Day 21

Day 21

May 1, 12:03 pm, Vellore
Well I can't believe that it is already the my last day here in Vellore. How quickly it has flown by! It has been a good week. I did dermatology this week and found it very interesting. The doctors were super, as I have come to expect here at CMC. They really seem to know their stuff and are generally very friendly and willing to teach. On outpatient days, I spent most of my time working with Dr. Anisha. She is a PG registrar, which is sort of the equivalent of our residency. She was great. She taught a lot and showed me a lot of interesting things. Dermatology is a great rotation to do because even when you don't know what is being said between the patient and the doctor, there are always plenty of physical finding that you will be able to observe. In just a few days I saw so much more derm pathology than the rest of my rotations back home combined. It was great.

I saw a number of cases of leprosy, or Hansen's disease, which was very interesting for me. I've already posted my paper on the topic, but I'll just say that it was so great to learn about this disease because it is so different than what I imagined it would be. You have these horrible ideas of what leprosy is, this stigma... but I never really knew anything factual about it. I also saw a number of really bad cases of pemphigus. Wow. Talk about a horrible condition to have. There was also a lot of psoriasis, a case of chicken pox in a middle-aged man, an eruptive xanthoma, melasma, tinea versicolor, and many other things. So yes, outpatient days were quite enjoyable. And I learned a lot about physical exam... especially for leprosy.

Rounds were also pretty good. Ma'am, as they call their attending, was very nice to us and made sure to include us and teach us about the cases. It was neat to see how quickly a bad case of pemphigus could turn around with proper treatment.

So all in all, being here has been a great experience for me. It has really been neat to see how medicine is such a common language and can bring strangers from different cultures together. It is basically the same here as it is back home, only the details and resources are different.

I've also been reminded here how much we are blessed with back home. We have so much at our fingertips and I know that I take much for granted. However, I have also see that you don't need much to be happy. It is all a matter of how you look at things and I know that I look at things differently now than I did before coming here.

I'm feel very grateful to those who provided the resources and made it possible for me to come here. If you read this, THANK YOU! It has been wonderful.

Tropical Medicine Paper: Hansen's disease

Bryan Child

MEDI 7003

Tropical Medicine Paper

 

Topic: Hansen’s Disease

 

Although it may be a common topic for this assignment, I have chosen to discuss the topic of Hansen’s disease, or leprosy. I wanted to discuss something that I have actually seen here in India. Although I have only completed my first day of dermatology at this point, I have already seen three cases of Hansen’s disease. And while it may be common here, I must admit that I am still quite ignorant of the disease. I know more of the stigma associated with the disease than the actual facts. As such, I will use this paper to discuss some of the details of leprosy. I will cover epidemiology, microbiology / transmission, risk factors, classification, clinical features, diagnosis, and treatment.

 

Epidemiology: The prevalence of leprosy varies greatly from country to country, with the vast majority of cases presenting in developing countries. Very few cases are newly detected in the United States, only 112 cases in 1999, and approximately 85% of new cases in the U.S. are among immigrants. In 2000, 90% of cases were present in just 11 countries, led by India and Brazil. The disease is generally more common in males than females, at a ratio of 1.5 to 1.

 

Microbiology/Transmission: Leprosy is actually caused by Mycobacterium leprae, an acid-fast bacillus. It is an obligate intracellular parasite that multiplies very slowly (generation time of 12.5 days). It grows best at temperatures from 27-33 degrees Celsius. As such, it most commonly affects cooler areas of the body such as the skin, nerve segments near the skin, and the mucous membranes of the upper respiratory tract. The definitive rout of transmission of leprosy has not actually been proven. However, it is believed to be spread via the respiratory route, similar to TB, since the nasal discharge of untreated patients often contains large numbers of bacilli. From the respiratory tract, hematogenous dissemination can occur, spreading to the skin and nerve. It is also possible that the organism occasionally enters through breaks in the skin, as there have been some reports of contact with infected armadillos. The bacilli can survive for several days in the environment. The incubation period is 2-5 years for TT cases and 8-12 years for LL cases (classifications discussed later). Most people develop an effective immune response and clear the bacteria. Only a small minority, about 5%, fail to do so and develop clinical leprosy.

