tag:blogger.com,1999:blog-48785174871484843042024-02-18T19:52:52.055-06:00The Primal TransplantA story of living with new lungs, a new lifestyle, and swinging kettlebells.John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.comBlogger211125tag:blogger.com,1999:blog-4878517487148484304.post-58777975541493585982022-11-23T22:11:00.002-06:002023-07-04T12:21:15.832-05:00The "It's Been a Long Time Since I've Written a Post" Post<p>I can't believe that it's coming on a year since my last post. It has been one eventful 11 months and by our Lord's grace, I'm still here and doing well.</p>In June I was a member of a panel that presented the <a href="https://lungtransplantfoundation.org/bos-pfdd/" target="_blank">Bronchiolitis Obliterans Syndrome (BOS) Externally-led Patient-Focused Drug Development Meeting</a> to the FDA. This was a very interesting experience that will hopefully lead to more patient centered clinical trials. More quality trials <div>may lead to a cure of this syndrome that has cost the lives of so many lung transplant recipients. A written report of the meeting will be published soon.<div><br /></div><div>As I've mentioned before, my Sweetie and I live in a senior living community. The community has been very good for her and we have become involved in the activities that she is able to do. We participate in most of the physical activities and we are active in the community church. Well, maybe a bit more than active. The couple that led the church are moving in with one of their children and I have taken over the responsibility of leading our worship services. We have leaders from local churches visit each week to share the main message of the service and we share the Lord's Supper monthly. It is a ministry that I am blessed to be a part of.</div><div><br /></div><div>Health wise we are doing well. Covid has blown through the community a couple times this year and we were able to avoid it so far. Currently Covid, RSV and the flu are concerns in the community, but people who are ill are doing a fairly good job of self isolating. Of course we are up to date on all our Covid Vaccine shots and our flu shot. I've also had 3 doses of Evusheld (monoclonal antibodies) and am participating in several studies involving transplant recipients and Covid 19. We're doing our best to avoid infection over the next few months.</div><div><br /></div><div>V and I are both progressing in our individual issues. As I go over what all is going on, please keep in mind that I am still much healthier than I was the year prior to my transplant and that many of my issues are a part of the lung transplant package and I've written about the possibility of these issues much earlier in the blog. It's also important to mention that V and I are very happy and make a great team. I'm her memory and she's my muscle.</div><div><br /></div><div>During V's most recent visit with her neurologist she scored a 9 on the <a href="https://www.dementiacarecentral.com/mini-mental-state-exam/" target="_blank">Mini-Mental State Exam (MMSE)</a>. On a positive note, a score of 9 means she won't be having to take that exam during our future routine neurology visits. The ability to maintain the strength and energy to care for my Sweetie is an important part of my decisions about my personal treatment plans.</div><div><br /></div><div>If you've been reading along for a while, you'll probably remember that the upper lobe of my right lung is permanently collapsed and that I've had several major infections, a major pulmonary embolism, a few acute rejections, and that I'm in <a href="https://primaltransplant.blogspot.com/search/label/Chronic%20Rejection" target="_blank">chronic rejection.</a> The chronic rejection had been stabilized by the <a href="https://primaltransplant.blogspot.com/search/label/Clinical%20Trials" target="_blank">Extracorporeal Photopheresis clinical trial</a> that I've been participating in. </div><div><br /></div><div>It's starting to look like the <a href="https://primaltransplant.blogspot.com/2021/08/sars-cov-19-covid-19-with-lung.html" target="_blank">Covid infection</a> that I had summer before last has triggered relapse back into chronic rejection.</div><div><br /></div><div>My clinical spirometry results over the past year indicate a slow and steady decline in <a href="https://www.ncbi.nlm.nih.gov/books/NBK540970/" target="_blank">FEV1</a>.</div><div><br /></div><div><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhFfHDuh3pL5HeTsAZQq56ag5pZL5-0WqWkON6akLhyNIa31dmDhH79OInDmnTJmxMlEyVN7T33KPIwWmBHEF51xsdGZ4gdehzSHTIFQn24UVLsxQH3RmWu_BO2qtAC7sgClcR2PpDABT8ZnYNjmytn3kRbpV-8wLuiozXkDZqhnOHQ1UsWs0x3HX4hPA/s707/2022%20FEV1.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="423" data-original-width="707" height="191" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhFfHDuh3pL5HeTsAZQq56ag5pZL5-0WqWkON6akLhyNIa31dmDhH79OInDmnTJmxMlEyVN7T33KPIwWmBHEF51xsdGZ4gdehzSHTIFQn24UVLsxQH3RmWu_BO2qtAC7sgClcR2PpDABT8ZnYNjmytn3kRbpV-8wLuiozXkDZqhnOHQ1UsWs0x3HX4hPA/s320/2022%20FEV1.png" width="320" /></a></div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">This decline could be chronic rejection, or it could be infection. I currently have two infections in my lungs. The numerical column of the chart is liters of air. Just as a reference for where my lungs are now, my highest FEV1 after transplant was over 5 liters.</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">I've been hospitalized twice this year. Once back in May due to my body not liking a medication change. I've been having <a href="https://www.mayoclinic.org/diseases-conditions/premature-ventricular-contractions/symptoms-causes/syc-20376757" target="_blank">premature ventricular contractions (PVCs)</a> and my meds were not controlling them very well. My cardiologist replaced my meds with new ones and my body reacted poorly, like get to the ER poorly. We got that lined out with a tweak of the medications and all is well now. I still have PVC's, but they are pretty much under control.</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">My second hospitalization was due to infection. High fever, dropping spirometry, the usual infection symptoms sent me to the ER. A bronchoscopy found a fungal infection (aspergillus) that we are treating with an antifungal medication. I am currently in month 4 of a 6 month treatment plan. A couple months later Mayo Clinic returned positive results for a bacterial infection, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4550155/" target="_blank">Mycobacterium abscessus complex</a>. We don't yet have a treatment plan for this latest infection for a couple of reasons. First we have to finish up the course of treatment for the fungal infection before starting any new heavy duty treatments, and second just because the bacterial is present doesn't mean it is currently actively progressing. Right now we are taking a 'wait and see' approach before taking any action. I'm ok with that as my primary goal physically is to have the strength and energy to take care of my Sweetie. And, like everything else, I've put this in our Lord's hands so there is no need to worry about things that have been offered up to the Lord.</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">One thing I really enjoy doing is computer gaming and I was invited to participate in the closed beta test of Diablo IV. A closed beta test is a pre-release test of a games features and mechanics. I've been looking forward to playing this game since it was announced so gaining access to the beta was awesome. My grandson calls me an "elderly gamer". I get a kick out of that as I've been very highly rated in the games that I play often.</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">Here is a picture of V and I at my birthday dinner. Our daughter got a gift cert to <a href="https://sixtyvines.com/" target="_blank">60 Vines</a>. It had been since before Covid that we've been there. Really enjoyed ourselves.</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiPt7SWV2v9GbjlYgJhBA4Wg7bDtffqaCXoUWM1v3_Ld4KLbbssl6HmmsJws3iBeC5xI_r7JkwwQi3UzynXDwcCmKRY8MnZipvFYhnru_ZRpUJ-vmkkuvch_q7Rlo4wtzQ1UbaYlG1T-59dRRa6hAdDt8AnlIJKUH3h0lQPbq3KPB1oCJVA9aBkeDtrXw/s3774/V%20and%20I.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2332" data-original-width="3774" height="198" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiPt7SWV2v9GbjlYgJhBA4Wg7bDtffqaCXoUWM1v3_Ld4KLbbssl6HmmsJws3iBeC5xI_r7JkwwQi3UzynXDwcCmKRY8MnZipvFYhnru_ZRpUJ-vmkkuvch_q7Rlo4wtzQ1UbaYlG1T-59dRRa6hAdDt8AnlIJKUH3h0lQPbq3KPB1oCJVA9aBkeDtrXw/s320/V%20and%20I.jpg" width="320" /></a></div><br /><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">Tomorrow is Thanksgiving. One thing you learn with a lung transplant is to be thankful for every breath. </div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">Thanks for reading. It's kinda therapeutic to be able to put my journey into words.</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">Happy Thanksgiving my friends.</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;"><br /></div><br /><div><br /></div></div>John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com2tag:blogger.com,1999:blog-4878517487148484304.post-23049445794636390942022-01-08T10:45:00.002-06:002022-01-08T10:45:19.954-06:00Seven Years LaterIt's been seven years since my bilateral lung transplant, and wow, a lot can happen when you have an extra seven years of life.<div><br /></div><div>I've been able to watch grandchildren become young men and women, and hopefully have some small positive influence in their lives. I've made new friends and reconnected with an old one. My walk with our Lord is much closer than it has ever been, and I'm in a really good place inside my head.</div><div><br /></div><div>If you've been reading along, you know that there have also been some challenges along the way. Most of the challenges are part of the lung transplant package, others were quite unexpected. Who would have thought we'd lose over 800,000 people to a virus here in the United States, and people would still be resistant to doing anything help at least slow the spread. Or, that my wife could be diagnosed with Alzheimer's in the same year that I was transplanted. Life is interesting :) We live in a senior community that can supply the extra help that we sometimes need, and we are enjoying being here much more than I ever would have expected. I am the youngest in the community, there are couples here that have been married longer than I have been alive. I'm learning a lot.</div><div><br /></div><div>I just finished up my transplant annual exams the other day. No matter how the year's been going, I look forward to these scans, labs and tests, they are a good spot-check of my health and where it is trending. My chest CT scan is a compact picture of what my wonderful lungs have endured, each finding a reminder of earlier challenges. Thankfully this latest scan didn't identify anything new :)</div><div><br /></div><blockquote><span face=""Source Sans Pro", Calibri, Arial, sans-serif" style="background-color: #f8f8f8; color: #363636;">Lungs and pleura: Postsurgical change of bilateral lung transplant. Mild posterior right pleural thickening, unchanged. No pneumothorax or pleural effusion. No central endobronchial mass. Complete collapse and bronchiectasis of right upper lobe, </span><span face=""Source Sans Pro", Calibri, Arial, sans-serif" style="background-color: #f8f8f8; color: #363636;">unchanged.</span></blockquote><blockquote><span face=""Source Sans Pro", Calibri, Arial, sans-serif" style="background-color: #f8f8f8; color: #363636;">Subtle patchy ground glass opacities of each lung base persists but have decreased. There is a mild degree of mosaic attenuation of the lungs on expiratory imaging, similar to previous studies. Hyperlucency of right lower lobe most evident </span><span face=""Source Sans Pro", Calibri, Arial, sans-serif" style="background-color: #f8f8f8; color: #363636;">involving superior segment, unchanged. Minimal subpleural reticulation at each lung base similar to previous studies.</span><br style="background-color: #f8f8f8; box-sizing: border-box; color: #363636; font-family: "Source Sans Pro", Calibri, Arial, sans-serif; margin: 0px; max-width: 100%; padding: 0px;" /><br style="background-color: #f8f8f8; box-sizing: border-box; color: #363636; font-family: "Source Sans Pro", Calibri, Arial, sans-serif; margin: 0px; max-width: 100%; padding: 0px;" /><span face=""Source Sans Pro", Calibri, Arial, sans-serif" style="background-color: #f8f8f8; color: #363636;">Focal, branching opacity at ventral lingula adjacent to chronic subsegmental atelectasis or scarring, is likely related to endobronchial mucous plugging, unchanged compared with previous studies. No consolidation. A few scattered small bilateral </span><span face=""Source Sans Pro", Calibri, Arial, sans-serif" style="background-color: #f8f8f8; color: #363636;">pulmonary nodules measure 0.4 cm or less in diameter and are unchanged. No new nodules.</span><br style="background-color: #f8f8f8; box-sizing: border-box; color: #363636; font-family: "Source Sans Pro", Calibri, Arial, sans-serif; font-size: 17.3333px; margin: 0px; max-width: 100%; padding: 0px;" /></blockquote><div><br /></div><div>The ground glass opacities are left over from my COVID infection earlier in the year. The "<i>but have decreased</i>" note is pretty awesome. </div><div><br /></div><div>I hadn't mentioned this, but right before Christmas I had an acute rejection episode. It was a minor rejection and was resolved with prayer and pulse steroids. I wasn't really sure just how my full series of pulmonary function testing would turn out. I went into "the box" expecting a loss in lung function, just was not sure how significant the loss would be. </div><div><br /></div><div>I started writing down all of my PFT results, but doubt many would really be interested. If you want to know any of my numbers, ask in the comments and I'll be happy share them. They are down a bit from last year, but for the most part higher than when I began my <a href="https://primaltransplant.blogspot.com/search?q=ecp" target="_blank">ECP treatments</a>. All things considered, they were better than expected.</div><div><br /></div><div>One really good test result was my <a href="https://www.medscape.com/answers/303239-77869/what-is-the-six-minute-walk-test-6mwt-in-pulmonary-function-testing" target="_blank">six minute walk test (6MWT)</a>. I was able to walk significantly longer than last year. As a matter of fact, my distance was back up to where it was in 2019. That's pretty awesome. We do a lot of walking in our senior community, along with some low intensity cardio. It seems to have done some good.</div><div><br /></div><div>I still have to get my bone density scan early next month, and a colonoscopy. I need to get off my rear and schedule that one, not something I enjoy. It's kind of like a tooth that should be extracted. I need to get it done, just really don't like the idea of volunteering for another procedure and more pain (the tooth extraction, not the colonoscopy),</div><div><br /></div><div>I didn't do my Extracorporeal Photopheresis treatment in December. It was due about the time I was having my acute rejection, another thing I need to get scheduled.</div><div><br /></div><div>I just counted and I have 34 different lab results from this year's annual so far. Quite a few of them have a little red exclamation mark indicating they are out of spec. That's one reason all of my medical is through one Team. My labs look really weird for a normal healthy person, but are routine for me. Some normal results from this years labs include liver function (yeah), cholesterol, Vit D, testosterone, and A1C. Magnesium is low, but I would have a hard time supplementing with even more than I do now. I'll look into changing brands a see what happens. That worked with my Vit D. I was always low until I found a brand that worked for me.</div><div><br /></div><div>This post is just kinda rambling on so I'll finish up here. It is awesome to still be here 7 years after my expiration date, not just here but thriving. We are blessed.</div><div><br /></div><div>Have questions about my medications? Lung transplant annual exams? Lung transplant and Covid now that we have vaccines? Any questions about lung transplant, please ask in the comments or send an email. I'll be happy to give an honest answer from my experience and perspective.</div><div><br /></div><div>Have a great year.</div><div><br /></div><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><div><br /></div>John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com0tag:blogger.com,1999:blog-4878517487148484304.post-61962263930523055722021-11-26T18:51:00.001-06:002021-11-26T18:51:55.541-06:00Faith is my Anchor<p>My faith isn't something I've often mentioned on this blog. I felt that talking about faith or politics might take away from the health and medical information I am trying to share with the transplant community. My faith is an important part of my life, and is the anchor that helps me to weather the storms that are part of the lung transplant package.</p><p>My walk with God has taken quite a few detours, but our Lord has always accepted me back. I’m sure most of us have seen the “Footprints in the Sand” poem on a card or poster. The author of the poem wrote about walking along the beach with our Lord and when looking back noticed that at their darkest hours there was only one set of footprints in the sand. When asked why there was only one set of footprints during their darkest days, the Lord answered, “When you saw only one set of footprints, it was then that I carried you”. In my case the single set of footprints was when I was off chasing something shiny or splashing in the waves or playing on the rocks. God never left me, but there were times when I sure did get distracted.