/medical hospital they will probably stock ketamine for use in anesthesiology. Ketamine is not used in anesthesiology in the same way that it originally was. Low doses are used to augment analgesia and anesthesia produced by other drugs. High doses are not used on their own - the outcome of that was normally a lot of side effects!
There is currently a shortage of ketamine in the UK due to a production problem at Pfizer. Imported version from Germany are in use instead. This probably has no relevance to the US but I thought it was worth a mention.
Posted by Chris O on July 18, 2014, at 14:31:15
In reply to Intranasal ketamine - Anyone?, posted by SLS on July 12, 2014, at 21:44:50
Scott:
Sorry to hear you are feeling so bad. I did hear a story on NPR (radio) about a year ago that touted the benefits of intranasal ketamine for treatment resistant depression. It focused on a group of people that were having great success with it. My psychiatrist said he doesn't believe there is enough evidence for ketamine to recommend it yet. He seems sold on TMS though. I hope you start feeling better soon.
Chris
Posted by Bob on July 20, 2014, at 12:34:35
In reply to Re: Intranasal ketamine - Anyone? » Bob, posted by SLS on July 18, 2014, at 13:01:05
>
> I'm sorry that DBS did not produce the results your were hoping for. I would be pretty angry. What site in the brain were the electrodes implanted - Brodman 25 or nucleus accumbens? How do they decide between the two? Can the outcome of DBS be predicted based upon symptom profile? Who makes the best and worst candidates for treatment?
>
> Thanks, Bob.
>I had mine done at the Columbia University & NY Presbyterian Medical Center in Manhattan. That site was part of a study named "BROADEN" that was started with Helen Mayberg and Emory University Medical Center here in the US (originally it began in Canada). This particular study employed the Brodmann Area 25 Anterior Cingulate Gyrus, whereas another study associated with the Cleveland Clinic was using the nucleus accumbens.
It's not that it did nothing... it did all kinds of things eventually - both good and bad. When I think about it, that's exactly what almost every treatment I've tried has done that wasn't totally ineffective. I was definitely more disappointed and angry than just a failed med trial but the possiblility of failure is very real and that must be kept in mind. I knew the odds weren't great. Like I have said before, I still feel that a very low level of stimulation might help me. It's still implanted in me and I have plans to go back up there to inquire.
As far as questions about methodology and effectiveness go, I'm not qualified to answer that and I don't think anyone really is. Like the medicines and possibly even more so I don't think the mechanisms of action are understood. The area of the brain they chose was study based and all the areas are best guesses based on previous brain research from such things as old psychosurgery procedures and theories as well as all the brain imaging and science from more recently. There are other areas under consideration in other studies: the aforementioned nucleus accumbens, the lateral habenula, the Medial Forebrain Bundle (MDF) and possibly some others. The studies try to pick people with the simplest, purest if you will, forms of MDD not complicated by bipolar, BPD, schizophreneic, or other syndromal aspects. I'd be surprised if they could predict whether a certain patient who met the criteria might respond better than another.
You managing to get DBS treatment for your illness is at this point entirely dependent on your ability to get recruited in a study. This is all affected by what active studies are available and currently enrolling, and then the logistics of you being able to participate based on time comittment and proximity to your location. None of these procedures are FDA approved and it's anyone's guess when they might be. Obviously if they become approved it will change the situation significantly. I "lucked out" getting accepted in NY since all the patients in both studies in the US amounted to only a handful. A good place to start would be clinicaltrials.gov or a similar resource. Search for DBS and depression.
- Bob
Posted by Bob on July 20, 2014, at 12:39:48
In reply to Re: Intranasal ketamine - Anyone? » Bob, posted by SLS on July 18, 2014, at 13:40:37
>
> My doctor wanted me to attempt to discontinue nortriptyline. His hope was that I could do without a TCA. I deteriorated within 5 days of reducing the dosage of nortriptyline from 150 mg/day to 100 mg/day.
>
> - ScottYou mentioned that your doctor wanted you try do get along without a TCA but then you added desipramine back in (a TCA, right?). Was that an action you took because of your subsequent detioration due to the reduction in nortriptyline or for some other reason?
- Bob
Posted by Bob on July 20, 2014, at 12:45:39
In reply to Re: Intranasal ketamine - Anyone? » Bob, posted by SLS on July 18, 2014, at 13:40:37
>
> I forgot to ask... Were you allowed to take any psychotropic drugs while your DBS was enabled? Are you taking any now?
>
> Thanks.
>
>
> - Scott
The studies were set up to address the treatment resistant population, probably out of a need to get patients since this wasn't exactly a procedure that is tried for anything less than MDD where other possibilities have been exhausted. As part of that I believe it is a little much to ask such a population to quit their meds - I know I wouldn't have been able to do it back then or now. I can't speak to what protocol might be in place for a current study but I would think it is likely that you could stay on meds. I am definitely taking meds now and likely will be for the rest of my life.150mg nortriptyline
15mg Brintellix
1.5mg Abilify- Bob
Posted by SLS on July 21, 2014, at 10:48:28
In reply to Re: Intranasal ketamine - Anyone? » SLS, posted by Bob on July 20, 2014, at 12:34:35
Hi Bob.
> The studies try to pick people with the simplest, purest if you will, forms of MDD not complicated by bipolar...
I doubt that I would qualify, then. I have occasionally experienced severe manic episodes in association with antidepressant treatment.
I really appreciate your input.
- Scott
Posted by SLS on July 21, 2014, at 10:54:07
In reply to Re: Intranasal ketamine - Anyone? » SLS, posted by Bob on July 20, 2014, at 12:39:48
>
> >
> > My doctor wanted me to attempt to discontinue nortriptyline. His hope was that I could do without a TCA. I deteriorated within 5 days of reducing the dosage of nortriptyline from 150 mg/day to 100 mg/day.
> >
> > - Scott
>
> You mentioned that your doctor wanted you try do get along without a TCA but then you added desipramine back in (a TCA, right?). Was that an action you took because of your subsequent detioration due to the reduction in nortriptyline or for some other reason?I asked to try desipramine instead of restarting nortriptyline in the hope that it would give me a cleaner, more energetic antidepressant response. Nortriptyline makes my mood seem "brighter" - which is nice - but I was getting nothing done. Overall, the response was not robust. I couldn't see myself seeking employment in that condition.
- Scott
Posted by Bob on July 21, 2014, at 11:35:12
In reply to Re: Intranasal ketamine - Anyone?, posted by SLS on July 21, 2014, at 10:48:28
> Hi Bob.
>
> > The studies try to pick people with the simplest, purest if you will, forms of MDD not complicated by bipolar...
>
> I doubt that I would qualify, then. I have occasionally experienced severe manic episodes in association with antidepressant treatment.
>
> I really appreciate your input.
>
>
> - ScottActually I'm not sure that would disqualify you if it has only occurred in response to treatment.
This is the end of the thread.
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