 

Risk factors: People in close contact with infected people have a greater, but still small, chance of becoming infected. The type of leprosy that a person is in close contact with also appears to be a risk factor, with contacts of the multibacillary patient having a higher risk than contacts of paucibacillary or single lesion patients. Older persons also appear to be at an increased risk of leprosy. Although it is difficult to separate the contribution of genetic factors from that of close contact, it does appear that there is some genetic component to leprosy susceptibility. This is likely related to the type of cell-mediated immune response that is elicited.

 

Classification: There are two principal classification systems for leprosy, the WHO and the Ridley-Jopling systems. The WHO classification system is simpler and is based upon the number of skin lesions and the number of bacilli detected on skin smear. Paucibacillary (PB) leprosy is defined as five or fewer skin lesions without detectable bacilli on skin smears. Patients with only one skin lesion are classified separately as single lesion PB. Multibacillary (MB) leprosy is defined as six or more lesions and may be skin smear positive. On the skin smear, the number of acid-fast bacilli found can range from a bacterial index (BI) of 0 to a BI of 6+. A BI of 2 or more at any skin site is an indication to treat as MB leprosy. The Ridely-Jopling system classifies leprosy on the basis of skin, motor, and sensory changes as well as biopsy findings. The classifications are: indeterminate (I), tuberculoid (TT), borderline tuberculoid (BT), mid-borderline (BB), borderline lepromatous (BL), and lepromatous (LL). Under most circumstances, the simpler WHO classification is easier to use and I, TT, and BT disease are generally equivalent to PB, while BB, BL, and LL disease are generally equivalent to MB.

 

Clinical Features: Indeterminate disease usually presents with a solitary hypopigmented 2-5 cm lesion. The center may show sensory loss, though the patient and the doctor are often uncertain about this loss. TT cases have skin lesions with well-defined borders and sensory loss. The patch is dry from loss of sweating and hairless. There may be one or more peripheral nerves affected, occasionally presenting as a mononeuropathy. BT disease presents with irregular plaques with raised edges and sensory loss. Satellite lesions are present at the edges. There is also asymmetrical peripheral nerve involvement. BB leprosy has many lesions with punched out edges and satellites are common. There is widespread nerve enlargement and sensory and motor loss. BL has many lesions with diffuse borders and variable anesthesia. Finally, LL presents with numerous nodular skin lesions in a symmetrical distribution. The lesions are not dry or anesthetic. There are also often thickened shiny earlobes, loss of eyebrows, and skin thickening. BL and LL have similar nerve involvement to BB. The most commonly affected nerves are: ulnar and median (claw hand), common peroneal (foot drop), posterior tibial (claw toes and plantar insensitivity), facial, radial cutaneous, and great auricular. It is important to note that the ulceration and digit loss seen in leprosy is due to secondary damage in neuropathic hands and feet and is not an intrinsic disease feature.

 

Diagnosis: Diagnosis of leprosy is based upon the following: a typical skin lesion (with loss of sensation in TT/BT patients), thickened peripheral nerves, and a skin smear from a lesion edge or ear lobe positive for mycobacteria. As such, the skin lesions need to be tested for sensation. The peripheral nerves should be palpated to assess for enlargement and/or tenderness. Nerve function should also be assessed by testing the small muscles’ power and sensation in the hands and feet. Eye function should also be checked, including visual acuity, corneal sensation, and eyelid closure.

 

Treatment: Management of leprosy consists of chemotherapy to treat the infection, education of the patient, and prevention of disability. The WHO recommended multi-drug therapy regimens are very effective. Relapse rates are 0.1% per year. Clinical improvement is rapid and adverse reactions are rare. For paucibacillary (2-5 lesions) leprosy, rifampicin 600 mg is administered monthly and dapsone 100 mg is administered daily for a total of six months. For multibacillary (more than 5 lesions) leprosy, rifampicin and dapsone are still taken as in paucibacillary leprosy, but the patient also is administered clofazimine 300 mg monthly and clofazimine 50 mg daily. Treatment is continued for a full year. The patient should be educated that within 72 hours of beginning treatment, they are non-infectious and can lead a normal social life. There are no limitations on touching, sex, or sharing utensils. They should also be taught that leprosy is not a curse from God or a punishment and that gross deformities are not the inevitable endpoint of the disease. Care and awareness of their limbs are as important as chemotherapy. Finally, care should be taken to prevent disability. Sensation and muscle power should be monitored in the patient’s hands, feet, and eyes as part of routine follow-up so that new nerve damage is detected early. Any new damage can be treated with prednisolone.