</p><p>Receiving a bilateral lung transplant is a blessing, a true modern day medical miracle. I am here today due to a precious gift from my donor family, the skill and dedication of my transplant team, and the Grace of God. Each and every breath is a blessing.</p><p>If you've followed this blog, you know that my transplant has come with physical challenges. I’ve had a moderate/severe acute rejection, I’ve had a UTI go septic, I’ve gotten stomach contents in my lungs that triggered my chronic rejection. I’ve had a Nissen Fundoplication to prevent that from happening again. I’ve had a procedure that killed off my T-Cells to try and stop my chronic rejection. The procedure wasn’t as successful as we would have liked so I’m in a clinical trial that’s changing the DNA of my white blood cells. One side effect of the clinical trial was a bad pulmonary embolism (is there such a thing as a good PE?) and another was hard to control blood pressure. The upper lobe of my right lung has collapsed 4 times and we couldn’t get it reinflated after the last collapse. As most of you know, my most recent challenge was COVID. All told I’ve been in the hospital a lot, and the ICU three times.</p><p>How have I remained resilient and positive after all of these challenges? First is my faith. My faith in our Lord Jesus is stronger now than ever. My life is in his hands, and as I mention often, every breath is a blessing. My wife is another source of strength. She has Alzheimer's and the two of us make an awesome team. She has been with me every step of the way. The social isolation due to COVID was hard on my her and her disease started progressing fairly rapidly. Finding, and being able to move into our senior community has been another blessing, and an answer to prayer.</p><p>Speaking of COVID... that is one scary diagnosis for anyone with transplanted lungs. The mortality rate for lung transplant recipients pre-vaccine was around 40%, and those who survived usually had damage to their new lungs and and other major issues. </p>You can imagine my thoughts after I got the notification of my positive test. As our daughter drove me to the ER, I was more concerned than scared. I was thinking of my Sweetie and her future care. Under normal conditions, my Team would let her stay with me in the hospital, that was not possible with COVID. Thankfully our daughter was able to cancel a couple business trips and stay with her. <div><br /></div><div>While in the hospital I was reading through the New Testament on my Kindle and the Lord highlighted a couple important lessons for me.</div><blockquote><span style="color: #1096e3;"><b>Matthew 6:34 “Therefore do not worry about tomorrow, for tomorrow will worry about itself. Each day has enough trouble of its own.”</b></span></blockquote>My Team and I had planned on my coming home after 5 days in the hospital. Things seemed to be going well until my CT scan on Day 4. We found that the virus had started effecting my lungs, so it was going to be another 5 days at least. I was reading James, and this really hit home.<span style="color: #1096e3;"><blockquote><b>James 4:13-15 “13 - Now listen, you who say, “Today or tomorrow we will go to this or that city, spend a year there, carry on business and make money.” 14 - Why, you do not even know what will happen tomorrow. What is your life? You are a mist that appears for a little while and then vanishes. 15 - Instead, you ought to say, “If it is the Lord’s will, we will live and do this or that.””</b></blockquote></span>By the 8th day I started hoping that I’d get out soon. We had one little scare that turned out to be a malfunctioning meter. My lung function was stable and I was off of supplemental oxygen, it seemed all was going well and on 'my' schedule. That was until chest X-ray results from the morning came in. The X-ray showed that I had a pneumothorax on my right side. A pneumothorax means I had air trapped between my lung and chest wall. There were a couple of options for removing the air, the most likely being inserting a chest tube for a few days. That was disappointing to say the least. I spent the afternoon thinking, praying, and continuing to read the bible. The next morning came and the my daily X-ray was taken and it looked good to me, but I’m not a radiologist (I have literally seen 100's of my own lung images though). When I spoke with my doctors that afternoon they mentioned that the pneumothorax had disappeared, gone, no evidence that it had ever been there. They were surprised and said they didn’t know how that happened. I told them it was prayer. I was discharged on the 10th day and my Team is very happy with my recovery. We are still working on some minor issues, but I feel great.<div><br /></div>Our God is an Awesome God. The same God that created our universe loves each and every one of us. He loves us so much that he sent his Son Jesus to walk among us, teach us, and most importantly to die on the cross for us. Jesus is our redeemer. His blood washes away our sins and through Jesus we can have eternal life in heaven.<div><br /></div>I was raised up a Lutheran and baptized as an infant. While I was in the Navy I became an Episcopalian. I drifted away from attending church until we moved to the senior community. My Sweetie and I met Maurice and Billie at dinner. We started a friendship and Maurice invited us to <a href="https://www.huntersglen.org/" target="_blank">Hunter’s Glen Baptist Church</a> where we've became members. This past Sunday I'm very honored to have been baptized as an adult by my good friend and mentor, Maurice.<div><br /><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen="" class="BLOG_video_class" height="266" src="https://www.youtube.com/embed/IrbS-Ppneew" width="320" youtube-src-id="IrbS-Ppneew"></iframe></div><br /><div>If you have read this far, awesome and thanks. If you have any questions or would like to know more, just ask in the comments or shoot me an email.</div></div>John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com0tag:blogger.com,1999:blog-4878517487148484304.post-48792107746831465092021-08-31T11:49:00.002-05:002021-08-31T11:49:35.073-05:00SARS-COV-19 (COVID-19) With a Lung Transplant<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMlzEIG594XFVmgWg5-maZFL8-4EAZmg1Cw_1PwLYBUZgHu5Xa3yDoQzFH9wsrlPmSUthacZLcxDbVE06lWYRbpJ5PV1bpauT5Xj2y8dBjx2MLQeqEsizfSSSHqN-8V6jpH4fgIZRAPxf3/s2048/20210819_002815945_iOS.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1536" data-original-width="2048" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMlzEIG594XFVmgWg5-maZFL8-4EAZmg1Cw_1PwLYBUZgHu5Xa3yDoQzFH9wsrlPmSUthacZLcxDbVE06lWYRbpJ5PV1bpauT5Xj2y8dBjx2MLQeqEsizfSSSHqN-8V6jpH4fgIZRAPxf3/s320/20210819_002815945_iOS.jpg" width="320" /></a></div><br /><p>This is the view from the <a href="https://utswmed.org/locations/clements/william-p-clements-jr-university-hospital/" target="_blank">UT Southwestern Clements University Hospital</a> 12th floor. The 12th floor is the COVID floor, and it is where I spent most of the past couple of weeks.</p><p> In an earlier post, <a href="https://primaltransplant.blogspot.com/#:~:text=December%2028%2C%202020-,Vaccine%20Emotions,-There%20are%20quite" target="_blank">Vaccine Emotions</a>, I mentioned "<i>And no, the vaccine isn't some sort of magical COVID shield. It's 90% effective in healthy individuals, likely less in the immunocompromised</i>." I wrote that post back in December when I received my first dose of the Pfizer COVID vaccine. I had been accepted to be part of the <a href="https://transplantvaccine.org/" target="_blank">National Vaccine Research Study for Transplant Recipients</a> and three months after my second dose of the vaccine I had not yet build up any spike protein antibodies. This did not mean that vaccination was not effective, just that the immunosuppressed may not develop the same response as people with a healthy immune system. Our hope is that the the vaccine did activate Memory T and B cells. I tried to talk my team into a third dose of the vaccine after my 3 month post vax labs came back negative, but they were reluctant to approve it due to lack of data on the effects of a third dose. Thing change rapidly as more information and data comes out, and my Team is now helping us get the 3rd shot.</p><p>I have not yet received the third dose because... I was infected with the SARS-COV-2 (COVID-19) virus. I thought I was coming down with a Summer Cold. Standard protocol for me and colds is a steroid taper and antibiotics. So I contacted the Team and went in for a PCR just to verify it was a cold and found that nope, I hit the COVID lottery.</p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjL7IgP-D-42FyYMfWK-R3qA2hke0gaxpi04xL7cXeD7y7JikzcjdX2J0BIdbmDw7bgEykIrtzvoFKAW9Ad6MwR8TPErGmWeQ7iVMrpohHmktgOo6CPFGa03_IOCifRBdV_hNhsREckV4tH/s1207/20210817_005722000_iOS.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="638" data-original-width="1207" height="169" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjL7IgP-D-42FyYMfWK-R3qA2hke0gaxpi04xL7cXeD7y7JikzcjdX2J0BIdbmDw7bgEykIrtzvoFKAW9Ad6MwR8TPErGmWeQ7iVMrpohHmktgOo6CPFGa03_IOCifRBdV_hNhsREckV4tH/s320/20210817_005722000_iOS.jpg" width="320" /></a></div><div><br /></div><div><br /></div><div>Since I thought I had a cold, I was taking Coricidin HPB. My symptoms while taking the cold medicine were an elevated temperature, cough, upper respiratory irritation, and diarrhea. My SpO2 dropped a bit and when admitted to the hospital I was placed on 2 liters of supplemental oxygen. </div><div><br /></div><div>I spent 10 days in the hospital, and a hospital stay with SARS-COV-2 (C-19 from here on) is not even close to the my experience with any of my other post transplant hospital stays. My transplant team was in charge of my care, which was a great comfort to me, but I was not on the lung transplant floor. I was on the C-19 floor, as expected. The floor was full and the staff busy. Some of my nurses/techs have been on the floor since the beginning, others came to the floor right out of nursing school. One of the common traits of my nurses was honesty. If you ask a question, you are going to get a direct and honest answer based on experience. I really appreciated this. Personal contact with doctors is rare when you are on a C-19 floor. A doctor never entered my room, all my contact with my Team was via phone or video chat. This is very understandable as my Team sees lung transplant patients on the 10th floor. It would be irresponsible to expose them to any additional COVID risk.</div><div><br /></div><div>My course of treatment included two treatment cycles of Remdesivir (10 total infusions), a steroid taper followed by pulse steroids followed by my current taper, and <a href="https://www.medpagetoday.com/opinion/second-opinions/94256" target="_blank">Convalescent Plasma</a>. Why plasma instead of monoclonal antibodies? Well, the monoclonal antibodies were our first choice but this therapy is not approved for inpatient treatment. The hospital and my Team (who are very good at getting approval for off label use of necessary meds) tried to get the treatment approved, but could not. We went with the plasma, and in my case, it appears that convalescent plasma is effective. This highlights how important it is to pay attention to your body, get tested if you have any symptoms, and start treatment early. The effectiveness of either monoclonal antibodies or convalescent plasma is significantly increased if used early on in the course of the disease.</div><div><br /></div><div>I assume that any transplant recipients reading this have received the COVID vaccine. If someone has received the life saving donation of an organ, and not yet availed themselves of the vaccine, I really would have to wonder why? Pre-vaccine immunosuppressed people had a very hard time with this disease, the vaccine really can and does make a huge difference.</div><div><br /></div><div>I had some ups and downs while in the hospital, but the end result is that I am home and doing well. I'm taking Nystatin for a yeast infection and will start a couple days of Lasix for swollen legs. I'm on room air and my pulse ox readings are normal and stable. Even my home spirometry remains normal. My hospital CT scan identified potential long term issues and we will be following up and keeping an eye on things.</div><div><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBEWoh-CImsHZA4OfghD6LcrVs8EAOQF6c9TM-MEM2qBR8Eo0kDN1xvgCX-j6pliM_kWj1yHhh4gw1AXTbh0CnXljFZHamvNqchZqrj5njKzmnjIL6URBd_qCpNe04jYUf7oOdpm3Nt8Z7/s1242/20210821_211147000_iOS.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="422" data-original-width="1242" height="109" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBEWoh-CImsHZA4OfghD6LcrVs8EAOQF6c9TM-MEM2qBR8Eo0kDN1xvgCX-j6pliM_kWj1yHhh4gw1AXTbh0CnXljFZHamvNqchZqrj5njKzmnjIL6URBd_qCpNe04jYUf7oOdpm3Nt8Z7/s320/20210821_211147000_iOS.jpg" width="320" /></a></div><p></p>To give you some idea of just how busy hospitals are on their COVID floors/wards; as soon as my discharge orders came in they started clearing out my room and getting ready to clean/sanitize it for the next patient who had been waiting in the ER.<div><br /></div>A bit more in support of the C-19 vax. My wife has Alzheimer’s and we are rarely more than 6’ away from each other. We eat, sleep, sit and shower together. We were also vaccinated together. Even though my suppressed immune system allowed me to catch C-19, my wife did not. Vaccines really do save lives.<div><br /></div><div>Ten days on a C-19 floor give a person plenty of time for reflection, prayer and reading the Bible. I am blessed in so many ways. I have a wonderful wife and live in community that supports the both of us. I am still here 6 years past my expiration date and each challenge we have faced over these years has been met with faith and the skill of my wonderful Team. Like Skillet sings in the song You Ain't Ready, "<i>What doesn't kill me makes me who I am"</i>. </div><div><br /></div><div>If you have any questions about my experience with COVID so far, please ask. I'll do my best to answer in the comments.</div><div><br /></div><div>Being a lung transplant recipient, with CLAD BOS-3, on Extracorporeal Photopheresis who has had SARS-COV-19, gives me the opportunity to participate in a couple more clinical studies. One of these days I'll have to write a post on all the studies/trials I've been a part of over the years. I've commented in the past that I wanted to be the subject of one of my Team's papers, but now I'm not so sure :)</div><div><br /></div><div>Have an awesome day my friends.</div>John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com0tag:blogger.com,1999:blog-4878517487148484304.post-78856528145779041792021-01-11T09:21:00.000-06:002021-01-11T09:22:02.130-06:00Lung Transplants and Self Image<p> I saw this beautiful post on Facebook that both celebrated a two year anniversary and talked about body image with a post transplant body. Shared with permission.</p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgFHMSYLM0d3_VgB25YtsUM00zROp8OvaO4DqLFVfnfqJVUJHPjl0EjDuaiiOivrSDYCfj4-4ihBMH7XGk6YAqPT5YJ2eODG0p6FgOk2iv8r1XT9CWs_xiFFJJjyMJnD5P2KxH8nBkp2IaS/s619/Kassandra+ltx.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="588" data-original-width="619" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgFHMSYLM0d3_VgB25YtsUM00zROp8OvaO4DqLFVfnfqJVUJHPjl0EjDuaiiOivrSDYCfj4-4ihBMH7XGk6YAqPT5YJ2eODG0p6FgOk2iv8r1XT9CWs_xiFFJJjyMJnD5P2KxH8nBkp2IaS/s320/Kassandra+ltx.png" width="320" /></a></div><br /> <div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh5VgPVglRawq7N2aiuAAS6_clJrbtmCZ7q3Mbzgk_Hp7n0ItFQYqzYLHNRimHz_qlufjkymGGWwBQgZ4WehcGe691WqtH-X-BF18c7eF-IJZqVEE2Z9CxXomL7gO10OGj1FDvVGsSAKZhV/s1528/Kassandra+ltx1.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1528" data-original-width="1284" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh5VgPVglRawq7N2aiuAAS6_clJrbtmCZ7q3Mbzgk_Hp7n0ItFQYqzYLHNRimHz_qlufjkymGGWwBQgZ4WehcGe691WqtH-X-BF18c7eF-IJZqVEE2Z9CxXomL7gO10OGj1FDvVGsSAKZhV/s320/Kassandra+ltx1.jpg" /></a></div><br /><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSiLoDuIw6Xl2DK2R2LkyvGkdfUZoRu0pHXVcbELMErrJ8zzGaQzyDkttL_Lr7O2OOhWN0Q5b0xbAIXmQmAvuyIQ9wWUErMTSosVanCsS4kvjndE0dye-8_1HUJetPLBGNqxaJzrggDPwy/s1088/Kassandra+ltx2.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1088" data-original-width="777" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSiLoDuIw6Xl2DK2R2LkyvGkdfUZoRu0pHXVcbELMErrJ8zzGaQzyDkttL_Lr7O2OOhWN0Q5b0xbAIXmQmAvuyIQ9wWUErMTSosVanCsS4kvjndE0dye-8_1HUJetPLBGNqxaJzrggDPwy/s320/Kassandra+ltx2.jpg" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiR9eRZ71BepdyLXwZyDh0u-MZxPmuNBlY2IrvrqN9e2JNUOfwv0oMOlMnmn0RS_xc01IlHUhYzyVCBPUaEEoOWOpuLCLFK-sBgYZFrt-jTr2VabSVZeVXeK4ZmitTM_XV_57OBUGiTzc5-/s1284/Kassandra+ltx3.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1256" data-original-width="1284" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiR9eRZ71BepdyLXwZyDh0u-MZxPmuNBlY2IrvrqN9e2JNUOfwv0oMOlMnmn0RS_xc01IlHUhYzyVCBPUaEEoOWOpuLCLFK-sBgYZFrt-jTr2VabSVZeVXeK4ZmitTM_XV_57OBUGiTzc5-/s320/Kassandra+ltx3.jpg" width="320" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjc0U0lqARxNkN70mSv49SFJyyMHt1k5kc_Ouh3VNw1XUruYozEfZc2jYciXY1boq3j40AiGYyX754u27xr44Bkfua4Al-O9WW9VYRomdcL4YH_M-zrIkk64vurXd0Z1XQen3ze3fufGgGm/s1355/Kassandra+ltx4.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1355" data-original-width="968" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjc0U0lqARxNkN70mSv49SFJyyMHt1k5kc_Ouh3VNw1XUruYozEfZc2jYciXY1boq3j40AiGYyX754u27xr44Bkfua4Al-O9WW9VYRomdcL4YH_M-zrIkk64vurXd0Z1XQen3ze3fufGgGm/s320/Kassandra+ltx4.jpg" /></a></div><br /><p>Kassandra's post got me to thinking about my own body and self images. It also got me thinking about how the procedures I've undergone, and the medications I take, have changed my body.</p><p>Each of my scars is a story. They are a permanent journal of my <a href="https://primaltransplant.blogspot.com/2016/11/an-advance-in-diagnosing-ipf.html" target="_blank">VATS Biopsy</a>, my <a href="https://primaltransplant.blogspot.com/2016/06/my-lung-transplant.html" target="_blank">lung transplant</a>, and my <a href="https://primaltransplant.blogspot.com/2017/05/nissen-fundoplication-update.html" target="_blank">Nissen Fundoplication</a>. They pair nicely with my earlier scars, keloids from burns when I was 4 years old, scars from a motorcycle wreck or two, and playing sandlot football. Like Skillet sings in their song "<a href="https://youtu.be/1obJEVDUeM0" target="_blank">You Ain't Ready</a>", "What doesn't kill me makes me who I am". These scars and my tattoos are a good visual record of who I am.</p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGV1vdIUhKp7DTPqlaUlmEKNsTq6F1hmc7kEG6W2bLb4kblZk17xAvI8bInb13CNm5NVI7oQzAH62gDP6VBKyIxuC7_Tb2UrretBy59aYnIzNgxFnW6xM1w_jBft46b5g9j43FMCsgO28f/s678/TX3.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="377" data-original-width="678" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGV1vdIUhKp7DTPqlaUlmEKNsTq6F1hmc7kEG6W2bLb4kblZk17xAvI8bInb13CNm5NVI7oQzAH62gDP6VBKyIxuC7_Tb2UrretBy59aYnIzNgxFnW6xM1w_jBft46b5g9j43FMCsgO28f/s320/TX3.png" width="320" /></a></div><br />This is me still swollen from my lung transplant. I had to lose a lot of weight to be transplanted and at the time of my surgery I was still heavy, and being swollen kinda makes me look like a grape. After my procedure I continued to lose weight until I got to a healthy goal. <p></p><p>Here I am healed and at (or at least near) my goal weight:</p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEivq_IjfOW9E9gHpvXntZTWeiyqaKNdafN-frKYdBuFgGJLOCTuy6ZOZblDP3NBQ-vaXeP4qeNcr7uHvZfKeJXTwOmvc0LWMvQ3dk0ABOr8Dn6blki3x6JGDBtcDkscPqzJEeMgExplGhhd/s769/TX5+small.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="391" data-original-width="769" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEivq_IjfOW9E9gHpvXntZTWeiyqaKNdafN-frKYdBuFgGJLOCTuy6ZOZblDP3NBQ-vaXeP4qeNcr7uHvZfKeJXTwOmvc0LWMvQ3dk0ABOr8Dn6blki3x6JGDBtcDkscPqzJEeMgExplGhhd/s320/TX5+small.png" width="320" /></a></div><br /> As you can see, lining up my nipples wasn't a very high priority when they put me back together 😎 what you can't see is that the nerves to my nipples are damaged and they are always sore. Loose fitting shirts with stiff/rough fabric really bothers them and some things that used to be very enjoyable can now be quite painful. Another thing you can't see is how they lined up my ribs after the procedure. My left side is perfect. I can tell where I was split, but even by feeling most people probably couldn't. My right side is a little out of line. If someone looks for it now they could probably pick it out, if they felt for it they would definitely be able to tell. I can also feel my Clamshell Sternometry Wires. None of this is a big deal and sure beats what would have happened without the transplant.<p></p><p>My intent with this post was to follow Kassandra's example and share some of the post transplant realities that do have an effect on my self/body image. </p><p>I spend one heck of a lot of energy trying to appear 'normal' when out and about. Losing 60% of my post-transplant highest lung function due to my chronic rejection is hard to hide. I walk slower than most, and if I try to walk faster I end up out of breath and having to take a break. I'm also about 15 pounds heavier than where I look and feel at my best. My team wants this weight so when things go sideways for a bit I have the energy reserves available to comfortably get to the other side. </p><p>I guess that the main thing that bothers me is my voice. Between the transplant, all the bronchoscopies, and the various other ...scopies with cameras and probes down my throat, my voice isn't what it should be. Phone conversations and even some in-person conversations can be difficult. My voice is the one thing that I am really self conscious about.</p><p>I've lost a lot of bone density due to the meds and I'm over 1" shorter than I was pre-transplant. The prednisone has made my skin pretty thin, and avoiding the sun makes me pale. I'm on Warfarin since the Pulmonary Embolism, so when someone misses an IV poke, the blood splotch can last for over a month. My spleen is enlarged, it's grown enough that you can tell just looking at me if you know what to look for. We're not sure what is causing that, but not much to do about it at the moment. So if someone's paying attention, they can tell that I'm not 'normal' healthy.</p><p>Like Kassandra mentioned, acne is a thing with the meds. I get it on my face and chest. Sometimes it's painful acne</p><p>In reality, any body or self image issues I may have after my transplant are insignificant compared to life before transplant. I almost feel guilty talking about them, almost like I'm disrespecting this wonderful gift given to me by my donor family. I am alive, and I am in much better shape than I was for at least a year prior to my transplant. I'm able to take care of my Sweetie and share in our children's and grandchildren's lives. Life really is good, and even though I'm not 'normal' healthy, I am enjoying being post-transplant, on long term steroid and immunosuppressants, and being treated for chronic rejection healthy 😎</p>John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com0tag:blogger.com,1999:blog-4878517487148484304.post-89134417359699664592021-01-04T19:55:00.000-06:002021-01-11T08:21:18.988-06:00Annual Exams<p> January 1st marked the 6th anniversary of my lung transplant. If you want to know more about the procedure, I wrote about it <a href="https://primaltransplant.blogspot.com/2016/06/my-lung-transplant.html" target="_blank">here</a>. An important part of living life with new lungs is all the monitoring we undergo to check how our lungs are doing and how the rest of our body is handling all the medications we take. Every year we have our annual examinations and I started mine today.</p><p>Today was labs (a few vials of blood and 22 results so far), two ultrasounds, a CT scan and a chest X-ray. A couple of routine tests that are normally done are being postponed this year due to COVID. This is both to minimize exposure and free up resources for more important things. I have a bone density test and the full pulmonary function test along with arterial blood gas next month. I expect the bone density test to show more loss due to my meds, and the PFT should be similar to last year's, except for maybe DLCO.</p><p>Now, why do I expect the PFT to be similar to last year when I am in chronic rejection? Drum roll please... Because my CT scan indicated that my lungs are stable, with no changes from last year.</p><p></p><blockquote>Lungs and pleura: No pleural effusion is seen. Right upper lobe collapse with underlying bronchiectasis is again seen. <b>Stable</b> right middle lobe volume loss noted. <b>Stable</b> tubular density within the lingula with associated scarring noted. <b>Stable</b> reticulation within the periphery of both lower lobes noted. Few scattered punctate nodular densities are <b>stable</b> bilaterally. Air trapping again noted. <b>No new</b> pulmonary lesions identified.</blockquote><p></p>That result is just plain awesome. The upper lobe in my right lung collapsed 4 times in 2018 before it became permanent and the middle lobe issue occured in 2019. I'm very happy the middle lobe issue hasn't progressed and there are no indications of progressing chronic rejection. My home spirometry 0n 1/1/20 and 1/1/21 are basically the same. If you average my spiro results from the 1st week of 2020 and average the results from the 1st week of 2021, my home spirometry has actually up just a tad. Add the CT result to my home spirometry, and it's looking like the <a href="https://primaltransplant.blogspot.com/2019/12/ecp-trial-news.html" target="_blank">ECP Clinical Trial</a> I'm participating in is working. This is very exciting news for me, and for the lung transplant community. Having a potentially effective treatment for chronic rejection gives hope for many of us. <div><br /></div><div>Lung transplant chronic rejection is referred to as Chronic Lung Allograft Dysfunction (CLAD) and my subtype of CLAD is Bronchiolitis Obliterans Syndrome (BOS). My designation is CLAD stage 3, BOS. For an explanation go to <a href="https://www.jhltonline.org/article/S1053-2498(19)31432-9/fulltext" target="_blank">Chronic lung allograft dysfunction: Definition, diagnostic criteria, and approaches to treatment</a>. </div><div><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgXB7Wln2ORHnhI_GcuMRHNGX0Ipl5ksoBXk7-aHW4t8EtBrbByzYtQvPEALFpeBwoNLauTWCUNDpmNfT-YYMcc2B0BCMkOaHF4h17kF_RbJBjl7oeZ8_W9y8V5uqVlh_KFCcYtVrSOJijj/s798/Oct+X-Ray.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="734" data-original-width="798" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgXB7Wln2ORHnhI_GcuMRHNGX0Ipl5ksoBXk7-aHW4t8EtBrbByzYtQvPEALFpeBwoNLauTWCUNDpmNfT-YYMcc2B0BCMkOaHF4h17kF_RbJBjl7oeZ8_W9y8V5uqVlh_KFCcYtVrSOJijj/s320/Oct+X-Ray.png" width="320" /></a></div><br /><div><br /></div><div>I tried to find a cool image for CLAD to post, but didn't find anything interesting so here is my chest X-Ray from last October.</div>John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com0tag:blogger.com,1999:blog-4878517487148484304.post-61646340695393889352020-12-28T12:08:00.020-06:002021-09-17T18:40:29.787-05:00Vaccine Emotions<p>There are quite a few emotional roller coaster rides associated with being a lung transplant recipient. The latest one I've hopped on is over the COVID-19 vaccine. I am enrolled in a <a href="https://transplantvaccine.org/" target="_blank">National Vaccine Research Study for Transplant Recipients</a> that will study COVID-19 antibody levels in transplant recipients
who get the COVID-19 vaccine. If I'm going to get the vaccine, might as well donate some data (blood) to science.</p><p>Last week the community we live in announced that they will be offering the vaccine sometime soon, then on Christmas Eve we found that the vaccine is scheduled for the 30th. Trigger the excitement emotion. I notified my Transplant Team and the Study Team. Since it was Christmas Eve, I just heard back from my Team. And... they haven't yet come to a consensus on recommending the vaccine to their patients. Trigger the disappointment emotion. Hopefully they will make a decision soon as I will have to cancel if they haven't come up with a recommendation by Wednesday. I do understand their hesitancy in recommending the vaccine without more definitive data, but it sure would be nice to be able to go our and about again without being as 'at risk' as we are now. </p><p>COVID-19 has been very hard on the solid organ transplant community. The overall mortality rate for someone who has had a transplant and is hospitalized for C-19 is <a href="https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1097/5885162" target="_blank">around 20%</a>. Much higher for lung transplant recipients. So yes, a trip to the pharmacy or store has to include a risk/benefit analysis. This is why the anti-maskers and COVID deniers are so dangerous to us. We have to do some things that involve interaction with the public, and their disregard to the most basic public safety protocols puts us at risk.</p><p>I could really jump up on my soapbox about the idjits who put us all at risk, but this is not the post for that. This does highlight another emotional part of the vaccine roller coaster, a bit of anxiety about being infected before we get the full effects of the vaccine. </p><p>And no, the vaccine isn't some sort of magical COVID shield. It's 90% effective in healthy individuals, likely less in the immunocompromised. Let's assume it is only 70% effective for us, this still makes us much less likely to be infected by incidental contact with the virus. Add a basic mask (30% effective) and our risk is reduced by 79%. Add in handwashing and social distancing, we can really minimize our risk and be able to see our loved ones and maybe even have a meal at a favorite restaurant. A bit of normalcy will be awesome.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjWnFAub_qPdMWT0jMxt_rYBmLleRT0kDR_Q2f-8nOi0wxbnNy7RZqB0pYl-VzK5vC6lE9KKNULSzlxRU7V8jE94aa4WYlIGN8C4X1dleIvFIKinQoz2xXXnvwT7SYG0d3ko2gcc55xA7-/s960/vaccine.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="540" data-original-width="960" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjWnFAub_qPdMWT0jMxt_rYBmLleRT0kDR_Q2f-8nOi0wxbnNy7RZqB0pYl-VzK5vC6lE9KKNULSzlxRU7V8jE94aa4WYlIGN8C4X1dleIvFIKinQoz2xXXnvwT7SYG0d3ko2gcc55xA7-/s320/vaccine.jpg" width="320" /></a></div><br /><p>Update: I had to cancel my vaccine appointment for tomorrow. I had to let them know if my Transplant Team had approved by early this afternoon, and that didn't happen. The Team just doesn't have the data yet to make the recommendation for me. Since I am participating in the ECP Clinical Trial there are other factors that need to be taken into consideration before I get the vaccine. So back to my cave I go.</p><p>Update to my update: Just after posting the previous, I received a call from the Team telling me I could go ahead and get the vaccine. Talk about an emotional roller coaster.</p><p>Update #3: Since I am getting the COVID-19 Vaccine tomorrow, I drew my first blood sample for the research study I mentioned earlier. Here's the kit I received in the mail today:</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiD3mP4iIn0jkIbyEFskpZuqWKYKFEaHGmBB8MOAJeXZhZKSJ-BUwVmwf4RJGFgdeqkEosIpe-YV-sfLFKRWQIHb1gNPUHvUWOSpyREvTf9zYz5fKaAfN-MDPOWwwH9lxTNVrOObi03sKPe/s2048/IMG_1517.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2048" data-original-width="1536" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiD3mP4iIn0jkIbyEFskpZuqWKYKFEaHGmBB8MOAJeXZhZKSJ-BUwVmwf4RJGFgdeqkEosIpe-YV-sfLFKRWQIHb1gNPUHvUWOSpyREvTf9zYz5fKaAfN-MDPOWwwH9lxTNVrOObi03sKPe/s320/IMG_1517.jpg" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">And here is the video of how to perform the blood draw:</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: center;"><iframe allowfullscreen="" class="BLOG_video_class" height="266" src="https://www.youtube.com/embed/iXQ1Z3Z-5O0" width="320" youtube-src-id="iXQ1Z3Z-5O0"></iframe></div><br /><div class="separator" style="clear: both; text-align: left;"><br /></div>Blood sample is drawn and delivered to FedEx. An interesting alignment of C-19 procedures is happening at the same time tomorrow. We get random COVID tests and ours came up for tomorrow, so we'll get swabbed then injected.<div><br /></div><div>Update #4: I have to admit to a surprising bit of baseline anxiety this morning. I am excited about the opportunity to get the vaccine and maybe get back to normal sooner rather than later. Being amongst the first lung transplant recipients, and likely the first who is also receiving Extracorporeal Photopheresis (ECP) to get the vaccine, does trigger the anxiety snake. Writing about it helps.</div><div><br /></div><div>Update #5: We received the first dose of the Pfizer vaccine. Initial side effects... relief, and some hope that we might be able to hang out with our grandchildren this summer.</div><div><br /></div><div>Update #6: It's coming on 6 hours since my vaccination and all is stable. Temperature, blood pressure, lung function, and heart rate and rhythm are all good to go. I was a bit tired earlier, and there is a minor amount of soreness at the injection site, but just another Wednesday evening here at Casa JR.</div><div><br /></div><div>Update #7: 26 hours since the vaccination. So far the side effects are pretty much right in between what I get for the flu shots and the pneumonia shots. The only thing happening is a slightly sore arm at the injection site. It's likely that my suppressed immune system would slow any immune system reaction to the vaccine. I had some concern about any effects my ECP treatments would have but everything seems to be just fine. A bonus about participating in the vaccine research study I mentioned above is that they will give us our test results during the study. It will be interesting to see how my immune system reacts to vaccine over time.</div><div><br /></div><div>Vaccine Dose #2 - I received the second dose of the Pfizer vaccine today. Hopefully I'm about 3 weeks away from returning to some form of normalcy. For me normalcy means still wearing a mask when out and about and using hand sanitizer/washing hands, but I will be able to go out. That is pretty cool.</div><div><br /></div><div>So far, about 2 hours post vaccine, the only side effect is soreness at the shot site. It is more noticeable than with the 1st dose. As with the 1st dose I'm taking Tylenol and Benadryl to help minimize any potential side effects.