 

Resources

 

1. Robert Jacobson, James Krahenbuhl, and Leo Yoder. Overview of Leprosy, from Up To Date. Updated September 4, 2008.

 

2. Michael Eddleston, Robert Davidson, Andrew Brent, and Robert Wilkinson. Oxford Handbook of Tropical Medicine, Third Edition. 2008. pages 448-451.

 

 

Day 11

Day 11

April 21, 7:28 pm, Vellore

Okay I'm doing tonight's entry on the computer. I think it would take me too long to write on the iPod and I don't want to be typing all night. I have laundry to do tonight! It has been a really great day though! Really, it was terrific. Definitely the best day I have had here in India thus far. I got to go out on nurses rounds with CHAD today. I guess I should explain about CHAD here.

I learned quite a bit about it today from the doctor that came with us. Yes, even though it was nurse rounds, there is this doctor (Dr. Sharon) that wanted to come along too. She was super super nice, and so was Olive, the nurse. Anyway, so the way CHAD works is that you have levels of health care workers. At the base you have your health aides. These are people that actually live out in the villages. They have some training, but apparently it is only like a year's worth of medical training. They are responsible for a population of about 5,000 people. So they are going out every day, house to house visiting with these people and finding out their problems and needs and whatever they are able to take care of, they take care of. They also keep good records of the people. They then report to a nurse. I hope I am remembering these numbers right. Even if I'm off, though, you get the idea. A nurse oversees the areas of two health aides. I guess that means they cover a population of about 10,000. They told me that a nurse will visit each village about every other week. They also take care of whatever they can and keep their own records. I lot of what is done is prenatal and postnatal care, and then chronic conditions. They seem to do a very good job of making sure that babies are delivered in an appropriate facility and home deliveries are seen as a failure of the system. Next up, you have doctors. I am not sure if there are different levels of doctors, but Dr. Sharon said that she covers the areas of, I believe, five nurses, or a population of 50,000. The doctor will visit each village about once a month and hold a clinic. I will be going out for a doctor run clinic on Thursday, so I'll get to see how that works.

Overall, I think this program covers 80 villages surrounding Vellore. It seems to be a very good program and works well. Dr. Sharon said it is difficult though because you have to find workers that are very motivated to do the work and keep good records and know what needs to be referred. Apparently the Indian government has a similar organization in other areas, but it does not work as well because the workers are not that motivated. They just take the money but don't do the work very well. To me, though, it seems like a very effective way to take care of a large rural population that has very little means. Of course, it takes a lot to get motivated and educated staff, but if you can do that, then this program should work well in other areas of the world as well. And maybe there are similar programs in other places that I just don't know about.

So anyway, I spent the day with Dr. Sharon and Nurse Olive and the two health aides. I wish I could remember their names. They were all so nice, it just made for a really wonderful day. It was nice, too, that I was the only student, so I could really talk with them a lot and learn a lot. We had a vehicle and we basically just went from house to house, visiting the people that the health aides and nurse decided we needed to see. It isn't exactly time-effective, which makes me wonder if it is cost-effective. But you know, these people are important too. And even if it is not cost-effective, they deserve care. That's what is so great about this program.

The people we so very kind to us. They see it as an honor for us to visit their homes and so they treat us very well. They would all give us something to eat or drink. We drank a lot of coconut water and ate a lot of coconut flesh. It was so good. I ate pretty much everything they gave me, even a little of the water. They were just too generous and I didn't feel that I could turn them down. I expect I'll probably get sick again, but at least if I do I'll feel that it was worth it.

We went and had lunch at the home of one of the health aides. Her mom fed us a lot and Olive also had brought quite a bit of food that she shared. They taught me how to eat Indian style, and again I couldn't refuse. They eat with their hands only. Actually, their hand. Only their right hand. Apparently the left hand is used for wiping and so even though they wash their hands and everything before they eat, they still never use their left hand to eat, only the right. I felt like I got the hang of it pretty well after a little bit, and they said that I ate very nice. haha. They told me that none of the students from the U.S. will ever eat with them, eating their food and eating the way they eat. Some of the other students from Europe and such do, but they said that the U.S. students never do, so they were impressed. The food was great though and her mom was also very nice. We actually spent a couple of hours there for lunch and had a good time. They are fun people, very happy and laughed a lot.