</div><div><br /></div><div>Dose #2, Update #1: I had no issues overnight. The only noticeable side effect is soreness at the injection site. It is probably the same as my pneumonia shot, a little more noticeable than after the first dose. </div><div><br /></div><div>Vaccine Dose #3 - Today I went in for my 3rd dose of the Pfizer vaccine. Solid organ transplant recipients and other immunocompromised folk are able to get a 3rd dose. It is important for us as we don't build up antibodies as easily or rapidly as healthy people. While I was there I also received the flu shot.</div><div><br /></div><div>Eight hours post vaccine I have had nothing noticeable in the way of side effects. Temperature and blood pressure have been stable. I did take Tylenol prior to the shot, and had a Starbucks Refresher after. Haven't taken Benadryl this time around as I no histamine reactions from the 1st two doses.</div>John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com0tag:blogger.com,1999:blog-4878517487148484304.post-15043903674275304762020-12-13T09:54:00.001-06:002020-12-13T09:54:48.563-06:00An Update From the Casa<p> It has been awhile since my last update, I'm really sorry about that.</p><p>We have been busy and have gotten lots done. As I've mentioned previously, my Sweetie has Alzheimer's. Her disease has progressed to the point where she really shouldn't be left home alone during my hospital stays. My Team has been really good about letting her stay with me when I am at my home away from home, but it is hard on her and adds stress to both myself and my Team. So... we've moved into a retirement community. Our new home is at <a href="https://www.atriaseniorliving.com/retirement-communities/atria-canyon-creek-plano-tx/" target="_blank">Atria Canyon Creek</a> in Plano. As you can imagine, there was a lot of emotions involved with the idea of moving and the process of packing and the move itself, but now that we are here my Sweetie is enjoying our new home. I've also hired some homecare help. Right now we have someone in once/week for 4 hours in the morning. This is to help my Sweetie get acclimated to having someone else around helping with our routine. If needed, we are set up for daily help. Two shifts at four hours each. First shift in the morning and second in the evening to help ensure V (my Sweetie) gets her meds, eats, can watch her shows on TV and get to bed. Financially this puts us at our very limit, there is zero money for anything else but the amount of stress that has been taken off of my shoulders from worrying about V and her future is well worth it.</p><p>Health wise I am doing very well. The <a href="https://primaltransplant.blogspot.com/2019/12/ecp-trial-news.html" target="_blank">Extracorporeal Photopheresis (ECP) Clinical Trial</a> has stabilized my chronic rejection. I really surprised myself during the move by being able to do much more physically than I imagined I could. Our daughter really helped us out by sending a person to help pack out the kitchen and providing movers to move the majority of our stuff. We did move a few Jeep loads by ourselves and I packed the rest of the house and unpacked everything. I had an issue with inflammation affecting my lung function (likely due to stress) so did a steroid taper. A week or so after the taper I started having a real hard time getting good numbers when doing my daily lung function testing. All of my other vitals were good. No temperature, blood pressure and heart rate were good, and home EKG was normal (for me). My incentive spirometry was down a small amount, but not by much. So I worked on getting my lung function up, blowing spiros and using my incentive spirometer throughout the day. I started having muscle spasms in my mid back and my diaphragm felt like it was being pulled up. These are some of the symptoms I had when the upper lobe of my right lung was collapsing (happened 4 times before it became a permanent thing). So I went into the Clinic for an X-ray and spirometry. My clinic spiro was great and my lungs looked really good. After some investigating it turns out that my home spirometer was failing and that I had irritated my diaphragm and caused the strained/spasming muscles through effort. I'm still sore but with a new spirometer not worried :) I've always depended on instrumentation and the data it provides in my professional life and my health journey. It's really bothersome when instruments fail me. On a bright note, It is kind of cool that I've outlived my spirometer.</p><p>I was able to (virtually) attend an Advanced Lung Disease medical conference last weekend. If you are an organ transplant recipient, or are around someone who has received an organ transplant, please continue to be very careful and aware of COVID-19. Despite what a lot of the click bait opinion sites state, C-19 is devastating and especially hard of the solid organ transplant community. Take care out there. We haven't gone through what we have, and do what we do, to be taken out by a virus that can be contained if everyone would just try to help out and contain it.</p><p>Thanks for reading, appreciate you.</p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi7p6K0y5FZiElP7Pf-xak_4sxeZCk8YDWFwHjTYXsViZtP0hEzOcr_tLGeit-feRBRGsL6UGerLIzL0x60xVswkuxWPhyYVC45UFiojsMpfzoYZUcKt61XE8ozNuYs0abAMS5vOxxgF3H9/s2048/IMG_1468.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2048" data-original-width="1536" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi7p6K0y5FZiElP7Pf-xak_4sxeZCk8YDWFwHjTYXsViZtP0hEzOcr_tLGeit-feRBRGsL6UGerLIzL0x60xVswkuxWPhyYVC45UFiojsMpfzoYZUcKt61XE8ozNuYs0abAMS5vOxxgF3H9/s320/IMG_1468.jpg" /></a></div><br /> <p></p>John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com0tag:blogger.com,1999:blog-4878517487148484304.post-24793860233119898372020-08-03T19:04:00.003-05:002020-08-03T19:04:54.134-05:00The Roller Coaster Ride That is 2020<div>January 1st was the 5th anniversary of my life with new lungs. Celebrating 5 years of a wonderful life that I wouldn't have without the wonderful gift offered by my donor family, the ongoing skill and care of my Transplant Team, and the grace of our Lord.<br /><br />This chart of my lung function over the past 5 years is a good visual diary of my life with new lungs.<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_bf785lwXF36MVpB_l3gq9YuTZ8hKIkVa3hZk4bQWHpK5gT8Xin2Fv7EWHgvKhh_hbJQqBdGxaRr_O9NlbVJt4rPlbKB1TFl1NePJQ0xUGYB7itQVZA_bWsqueAQvkViUIJ7YIw2ILYRo/s1600/Screen+Shot+2020-02-12+at+6.22.42+PM.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="458" data-original-width="1600" height="91" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_bf785lwXF36MVpB_l3gq9YuTZ8hKIkVa3hZk4bQWHpK5gT8Xin2Fv7EWHgvKhh_hbJQqBdGxaRr_O9NlbVJt4rPlbKB1TFl1NePJQ0xUGYB7itQVZA_bWsqueAQvkViUIJ7YIw2ILYRo/s320/Screen+Shot+2020-02-12+at+6.22.42+PM.png" width="320" /></a></div></div><div><br /></div>Since January 1st, 2020 has been one heck of a roller coaster ride. Seriously, we've been up, down and all around.<div><br /></div><div>January started our nice enough. The main thing I was worried about was monitoring the flu season and doing the routine things I do to avoid the flu. My lungs were doing very well, the <a href="https://primaltransplant.blogspot.com/2019/12/ecp-trial-news.html" target="_blank">ECP Clinical Trial</a> I'm participating in seemed to be effective. My lung function had stabilized and I was feeling good.</div><div><br /></div><div>Near the end of January came the first steep drop on the the roller coaster, I had a <a href="https://primaltransplant.blogspot.com/2020/01/pulmonary-embolism-my-latest-adventure.html" target="_blank">Pulmonary Embolism</a>. This was my 1st ambulance ride to the hospital, and ended up being my 3rd trip to the UTSW ICU. We caught the PE early so that there was no permanent damage to my lungs or heart. We have my blood thinner dose lined out and other than the fact that I get bruised by a strong breeze and bleed a bit excessively when cut, I'm fully recovered from that little event.</div><div><br /></div><div>I was back to feeling good when my blood pressure and pulse dropped to pretty low levels. This time the ambulance was hesitant to go all the way into Dallas, but after a call from my team and the fact that they got me stabilized, I did end up back at my home away from home, the 10th floor of UTSW. This trip was due to a mineral imbalance and dehydration. I was also having a lot of <a href="https://www.mayoclinic.org/diseases-conditions/premature-ventricular-contractions/symptoms-causes/syc-20376757" target="_blank">PVC's</a> at the time. We got that lined out, changed my supplements and boosted my water intake up to 3-4 liters/day. That's a lot of water. The water really helped my kidneys (stage 3 CKD due to meds) and dropped my Creatinine levels. A side effect of all that water is that my legs are now a bit swollen.</div><div><br /></div><div>After we got that issue lined out, I was feeling really good. As a matter of fact I was feeling better than I had in a long time. I was enjoying that ride to the top of the roller coaster. Then in June I was back to the hospital. This time my blood pressure was high and I couldn't get it under control with my normal meds. It took a few days in the hospital to get things back under control. The trigger of this episode may have been a Rhinovirus. Yeah, a stinking cold. That's the direction we went and I was back home and once again feeling good.</div><div><br /></div><div>I've had a couple more episodes of higher blood pressure, but my Team has given me the tools to address this issue. I now have the ability to take an EKG at home and this tool gives me a lot of comfort when things just don't feel right. With everything I am able to monitor, I can usually identify and address minor issues quickly.</div><div><br /></div><div>Last week I did a Barium Swallow Test to ensure that my swallower was still working, it is. I was also finally able to get in to see my Dermatologist. I had been seeing my Dermatologist once every 3 months. Last October we decided to go 6 months between visits over Winter, then COVID restrictions hit and my appointment got pushed back to last week. There were a few spots that needed frozen off, and one spot that required a biopsy. The biopsy indicates that I have a Squamous Cell Carcinoma that will have to be removed. Not a major issue and we'll get it taken care of soon.</div><div><br /></div><div>Some good news for the year is that I have completed the <a href="https://primaltransplant.blogspot.com/2019/12/ecp-trial-news.html" target="_blank">ECP Clinical Trial</a> and am now getting monthly Extracorporeal Photophereses treatments as maintenance. ECP does not cure or reverse chronic rejection, but it does seem to have paused it for awhile. My pulmonary function has been stable for 2020. That is an awesome achievement for a lung transplant recipient who has <a href="http://www.lungtransplant.utoronto.ca/Post_Transplant_Issues/Chronic_Lung_Allograft_Dysfunction__CLAD_.htm" target="_blank">Chronic Lung Allograft Dysfunction (CLAD) BOS3</a>. The 'BOS3' just means that I've lost more than 50% of my highest post-transplant lung function. We've worked hard to get me to this point, and I really appreciate all that my Team has done to help keep me healthy.</div><div><br /></div><div>As 2020 continues on, I'm sure the roller coaster ride will continue with it's dramatic highs and rapid drops. Just so long as we end up near where we started, we'll be alright.</div><div><br /></div><div>We do need to get a handle on stopping the spread of COVID-19. We almost had it under control, then came Memorial Day, and that's the day that the United States pretty much said "Screw it, time to party". All organ transplant recipients are in the "High Risk" demographic for COVID-19, lung transplant recipients especially so.</div><div><br /></div><div>Please wear a mask when you are around people you don't live with.</div><div><br /></div><div>Please maintain some distance from people you don't live with. 6 feet is an easy distance to visualize and is within easy talking distance from your friends.</div><div><br /></div><div>Please wash your hands after touching something that people you don't live with have touched.</div><div><br /></div><div>Getting everyone on board with doing these three simple things would go a long ways toward slowing the spread of this disease and saving lives.</div>John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com3tag:blogger.com,1999:blog-4878517487148484304.post-81615258848962807672020-03-20T14:56:00.001-05:002020-06-03T08:05:48.360-05:00COVID-19 and Lung Transplant <span><a name='more'></a></span>Scary times for lung transplant recipients and others with compromised immune systems. It seems that there is new information on COVID-19 coming at us hourly, and none of it is very positive. It's getting kind of scary out here. On a positive note what the rest of the world is considering a new normal of social isolation and infection control, we have been practicing since day 1 post-transplant.<br />
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We've been wearing masks, using hand sanitizer and washing our hands long before it was cool. Now we just have to tighten things up a bit. A message from my Team:<br />
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<i><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">To all Lung Transplant Patients</span><span style="box-sizing: border-box; color: #5b5b5b; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">:</span></i><br />
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<i><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">We write to share with you specific instructions with respect to COVID-19 given your medical history. While the severity of COVID</span><span style="box-sizing: border-box; color: #5b5b5b; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">-</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">19 infection is highly variable, it is especially severe among patients with complex medical problems</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">and</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">weakened</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.2px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">immune systems,</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.733333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">both</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.4px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">of</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.866667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">which</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.13333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">apply</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.2px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">to</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 0.133333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">you</span><span style="box-sizing: border-box; color: #5b5b5b; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">.</span><span style="box-sizing: border-box; color: #5b5b5b; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 2.6px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">As</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.933333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">a</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.06667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">lung</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.53333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">transplant</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.6px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">patient,</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.933333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">this</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.26667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">puts</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.26667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">you at</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">a</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.6px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">high</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">risk</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.933333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">of developing</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.33333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">the</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 0.533333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">most</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">severe</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">form</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.06667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">of</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">the</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.866667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">disease</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.466667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">from</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.26667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">this</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.533333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">virus.</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">Unfortunately,</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.26667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">we</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.4px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">do</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.26667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">not</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.266667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">have</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">any approved</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.4px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">medications</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.466667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">to</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 0.533333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.6px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">this</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.26667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">disease</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.53333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">at</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 0.6px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">this</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.06667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">time.</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 1.06667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">Thus,</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.933333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">we</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.46667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">are</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.26667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">recommending the</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.133333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">following:</span></i><br />