All in all, I'm not sure how many people we actually visited in the course of the day. Maybe 10? Maybe 15? We didn't actually visit that many houses, but we would always run into different people along the way that needed something and we would stop and talk to them and see what we could offer. The cases themselves were nothing too unusual. Like I said, prenatal, postnatal care, depression, a guy with some new psychiatric disorder, COPD, evaluation of weight loss. I didn't always know exactly what was going on, but I was more interested in the big picture of the program than the specific details of each case.

The areas we went to today were also very beautiful. Most all of the people were farmers. Rice, eggplant, chili's, fruits, tamarind, etc. And they live out close to the moutains, which are very pretty too. It was just so nice to be out in the country rather than here in the noise and madness of the city. I'll take the rural areas over the city any day.

I talked with Dr. Sharon about so many things! I feel like I could sit here all night and write them all, but I know this post is already getting way too long. We talked about the caste system and what a huge role it still plays in Indian society. Marriages are all arranged, except for rare cases such as Dr. Sharon's. Even for them it was difficult. Her husband was beaten by his father for wanting to marry her... I guess they are not of the same caste... but they persisted until both families (extended families) agreed. She said it was only possible because both families are educated. Otherwise, it would never happen. It amazes me that the caste system is still so integral. Muslims, apparently have no caste system, but even the Christians here follow it, which was a big surprise to me. That just doesn't seem to fit with Christianity. She explained how whenever there are elections, people just vote for whoever is their caste and their religion and speaks their language. Or else among the poor, they vote for whoever comes and picks them up in a bus and takes them to the polling station and pays them Rs 100 to vote for their candidate. She feels like the only time that India was close to being united was with Ghandi, but that didn't last.

There is just so much about this country that remains a mystery to me. It is so complex and amazing and astonishing.

I also learned a bit about CMC. What a great place! Their philosophy is that they don't want their students to have any debt when they finish school, because they don't want them to have to work for money. They want them to be able to serve. For that reason, tuition is insanely cheap, even by Indian standards. CMC actually puts in a lot of money for the training of each student. That's awesome.

Okay I really should stop. This is getting way too long. I'm just grateful I was able to have such a great day with these wonderful people. Their kindness inspires me.

Day 10

Day 10

April 20, 10:14 pm, Vellore
Today we started our CHAD rotation. My first night alone was fine, by
the way. A little hot, but I was able to sleep fairly well. The bucket
shower was fine, no big deal. Even the little squat toilet thing is
not too bad, to be honest.

But anyway, CHAD. Stands for community health and development. It's
quite the organization. I think I should have a better understanding
of it tomorrow though, after I go out and do home visits with the
nurses.

Today we were just doing outpatient clinic there at CHAD.
Unfortunately, the doctor that I was working with was not super. I
guess it's the same as back home... you work with some doctors that
are awesome and love to teach, and then there are others who make you
feel like you are just a bother. This guy barely said anything to me.
The majority of the patients went by without him ever even telling me
what they had come in for. A few of them he did give me a little bit
of information, but really it was only a little bit. "This man has
diabetes and came for a refill." And "This girl has a clavicle
fracture and you can palpate the callus formation." My favorite was
the negative PPD test that he had me palpate. Sweet. Again, I'm more
excited to go and do home visits tomorrow. And I'll explain more about
CHAD then.

We spent our time after work at the hospital computer lab, trying to
avoid the heat. When I checked, the heat index was 107. Tomorrow it is
supposed to be about 110. Ate dinner at the Hotel Aavana Inn. It was
pretty good, even though my grilled chicken sandwhich had more chicken
bones than actual chicken. Haha. The pineapple lassi was good.

Okay I'm tired. Sorry for the boring entry.