<i><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;"><br /></span></i></div>
<div style="box-sizing: border-box; caret-color: rgb(54, 54, 54); color: #363636; font-family: arial; font-size: 17.3333px; margin: 0px; max-width: 100%; padding: 0px; text-size-adjust: auto; width: auto;">
</div>
<ol start="1" style="box-sizing: border-box; caret-color: rgb(54, 54, 54); color: #363636; font-family: arial; font-size: 17.3333px; margin: 0px; max-width: 100%; padding: 0px; text-size-adjust: auto;">
<li style="box-sizing: border-box; color: #3f3f3f; font-family: "times new roman", serif; font-size: 10pt; margin: 0px 36px 0px 54px; max-width: 100%; padding: 0px;"><div style="box-sizing: border-box; margin: 0px; max-width: 100%; padding: 0px; width: auto;">
<i><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">Please</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.66667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">stay</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.93333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">at</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.2px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">home.</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 0.6px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">That</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.53333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">includes</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.33333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">not</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.533333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">goingto</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">restaurants,</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.33333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">theaters,</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.93333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">games,</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.53333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">banks,</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.66667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.266667px; margin: 0px; max-width: 100%; padding: 0px;">malls</span><span style="box-sizing: border-box; color: #5b5b5b; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.266667px; margin: 0px; max-width: 100%; padding: 0px;">,</span><span style="box-sizing: border-box; color: #5b5b5b; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">work,</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.93333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">etc. Avoid</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.733333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">visitors</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.06667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">at home.</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 1.66667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">Only</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.666667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">leave</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">home</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.933333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">for</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.0666667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">absolutely</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.666667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">unavoidable</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.333333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">activities.</span></i></div>
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<li style="box-sizing: border-box; color: #3f3f3f; font-family: "times new roman", serif; font-size: 10pt; margin: 0px 12px 0px 54px; max-width: 100%; padding: 0px;"><div style="box-sizing: border-box; margin: 0px; max-width: 100%; padding: 0px; width: auto;">
<i><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;">Please have a designated person be your contact with the 'outside </span><span style="box-sizing: border-box; color: #5b5b5b; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.266667px; margin: 0px; max-width: 100%; padding: 0px;">.</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.266667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;">' </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">This caregiver also needs to be careful so that they do not get infected themselves. Try to avoid shaking hands if you meet people, avoid touching objects or touching your face. Practice regular and thorough hand washing wit</span><span style="box-sizing: border-box; color: #232323; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;">h </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">regular soap or use approved hand</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -2.33333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">sanitizers</span><span style="box-sizing: border-box; color: #797e7e; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">.</span></i></div>
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<li style="box-sizing: border-box; color: #3f3f3f; font-family: "times new roman", serif; font-size: 10pt; margin: 0px 24px 0px 54px; max-width: 100%; padding: 0px;"><div style="box-sizing: border-box; margin: 0px; max-width: 100%; padding: 0px; width: auto;">
<i><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">You</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.66667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">should</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.46667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">not</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.666667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">go</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -2.06667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">to</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.6px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; font-weight: bold; margin: 0px; max-width: 100%; padding: 0px;">elective</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; font-weight: bold; letter-spacing: -1px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">or</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.466667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">regularly</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">scheduled</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.733333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">follow</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.13333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">up</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -2px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">clinics</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.46667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">if</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.333333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.4px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">are</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.06667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">feeling</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.46667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">well.</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 0.4px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">Please</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.13333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">call the</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 0.2px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">transplant clinic</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.666667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">if</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.2px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">you</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.666667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">have</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.666667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">any</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">questions.</span></i></div>
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<li style="box-sizing: border-box; color: #3f3f3f; font-family: "times new roman", serif; font-size: 10pt; margin: 0px 6px 0px 54px; max-width: 100%; padding: 0px;"><div style="box-sizing: border-box; margin: 0px; max-width: 100%; padding: 0px; width: auto;">
<i><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">If</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">you</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.86667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">are</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.86667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">acutely</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.26667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">ill,</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -2.26667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">please</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.53333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">call</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.93333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.533333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">lung</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.66667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">transplant</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.6px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">clinic</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.86667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">or</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.13333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">send</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">a</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.66667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">MyChart</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.13333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">message.</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.26667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">Please</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.26667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">avoid</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.66667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">coming to the clinic without calling us. We want you to be safe and will guide you regarding where to come for the</span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 0.4px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">treatment.</span></i></div>
</li>
<li style="box-sizing: border-box; color: #3f3f3f; font-family: "times new roman", serif; font-size: 10pt; margin: 0px 6px 0px 54px; max-width: 100%; padding: 0px;"><i><span style="box-sizing: border-box; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;"><br /></span></i></li>
</ol>
<div style="box-sizing: border-box; caret-color: rgb(54, 54, 54); color: #363636; font-family: arial; font-size: 17.3333px; margin: 0px; max-width: 100%; padding: 0px; text-size-adjust: auto; width: auto;">
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<div style="box-sizing: border-box; caret-color: rgb(54, 54, 54); color: #363636; font-family: arial; font-size: 17.3333px; margin: 0px 12px 0px 6px; max-width: 100%; padding: 0px; text-size-adjust: auto; width: auto;">
<i><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">The</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.86667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">novel</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.4px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">coronavirus,</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.933333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">referred</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.933333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">to</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.266667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.86667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">the</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 0.733333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">COVID-19</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.533333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">virus,</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.46667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">is</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.33333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">spreading</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">rapidly</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.933333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">throughout</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.266667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">the</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.26667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">country</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">and</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.73333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">there are</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.46667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">now</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.06667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">multiple</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.2px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">confirmed</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.2px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">cases</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.2px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">infected</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.733333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">with</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.26667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">this</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.66667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.4px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">in</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.666667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">the</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.6px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">Dallas</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.33333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">County</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.666667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">in</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.2px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">addition</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.53333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">to</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.333333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">the</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.13333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">cases</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.13333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">in</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.133333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">Collin</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">and Tarrant County</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.06667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #5b5b5b; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">.</span></i><br />