Day 9

Day 9
>
> April 19, 3:07 am, Pondicherry
> Just started puking my guts out again. Lovely. I want to go home.
>
> 10:44 pm, Vellore
> Back in Vellore. Home sweet home. Hardly. Coming back after being
> away to Mamallapuram and Pondy, I'm reminded what a crowded, busy
> town this is. It's really not the most pleasant town.
>
> We spent the morning and early afternoon seeing some of the sights
> of Pondicherry. I didn't feel too sick in the morning. I really
> think I just threw up because my bowels aren't moving (as a result
> of the immodium I took the other day). I must be backed up. But
> getting it all out last night felt sort of good, after it was over.
>
> So this morning we first walked to Le Cafe. It's this nice little
> cafe right on the sea wall. Very nice place. I drank lemonade. Then
> we wandered over to the main Ashram place. It's where Sri Arubindo
> and The Mother are both entombed/enshrined. Their tomb was very
> intricately covered with a flower petal design. The whole place had
> lots of flowers growing all over. It was pretty. Arubindo and The
> Mother are apparently the founders of this Ashram thing. It's some
> sort of philosophy that combines yoga and modern science? Anyway, it
> was very peaceful. People were meditating and praying near the tomb/
> shrine.
>
> After that we walked through this other temple that we sort of
> stumbled upon. There was an elephant that blessed you if you gave it
> food or money. It was awesome. You give him something and then sort
> of bow your head and he touches the top of your head with his trunk.
> Not sure what the blessing is for... to get married? To be fertile?
> I'd really just like to stop vomiting!
>
> Next we walked to coffee.com. This was a really cool little Internet
> cafe. They even had wifi, so I got to just use my iPod touch. My can
> of sprite also was nice for the stomach.
>
> After that we walked over to this old catholic church that was quite
> pretty and then went to have lunch at this place called satsanga, I
> think. Katherine had really been wanting to go there. It was a
> pretty good place. Jerry was disaapointed because his shrimp
> cocktail wasn't what he expected, but everyone else was pleased with
> their meal. They had a lot of French seafood dishes. I ate a small
> bowl of chicken soup. Very tasty.
>
> By the time we finished up there we figured it was about time to
> head back to Vellore. We ended up just paying for a taxi all the
> way. Rs 2400 for AC. We were able to fit all 5 of us, 2 in front and
> 3 in back. It was an old ambassador model, "Indian Benz", according
> to our driver. We had to stop about every hour because the car would
> be close to overheating. It was amusing. He would get all this water
> and just dump it all over the engine and in whatever holes he could
> find. But about 4 hours of bumpy roads later, we made it back.
>
> Tonight I'm staying by myself for the first time. The girls and Neil
> and Jerry are over at this new place. Seemed pretty nice, but I
> wanted a little space and privacy for a change. This place is not
> great though. It's okay, but I might get tired of no AC and no
> shower head or sit-down toilet. If I get sick of it, I may just go
> stay with them again. We'll see.
>
> I finally did some laundry tonight. Just hand-washed a few things in
> the bucket in the bathroom. I've got a headache right now, maybe
> just from the heat and the travel all afternoon on bumpy roads. I
> think I'll go to sleep before too long. Tomorrow morning we start
> CHAD.
>
>
>

Day 8

Day 8
>
> April 18, 9:12 am, Mamallapuram
> Sorry about that last one. I was so exhausted that I started writing
> jibrish so I decided I better just stop and go to bed. Anyway, this
> is a nice little town. It is much smaller and quieter than Vellore,
> so it's nice to get away from that. It's also right on the beach,
> which is cool.
>
> I am feeling much better though, as a side note. Thank goodness that
> the food poisoning stuff only lasts for a day or two, because it
> would really suck if it was longer! For that day you feel like you
> will never want to eat again. It's horrible. But I'm pretty close to
> 100% today, so it's all good.
>
> This place has lots of tourists. The hotel we are staying at, sea
> breeze, is pretty much all white people. It's expensive too! Paying
> more than at the Aavana for a non-AC room. Oh well, at least they
> have a beautiful pool and free breakfast. The pool felt great this
> morning before breakfast. But back to yesterday... since there are
> so many tourists the people here are very good at working you to buy
> their stuff. This town is known for it's stone carvers, and they are
> all over town. I guess it's been that way for years, because there
> is all the ancient stonework here too. It's pretty cool. Okay we're
> getting ready to head out. I'll finish later.
>
> 10:54 pm, Pondicherry
> Okay it's later, but I really don't feel much like writing. I'm
> starting to realize that India is very much a love/hate relationship
> and I'm currently leaning towards the hate end. Don't get me wrong,
> we're in Pondicherry right now and it's really nice. I just can't
> fully enjoy it because my stomach is bugging me. My bowels are not
> moving now, I guess because of the imodium and pepto I took, and I
> just feel sick. I don't want to eat anything and I feel nauseated.
> Sucks, especially because Pondicherry has some great places to eat!
>
> The other thing is the heat. It is almost unbearable well you are
> feeling fine, but throw in some stomach problems and a little nausea
> and it's just downright hellish. Seriously, it is sweltering. Even
> the Indians think it's too hot and complain.
>
> That being said, Pondicherry (or Puducherry as it's called now) is
> pretty awesome. It's where the French used to be and you definitely
> feel the French flair here. Definitely in the architecture, as well
> as in the well-shaded, well-paved, wide boulevards. It really
> doesn't feel like the rest of India that we've seen.
>
> They have a very nice main boulevard that goes along the sea. It's
> very pretty and tonight it was packed with people. It seems the
> whole town is out there enjoying the ocean breeze and the relative
> cool of sundown.
>
> We spent a couple of hours on the bus today from Mamallapuram. I sat
> next to a really nice man, Jalil. He was from Chennai and on his way
> to Pondy for a wedding tomorrow. I asked him if it would be a big
> party and he said yes, except without strong drink because they are
> Muslim. I explained to him that in my religion we don't drink strong
> drink either and he was very happy about that. It was nice to be
> able to talk to someone here, because I feel that is how you really
> get to know a place. I think too many Americans come here, and to
> other places, with a sort of attitude that they better than these
> people, or that it is them vs. us, you know? Like every Indian you
> meet it trying to swindle you or something, and so they are never
> really friendly with the people. They come and see their country and
> their sights and bargain with them so as not to pay too much for
> something they want, but they don't actually take any time to be
> friendly with the people.
>
> Sorry for the soapbox. Just something I've observed.
>
> So anyway, it was nice to get to know Jalil (maybe Halil?) a little.
> He is a truck driver... drives goods from Chennai all the way up to
> Agra, which he said usually takes about 5 days. 3 at the very least.
> He has a wife and 2 daughters, the older of which is getting married
> on May 10th. He taught me a couple of words... nandri is thank you
> in Tamil, and I think it was Vanacom that means good morning/
> afternoon/evening, which is also accompanied with the little hands
> together in front of you bow/head bob thing. At least that's how he
> did it.
>
> We spent a good chunk of our time today eating at the nice place...
> I can't remember the name. Really we were just hanging out there,
> only ate a little. But it was a really nice place with AC and TVs
> (had to watch cricket). Much nicer than anything we've seen until now.
>
> We're stating at some international guest house. It's not bad. No
> AC, but a toilet and shower head. It's an Ashram place. Apparently
> Ashram is some blend of like yoga and modern science that started
> here and a lot of people come here to practice or study it. So they
> have these Ashram guest houses.
>
> The morning in Mamallapuram was pretty nice too. Saw the Shore
> Temple and the Five Rathas. Pretty cool stonework from like the 7th
> century AD. Yesterday we hired a guy to give us a walking tour of
> some of the other sights. It was pretty interesting. Nice guy, very
> informative. Hinduism is so complicated. So many different people
> and stories to remember! It's hard to keep them all straight, but
> interesting.
>
> Vishnu is, apparently, a favorite though. He is the protector and I
> think there are more temples and more worship of him.
>
> Anyway, I could probably go on all night. I didn't intend to write
> so much. I need to put on some more Off before I go to sleep. I
> think this place has mosquitoes. Ugh.
>
>
>

Day 7

Day 7
>
> April 17, 11:10 pm, Mamallapuram
> Well it's already been a week since we left! One down, four to go. I
> found a new place to stay. It's called Vishnu annex and it is dirt
> cheap. It's just a couple blocks down from Aavana. Rs 170 per night!
> Of course, that is for non-AC, a squat toilet, and no shower head. I
> think I can handle it though. We'll see. It has a good fan and a tv
> and I'll have a little space to myself, which will be nice. So
> anyway, we left all our luggage there today and took a taxi to
> mamallapuram. It was a long hot ride and we even hit a motorcyclist.
> Got it on video. Yeah baby.
>
> This is a pretty cool little town. It has all these really old stone
> carvings and stuff, from like 1400 years ago. It also has a cool
> temple out by the beach. I'll have to put some pics up later. It's
> very neat though.
>
> Man, I am falling asleep writing this. Better get to ...
>
>
>