<i><span style="box-sizing: border-box; color: #5b5b5b; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;"><br /></span></i></div>
<div style="box-sizing: border-box; caret-color: rgb(54, 54, 54); color: #363636; font-family: arial; font-size: 17.3333px; margin: 0px; max-width: 100%; padding: 0px; text-size-adjust: auto; width: auto;">
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<div style="box-sizing: border-box; caret-color: rgb(54, 54, 54); color: #363636; font-family: arial; font-size: 17.3333px; margin: 0px 12px 0px 6px; max-width: 100%; padding: 0px; text-size-adjust: auto; width: auto;">
<i><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">The</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.93333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">vi</span><span style="box-sizing: border-box; color: #5b5b5b; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">r</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">u</span><span style="box-sizing: border-box; color: #5b5b5b; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">s</span><span style="box-sizing: border-box; color: #5b5b5b; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.46667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">can</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.53333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">stay alive</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.2px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">on</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.66667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">inanimate</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.26667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">objects</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.13333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">such</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.4px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">as</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.73333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">door</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">handles,</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.53333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">arm</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.66667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.4px; margin: 0px; max-width: 100%; padding: 0px;">chairs</span><span style="box-sizing: border-box; color: #5b5b5b; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.4px; margin: 0px; max-width: 100%; padding: 0px;">,</span><span style="box-sizing: border-box; color: #5b5b5b; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.0666667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">and</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">table</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -2px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">surfaces</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">anywhere</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">from</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.6px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;">9 </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.2px; margin: 0px; max-width: 100%; padding: 0px;">hour</span><span style="box-sizing: border-box; color: #5b5b5b; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.2px; margin: 0px; max-width: 100%; padding: 0px;">s</span><span style="box-sizing: border-box; color: #5b5b5b; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.86667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">to</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 0.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.866667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">days.</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 1.13333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">There</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.666667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">are</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.26667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">reports</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">that</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.733333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">up</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.73333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">to</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.0666667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">40%</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.46667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">of</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 0.333333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">infected</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">patients</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.866667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">do</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.33333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">not</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.4px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">develop</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.533333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">symptoms,</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.866667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">but</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 0.6px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">some of these patients can still spread the infection to other people. This potentially contributes to the spread of this infection.</span></i><br />
<i><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;"><br /></span></i></div>
<div style="box-sizing: border-box; caret-color: rgb(54, 54, 54); color: #363636; font-family: arial; font-size: 17.3333px; margin: 0px; max-width: 100%; padding: 0px; text-size-adjust: auto; width: auto;">
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<div style="box-sizing: border-box; caret-color: rgb(54, 54, 54); color: #363636; font-family: arial; font-size: 17.3333px; margin: 0px 6px; max-width: 100%; padding: 0px; text-size-adjust: auto; width: auto;">
<i><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.933333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">these</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.866667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">characteristics</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.53333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">of</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.533333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">this</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.6px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">virus,</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.2px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">we</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.53333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">expect</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.4px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">the</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.2px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">infection</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.46667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">to</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.6px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">spread</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.06667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">over</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.533333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">the</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.4px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">next</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.333333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">few</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.13333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">weeks</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.06667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">and</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.933333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">additional cases</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.13333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">tobe</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 0.133333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">confirmed</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.46667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">locally.</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 1.66667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">We</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.6px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">cannot</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">predict</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.4px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">the</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.53333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">pace</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">and</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.46667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">extent</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.933333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">of</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.533333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">the</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.866667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">spread</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.866667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">of</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.4px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">the</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 0.733333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">virus</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.73333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">in</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.533333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">the</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: 0.0666667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">community, or the time it may take for its prevalence in the community to drop significantly. The worst case scenario of widespread</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.33333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">and</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.86667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">prolonged</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.6px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">community</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.13333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">spread</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.6px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">(people</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.46667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">to</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.533333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">people</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.86667px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">transmission)</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.6px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">placing</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -2px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">everyone</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.93333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">at</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.13333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">a</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1.8px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">significant</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -1px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">risk of getting</span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; letter-spacing: -0.733333px; margin: 0px; max-width: 100%; padding: 0px; white-space: pre-wrap;"> </span><span style="box-sizing: border-box; color: #3f3f3f; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">infected</span><span style="box-sizing: border-box; color: #5b5b5b; font-family: arial, sans-serif; font-size: 10pt; margin: 0px; max-width: 100%; padding: 0px;">...</span></i></div>
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It is now more important than ever that we track our health and are diligent about taking our meds. My Team requires that lung transplant recipients performs daily home vitals and spirometry. This is so very important. If you know how your temperature, blood pressure and lung function trends with the weather, allergies and other variables, you will recognize when something is wrong. If something is wrong, your Team can use your records to help quickly diagnose the issue. When I had a Pulmonary Embolism, my at home spirometry helped to quickly rule out other causes of my shortness of breath. <br />
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My Team has defined triggers for when we should contact them. Some prompt a MyChart message, others a call no matter the time, and others a call on the way to the ER. These triggers haven't changed. Any respiratory virus can be hazardous to us. This new variant of Coronavirus is more aggressive than most, but our defenses are the same.<br />
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If you wear a cloth mask, please make sure you wash it after use. <br />
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If you wear a paper procedure mask, only wear it once. If you must reuse a paper mask, wait days before reusing to allow any virus to die off before reusing.<br />
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I personally use a Neti Pot daily. A nasal rinse seems to help me.<br />
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These are scary times, but we can get to the other side. Listen to your Team, they have your best interest at heart. Our Teams are communicating with each other. No matter what country, the transplant community is a small one and they are sharing information. They are learning from each other and adjusting protocol as necessary.<br />
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Do I have worries? Oh yeah, plenty. Am I panicked? Nope. Just very cautious, and caution is warranted. Caution can save our lives :)<br />
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My biggest worry is a supply chain disruption, running out of meds is something I have no control over. What I can do is change any 30 day supply prescriptions to 90 day, and that is in process as I type.<br />
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Stay safe my friends. Comments and ideas are always welcome.<br />
<br /><span><!--more--></span>John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com0tag:blogger.com,1999:blog-4878517487148484304.post-68566346429630712932020-01-26T16:17:00.001-06:002020-01-27T21:10:06.879-06:00Pulmonary Embolism - My Latest Adventure 2019 was a really good year for me health wise. Yeah, I have chronic rejection, but I did not have an overnight stay in the hospital all year. That streak recently ended in a big way with an ambulance ride to my hospital.<br />
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The Cliff Notes version is that I had a Pulmonary Embolism (blood clot in my right lung). My Team decided to clear the clot using <a href="https://www.webmd.com/stroke/guide/thrombolysis-definition-and-facts#1" target="_blank">Thrombolysis</a> to deliver medication via a catheter right to the clot in my lung. This resulted in a two day stay in the ICU and quickly cleared the clot. I spent a few more days in the hospital while they got me stabilized and am now back home. I'm a bit wrung out, but not much the worse for wear.<br />
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Now for the long version if you are interested.<br />
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The day of my Pulmonary Embolism (PE) started out just like any other day. Woke up, took meds, did computer stuff and took more meds. I took a shower, shaved and all that stuff with no problems. It takes a little longer to get that routine done due to the rejection, but this did not take any longer or use more energy than usual. We went to lunch and on the way I stopped for gas. Other than a vagrant hassling me a couple of times, getting gas was issue free. We went to Raising Cane's Chicken Fingers for lunch, and this is where the issues started. I got very out of breath just walking from the car into the restaurant. I ordered and sat down. When I went to pick up our food, I could hardly make it back to the table I was so out of breath. I asked my Sweetie to get to-go boxes as I wanted to get the heck out of there. By the time she got back to the table I was feeling a little better and tried to eat. I got one chicken tender down before I had to go. By the time we got home, I felt better, but still a bit out of breath. I took my vitals and my pulse was elevated into the mid 120's, blood pressure was pretty much normal, and my spirometry was normal. The normal spiro confused me, I thought I was having an acute rejection episode going on. I called my Team and they said to come into the ER. It's been so long that I've spent an overnight in the hospital that I didn't have a go bag ready. I went to get some stuff gathered and started having a really hard time. My heart rate went up to over 150 and I was scary out of breath. There was no way I could drive so called 911. The 911 operator was awesome. Lots of people can't understand me over the phone in the best of times, she got everything perfect, the first time. You may be wondering why my wife wasn't helping me more, she has Alzheimer's and was doing her best to keep me comfortable and help out. When the ambulance and fire truck arrived, I explained that I had to go to UT Southwestern and asked if my Sweetie could ride with us. They said yes to both which took a huge load off of my mind.<br />
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When we got to the ER they did the routine ER stuff. My team had already been in contact with the ER doctor and they were ready for me. I was sent for a CT of my lungs with contrast fairly quickly. My daily at-home vitals and spirometry, and the data I got prior to calling the ambulance, helped them narrow down the possible issues quickly and I did not have to have a bronchoscopy to rule out acute rejection. The CT Scan showed:<br />
<blockquote class="tr_bq">
There is an acute branching moderate-sized pulmonary embolus in the lateral and posterobasilar segmental arterial branches of the right lower lobe.</blockquote>
Basically a blood clot in the lower lobe of my right lung. While in the ER we did an ultrasound of my legs to check for DVT blood clots in my legs. There were none. A room opened up for me and I left the ER for the 10th Floor. The 10th floor at UTSW is my home away from home.<br />
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Since I'm a lung transplant recipient, it is important that we quickly clear the clot. I was placed on an IV of Heparin and scheduled for <a href="https://www.webmd.com/stroke/guide/thrombolysis-definition-and-facts#1" target="_blank">Thrombolysis</a>. Basically a catheter was inserted into my Jugular Vein, through my heart and into my Pulmonary Artery. The catheter was guided to the clot so medication could be administered right on the clot. The medication (tPA) was delivered through the catheter and Heparin was delivered via a sheath around the catheter. Now comes the rough part of this episode.<br />
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I was transferred from surgery to the ICU with my own nurse and everything. The major concern while receiving this clot buster medication is bleeding. Bleeding can happen anywhere so I was pretty much continuously monitored. Every half hour I had to answer questions about where I was at, what month/year it was... for signs of bleeding in my brain. All this time I am a bit out of breath and I have to admit that panic/anxiety tried to take over a couple of times through the night. An Ultrasound Tech came in to check for clots in my arms and shoulders and this really helped to break the cycle of panic and I was able to keep it from taking over. I was scheduled for them to go in and see how the clot was doing first thing in the morning. About an hour before I was supposed to go down for the procedure, I experienced severe nausea. Dry heaving over and over again. The regular anti nausea med didn't help much, but the second one took care of the issue and I was fine by the time I got back to surgery. When they went in to look at the clot it was gone so they were able to remove the catheter. That was a huge relief. One more night in the ICU for monitoring then I was back on the floor.<br />
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The goal when I got back on the floor was to get my Warfarin dose right to keep my <a href="https://www.mayoclinic.org/tests-procedures/prothrombin-time/about/pac-20384661" target="_blank">INR</a> in the therapeutic range.<br />
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From ambulance ride to ride home was Saturday to Saturday. I have a new med and new labs, but I'm not much worse for wear.<br />
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Like Skillet sings in the song "<a href="https://youtu.be/1obJEVDUeM0" target="_blank">You Ain't Ready</a>":<br />
<blockquote class="tr_bq">
"What doesn't kill me makes me who I am"</blockquote>
I am very thankful to my donor family for the gift of these lungs that have done me so well for the past 5 years, for my Team who work so hard to keep me healthy, and to the Lord for making everything right.John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com0tag:blogger.com,1999:blog-4878517487148484304.post-6931526564225447282019-12-05T18:16:00.000-06:002020-01-27T21:10:26.872-06:00ECP Trial News<br />
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Back in July I mentioned that I had been accepted into the observational arm of a <a href="https://clinicaltrials.gov/ct2/show/NCT02181257?id=NCT02181257&rank=1&load=cart" target="_blank">clinical trial involving Extracorporeal Photopheresis</a> (ECP). This is a Medicare study to show ECP works well enough that the procedure can be covered by Medicare. I was a bit disappointed that I wasn't getting the treatment, but happy to be contributing to the trial.<br />
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I am very happy to report that I was transferred to the treatment arm of the trial and finished up my third cycle of the treatment. It feels pretty awesome to be receiving a treatment that may slow my chronic rejection.<br />
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A quick recap and explanation about my rejection. There are two kinds of lung transplant rejection, acute and chronic. Here is a <a href="https://www.thoracic.org/patients/patient-resources/resources/lung-transplantation-rejection.pdf" target="_blank">quick description of lung transplant rejection</a>.<br />
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Acute rejection often comes on quickly, and can be usually be treated. I had a pretty severe acute rejection about a month after my transplant. The rejection was triggered by a Coronavirus and took some pretty intensive in-hospital treatment to recover from. I have an awesome Team, they took care of that issue, and the myriad of others that followed.<br />
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A chronic rejection may come on slower, and has far fewer treatment options. My chronic rejection was triggered by getting stomach contents in my lungs. We treated for acute rejection and performed a Nissen Fundoplication. The rejection slowed, but continued. Once diagnosed with chronic rejection I went into the hospital for a Thymogobulin Treatment. The Thymogobulin reduced my T-Cell count from over 1600, to less than 30 cells/ul. The Thymo did a nice job of stabilizing my rejection.<br />
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My highest post transplant spirometry included an FEV1 of over 5.8L. FEV1 is the amount of air I can forcibly exhale in one second. My current FEV1 is around 2.0L. This puts me in Class 3 rejection. Specifically Class 3 BOS.<br />
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From the rejection link above:<br />
<blockquote class="tr_bq">
Over time, you may develop slowly worsening, chronic rejection called chronic lung allograft dysfunction (CLAD). A common form of CLAD is called bronchiolitis obliterans syndrome (BOS)...</blockquote>
So I'm rejecting, it's progressing (slowly), and I'm in a clinical trial of a treatment that has been shown to slow the progression of the rejection.<br />
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Extracorporeal Photopheresis is a procedure that involves removing 1.5 L of blood, separating the white blood cells from the red, treating the white blood cells with a medication then hitting them with UV light. The whole batch is returned with a bit of saline to keep things flowing smoothly.<br />
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Here is a good <a href="https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/Arcasoycomment08112011.pdf" target="_blank">explanation of the procedure and how it helps with chronic rejection</a>.<br />
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This shows the results of an earlier trial of ECP, and why we have hope that this is going to help keep me healthy.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjg7nTcz4hiKfSQB7kkzmTTWlHxZXNi1wSjYUyPOnoffD46crrqXTDUQv2F34YXXMTllz1wZip7xB3sCCneI0p1FHtD69SUh9UQ4Z8sXCEGQUUQkbjKhIMCw3tj0bLDMGFmFHeUK0cDzIMt/s1600/Screen+Shot+2019-12-05+at+4.36.51+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1097" data-original-width="1600" height="219" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjg7nTcz4hiKfSQB7kkzmTTWlHxZXNi1wSjYUyPOnoffD46crrqXTDUQv2F34YXXMTllz1wZip7xB3sCCneI0p1FHtD69SUh9UQ4Z8sXCEGQUUQkbjKhIMCw3tj0bLDMGFmFHeUK0cDzIMt/s320/Screen+Shot+2019-12-05+at+4.36.51+PM.png" width="320" /></a></div>
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I've had 6 treatments in these first 3 cycles. Only noticeable side effects are lightheadedness during the procedure, very sensitive to light after the procedure (increasing with each procedure), and tiredness for the rest of the day.<br />
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Now it's up to me to keep myself healthy during the current Cold/Flu/RSV season.<br />
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<a href="https://utswmed.org/conditions-treatments/photopheresis/" target="_blank">My ECP Team</a>John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com1tag:blogger.com,1999:blog-4878517487148484304.post-61453643668082731382019-10-09T21:19:00.000-05:002019-10-09T21:19:25.406-05:00Checking InI sure am slacking on writing posts. No particular reason other than not sure what to write about that's new information that might be of interest.<br />
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I am kind of excited that it's coming up on a full year since I've been in the hospital. Excited and a little superstitious about mentioning it. About this time last year the upper lobe of my right lung collapsed several times and we never did figure out why. There is permanent damage to that part of my lung, but it has not progressed.<br />
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I went to my once every 3 month check in with the Team on Monday, and everything is stable. X-ray results indicate "<i>Postsurgical changes of bilateral lung transplant. No cardiomegaly. No effusion, pneumothorax or focal consolidation. Stable right apical pleural-parenchymal thickening. No acute osseous findings."</i> and all of my labs look good. The medications have been rough on my kidneys and my Creatinine levels run high and I remain well within my normal band, 1.58 mg/dl this time.<br />
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We were fortunate enough to be gifted tickets to one of the last Ranger's games at the Ballpark in Arlington. Wearing SPF 100 and brought my own shade. We were also able to carry in several liters of cold water and had a great time. That's my best friend next to us. When so many became distant when I was really sick, Saul stood with me. I really appreciate that guy.</div>
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If there is anything you would like me to write about, or have any questions, write them down in the comments. I'd be more than happy to answer.</div>
<br />John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com0tag:blogger.com,1999:blog-4878517487148484304.post-49782440264984302512019-07-09T17:08:00.002-05:002019-07-09T17:08:54.396-05:00ECP Trial UpdateYesterday I mentioned that my Team had requested that I be evaluated for participation in a <a href="https://clinicaltrials.gov/ct2/show/NCT02181257?id=NCT02181257&rank=1&load=cart" target="_blank">clinical trial using Extracorporeal Photopheresis </a>to help slow the progression of chronic rejection. A lot has happened since then.<br />
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I received a call from the ECP team at UTSW early this morning and was sitting in an exam room by 10:00. There was a physical exam checking vitals and to see if I had good veins (I do), then I met with the team and we went over the trial. We talked about the goals of the trial, how photopheresis worked, and the potential negative effects of the procedure. I filled out a quality of life survey (these have really improved over the past few years and applied to participate in the trial. There are two arms to the part of the trial I qualified for. One arm receives the treatment, and the other is the observational arm.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj4GWQtfbMU1ZZms0KfBwNo2mo3SuGyamL7dH6VJ-C7s23fYkHnBdLdBBdeOKd1tM0_6QeIAldzQuIafbcaWWOP4fRb2x4_S75Glr8DO6An-LUIAkLT1HsGcl7iaI6kHghEL13M_7Gc4o5b/s1600/Screen+Shot+2019-07-09+at+2.25.10+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="324" data-original-width="1600" height="80" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj4GWQtfbMU1ZZms0KfBwNo2mo3SuGyamL7dH6VJ-C7s23fYkHnBdLdBBdeOKd1tM0_6QeIAldzQuIafbcaWWOP4fRb2x4_S75Glr8DO6An-LUIAkLT1HsGcl7iaI6kHghEL13M_7Gc4o5b/s400/Screen+Shot+2019-07-09+at+2.25.10+PM.png" width="400" /></a></div>
I got a call this afternoon and... I've been accepted into the trial as part of the observation arm. Not quite what I was hoping for, but I am still a part of this important trial. Also, if my rate of decline increases I could be transitioned to the Treatment Arm. So treatment is still a possibility for me.John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com0tag:blogger.com,1999:blog-4878517487148484304.post-66704641326942053652019-07-08T19:47:00.000-05:002019-07-08T19:47:14.549-05:00How Are You?<div class="separator" style="clear: both; text-align: left;">
My new lungs are pretty awesome. They've been thru a lot, and my immune system is doing it's very best to reject them, but they just keep on keeping on. This image is of my lung function over the past 4 1/2 years, from transplant to now.</div>
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Lots of stories in those dots. My early major acute rejection followed by a nice long era of improvement. Then we have the beginning of my chronic rejection, likely triggered by stomach contents getting into my lungs. A Nissen Fundoplication and lots of hard work by my team got that mostly stabilized. The chronic rejection continued to eat away at my lung function, so we decided to try a Thymoglobulin Treatment. That treatment got me stabilized for a nice period, until the upper lobe of my right lung collapsed. The collapsed lung seems to have triggered the progression of my chronic rejection again, Chronic rejection isn't something you can cure, it is just something that you can slow down or even pause for a bit if you are lucky. I have been lucky.<br />
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I'm writing this post to answer the question "How are you doing" when asked by friends and family. When things are normal, I usually say "I'm doing well" or "I'm fine", and I mean it, I feel that i am doing well, as a matter of fact, better than well. I'm still alive and I'm feeling better that I did before my transplant. If I talk about my rejection, or how my meds are messing with the rest of my body, people feel sad or sorry for me. I want my friends and family to be happy that I'm still here and that I am doing well, The rest of this stuff is just part of the package of accepting a lung transplant. If you look at the numbers, about 40% of the people who were transplanted about the same time as I was have passed, and I'm still here. Next weekend we are going to watch our granddaughter compete in a national Taekwondo tournament in Denver, then another granddaughter is going to stay a week with us. Life is awesome.<br />
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UT Southwestern has been accepted to participate in a <a href="https://clinicaltrials.gov/ct2/show/NCT02181257?id=NCT02181257&rank=1&load=cart" target="_blank">clinical trial involving using Extracorporeal Photopheresis</a> to help slow the progression of one type of chronic rejection. My Team submitted me to be a part of this trial today. They tried to get this treatment for me awhile back, but Medicare would not cover it. This trial to prove to Medicare that this treatment is helpful to lung transplant patients. If accepted, I'll be sure to post a lot about my experience.<br />
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So how am I doing? I'm doing great :) Yeah, my kidneys are having issues with all the meds (Stage 3 CKD) and my bones aren't what they used to be (Osteopenia on the verge of Osteoporosis). Lung function is trending down, but plenty of room to go before I start having 'real' issues :) All stuff my Team and I are working on. <br />
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How are you?<br />
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<br />John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com0tag:blogger.com,1999:blog-4878517487148484304.post-15647232719901457232019-05-02T18:47:00.000-05:002019-05-02T18:47:26.977-05:00I'm Stable and the Dallas Stars are Rocking It.Last November while in the hospital with my collapsed lung, I was watching the Dallas Stars and hoping that they would make go at it this post season - and that I would be here to see it. The Stars have won their first round in the playoffs, are playing very well in the second, and yes I'm still here.<br />
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<a href="https://www.si.com/nhl/2019/05/02/dallas-stars-st-louis-blues-game-four" target="_blank"><img border="0" data-original-height="724" data-original-width="1300" height="178" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5nI7FMrxNUOvGWMytx4uJXFTpMYKVGpS5mbzLsphxU-0weZoFe67c18GiB-vMmqFF7Z5cxeOF7FUiMS81tVB5u2acd7FYRrbbHk7T4hhX7gGsLKrpF0n8J89IdWU1YaJzsWt6dudvUTig/s320/dallas-stars-st-louis-blues-game-four.jpg" width="320" /></a></div>
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As a matter of fact I'm doing quite well. I almost don't want to talk about it so I don't jinx things. This is the first time I've made it to May in a new year without having to be admitted to the hospital at least once. I'm very happy about this accomplishment.<br />
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If you've been reading along, you know that I am having issues. I am rejecting my lungs, but the rejection has been stabilized. The official name is <a href="http://www.lungtransplant.utoronto.ca/Post_Transplant_Issues/Chronic_Lung_Allograft_Dysfunction__CLAD_.htm" target="_blank">Chronic Lung Allograft Dysfunction (CLAD).</a> My type of rejection is primarily obstructive (Bronchiolits Obliterans Syndrome - BOS), and I am classified as BOS 3. There are also some restrictive components with my rejection. but I am primarily BOS. Chronic rejection is a bad thought for those of us living with new lungs. There isn't any "cure" for chronic rejection and the articles you find during a web search don't offer much in the way of hope. Pretty much like web searches for IPF. But just because there is not cure does not mean there is nothing for us to do. My Team has worked hard to get me stabilized a couple of times now, and I am enjoying my current stability. My latest X-Rays indicated:<br />
<blockquote class="tr_bq">
1. Stable right upper lobe volume loss with underlying bronchiectasis.<br />2. Stable mild right middle lobe volume loss. No acute consolidation. </blockquote>
The volume loss indicated in the X-Ray results is because the upper lobe of my right lung has collapsed three times that I'm aware of, the last was on Christmas Day while we were visiting family. I was cooking a rib roast when it happened. Dinner turned out awesome because I didn't let anyone know until we got back to Texas. Seriously, there wasn't much anyone could do other than what I had already been doing so it wasn't an emergency. I did visit the Team when we got back and things were as expected. Later, at my January annual visit we found that the middle lobe was starting to also have issues. So I'm happy to see that both lobes are stable from January. Stable is good.<br />
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Keeping these lung healthy does come at a cost, but well worth it. The medicine that is keeping me alive is kinda rough on the rest of my body. My list of Current Health Issues listed on MyChart is becoming a bit of a long read. I'd list the major issues, but really don't want to come across as complaining. I really don't feel negative about any of this. I am still alive and life is wonderful. Yesterday we enjoyed our granddaughters orchestra concert, and before that we watch her win the sparring portions of two Taekwondo tournaments. Both times she beat boys older than her. She's on top of the world. This Summer another granddaughter is coming to stay with us for awhile, we get to share with her some of the really awesome stuff that the DFW Metroplex has to offer. So yes, the issues that come with a lung transplant have been worth it to me and my family.<br />
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If you are interested in some of the medication related issues that I'm experiencing, just ask. It would be a good topic for a future post.John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com0tag:blogger.com,1999:blog-4878517487148484304.post-90747065785028959262019-02-01T14:37:00.000-06:002019-02-07T20:57:47.611-06:00Fourth Annual Post-Transplant Exam<div class="tr_bq">
On January 1st I celebrated the fourth anniversary of <a href="https://primaltransplant.blogspot.com/2016/06/my-lung-transplant.html" target="_blank">my lung transplant</a>. Four years of new life thanks to the wonderful gift from my donor family.</div>
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With each anniversary, comes my annual post-transplant exam. The annual exam is basically a very thorough physical. The test/exams for the day included labs (14 vials), a CT of the chest, ultrasounds of my heart and abdomen, a bone density test, chest x-ray, a 6 minute walk test, arterial blood gas, a couple pulmonary function tests, and a physical exam.<br />
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The lab results were routine. My white blood cell count is a little high, 7.09x10(9)L. We prefer it to be a point or two lower and will adjust my meds a bit to get it down. My Creatinine, an indicator of kidney function, is high but not higher than what has become normal for me. I average about 1.4 mg/dl creatinine which indicates how hard the meds are on my kidneys. Other than that my labs were all good. Immune system properly suppressed, cholesterol and A1C are normal. and liver function is good.<br />
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My bone density exam showed the the meds continue to demineralize my bones. I've lost between 17 - 19% of the bone mineral density in my hips since my transplant. I'll be seeing my Mineral Metabolism Doc next month.<br />
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Now we get to the part of the exam that shows the condition of my lungs and progression of my chronic rejection. The X-rays, CT of my chest, and full Pulmonary Function Tests offer a solid picture of where I stand at the moment. You have to look at all three together to get the full picture.<br />
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From my X-ray:<br />
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Lungs and pleura: Stable right upper lobe volume loss with underlying bronchiectasis noted. Mild right middle lobe volume loss seen. No acute consolidation.</blockquote>
From the CT:<br />
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IMPRESSION:<br />
1. Complete right upper lobe collapse with mild bronchiectasis as before. Stable mild bronchiectasis and volume loss of the middle lobe. No endobronchial mass identified.<br />
2. Air trapping on expiratory phase images is suggestive of small airway disease such as bronchiolitis obliterans.<br />
3. Near complete resolution of previously noted groundglass opacities at the lung bases with few residual groundglass and reticular opacities at the left costophrenic recess.</blockquote>
And from my PFT's:<br />
<blockquote>
Forced expiratory flows are severely reduced with a moderate reduction in the
forced vital capacity.<br />
No bronchodilator response<br />
Lung volumes reveal a normal total lung capacity with incomplete exhalation of
the vital capacity and trapping of a large residual volume<br />
Diffusion capacity is moderately reduced<br />
Sever obstructive ventilatory defect with air trapping and impaired diffusion.
COPE/Emphysema. Vascular disease, Bronchiolitis cannot be excluded </blockquote>
The most interesting part of these results relate to my collapsed lung. I have been having issues with the upper lobe of my <a href="https://primaltransplant.blogspot.com/2018/11/post-hospital-update.html" target="_blank">right lung collapsing</a>. We've been able to get it reinflated a couple of times, but it appears that it is going to be collapsed more often than not. What is new in these results is volume loss in my middle lobe. That's not at all what I was expecting, and a bit disheartening. I'm not quite as stable as I had hoped.<br />
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The air trapping noted in these findings is indicative of my chronic rejection. The air trapping combined with the >50% loss in lung volume from my highest results shows the progress of the rejection.<br />
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The good news about these results is the 'Near complete resolution of previously noted groundglass opacities..." This indicates that we have addressed the unidentified infection that was previously an issue.<br />
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So the end result of this exam is that we will be adjusting my meds a bit to drop the WBC, and I'll be using <a href="https://www.nationaljewish.org/treatment-programs/medications/airway-clearance-devices/acapella-choice" target="_blank">Acapella </a>airway clearing device along with my incentive spirometer each day to potentially help with the collapsing lung.<br />
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Update:
My goal after this visit is to stay out of the clinic and hospital until my next quarterly exam :)<br />
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Since every blog post needs an image, here is the box we sit in for our full pulmonary function tests.<br />
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<a href="https://upload.wikimedia.org/wikipedia/commons/8/83/Body_Plethysmography_chamber_01.jpg" target="_blank"><img border="0" data-original-height="600" data-original-width="800" height="240" src="https://upload.wikimedia.org/wikipedia/commons/8/83/Body_Plethysmography_chamber_01.jpg" width="320" /></a></div>
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Image found <a href="https://livingwellwithabaddiagnosis.blogspot.com/2011/02/februarys-interstitial-lung-disease.html" target="_blank">here</a></div>
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Update: I've increased my CellCept to 1500 mg twice/day and I'm a line item topic of discussion for the Team's weekly meeting next week. They are going to attempt to refer me to Extracorporeal Photopheresis again, but it is not likely it will be approved by Medicare, again.</div>
John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com2tag:blogger.com,1999:blog-4878517487148484304.post-18871757549273341382018-12-07T12:03:00.001-06:002018-12-09T17:12:20.325-06:00Chest Muscle vs Body Fat as an Indicator of ICU SurvivalIf you have been reading along with me for awhile, you know that losing weight has been a large part of my journey. When I first met my Transplant Team, I was denied the opportunity for a transplant because I had too much body fat. At my heaviest I weighed 289 lbs. At the bottom of my weight loss journey I weighed in the mid 140's. I feel my best in the mid 150's, but my Team wanted me to put on a bit more weight to give me an energy reserve for those times when I was sick. I'm currently in the low 170's and this makes my Team (and my Mom) happy. I would prefer to be lighter. I bring this up because the results of a recent study indicate that body fat may not provide any additional chance of surviving a visit to the ICU. From <a href="https://www.pulmonologyadvisor.com/" target="_blank">PulmonologyAdvisor:</a><br />
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<a href="https://www.pulmonologyadvisor.com/critical-care/pectoralis-muscle-area-intensive-care-unit-survival-disability/article/817665/?utm_campaign=Relevant++News&utm_content=80770988&utm_medium=social&utm_source=twitter&hss_channel=tw-34827666" target="_blank"><img border="0" data-original-height="250" data-original-width="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPgIDw79v6iZjyVcqHSiUj-J2qCzBzTt1PrNBX_zJSz0dFmLnjfb35eWDvMDLwlMlgUMfSIrNUiqZGYg3Ohxu0GXko3mskuNpYXltnj5yzxzP_Oul8gbS7rxQCASV8q_pDO7XDtgDzra5s/s1600/pectoralmuscleg524390968_1510934.jpg" /></a></div>
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<a href="https://www.pulmonologyadvisor.com/critical-care/pectoralis-muscle-area-intensive-care-unit-survival-disability/article/817665/?utm_campaign=Relevant++News&utm_content=80770988&utm_medium=social&utm_source=twitter&hss_channel=tw-34827666" target="_blank">Amount of Muscle Mass During ICU Admission May Be Linked to Survival</a></div>
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The above article suggests that the amount of muscle in your chest is a much better indicator of survival than amount of body fat when you visit the ICU.<br />
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Larger PMA at admission was associated with significantly better outcomes, including higher rates of 6-month survival ..., lower rates of hospital mortality ..., and more ICU-free days (.... In contrast, SAT was not significantly associated with any of the measured outcomes.</blockquote>
PMA = Pectoralis Muscle Area. SAT = Subcutaneous Adipose Tissue.<br />
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What this says to me as a patient who spends a lot of time in the hospital, and some of that time will be in the ICU, is that I should maintain my body fat and muscle mass pretty much the same as a healthy individual.<br />
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It is also a bit of a concern for me as during my last visit the Doctor mentioned that the muscles in the right side of my chest are shrinking. Back to the kettlebells I go.<br />
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Something to talk with my Team about during our next visit.<br />
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12/9/18 - Muscle mass and core strength are also shown to help with<a href="https://primaltransplant.blogspot.com/2016/10/university-health-network-toronto-study.html" target="_blank"> lung transplant recovery</a>.John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com2tag:blogger.com,1999:blog-4878517487148484304.post-62029438776902565872018-11-30T18:37:00.001-06:002018-12-05T14:29:47.622-06:00Post-Hospital UpdateThursday was my two week post-hospital followup visit with my Team. The reason I was in the hospital is that the upper lobe of my right lung had <a href="https://primaltransplant.blogspot.com/2018/11/my-latest-hospital-stay.html" target="_blank">collapsed for the second time.</a> The first tine it collapsed, it re-inflated during a bronchoscopy. The second time it collapsed we couldn't get the issue resolved during my hospital stay and I came home with the very good possibility that this was my new normal.<br />
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My home therepy included a 60mg prednisone taper, three weeks of oral antibiotics and using an incentive spirometer.<br />
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During the two weeks following my hospitalization my home pulmonary function testing (PFT) results improved to my pre-collapse capacity and I feel much better. I was looking forward to seeing my X-rays and wasn't too surprised to find that my lung has done a good job of recovering. It's not fully inflated, and you can tell that there are issues, but it is much better than when I left the hospital. We still don't have a good explanation for why it collapses, or why it has re-inflated. Our working theory at the moment is that during a transition off of an antifungal mediation my immunosuppressant medication levels got out of balance for a few days resulting in a rejection episode.<br />
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Visually, the tissue in that area is more white than pink indicating to the Team reduced blood flow to that lobe. My next annual series of testing is in January. The VQ scan should have some interesting results.<br />
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My current plan is to monitor the issue. I continue to perform daily PFT's (as should all lung transplant recipients) and will be having chest X-rays every 2 weeks or so for awhile.<br />
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On a side. and likely related note, the Doc mentioned that my chest muscles on the right side are shrinking. He's not sure why atrophy is only on that side, more interesting stuff.<br />
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I couldn't find an image of an X-ray similar to mine, so here's one of me trying on a silly Christmas jacket.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj9eV7vge53-zFAUVnp9Jrp8LTcCZzobPNa8malESpHqKM1ti1sDUhC8bCzeyo8r4orTuXv6ZNJX2xcj95atylnOuWk54sIttkoQn8ZqmBa3sVh_E4mY_0gXvD0zTACDq-XRes7l1dOILz0/s1600/IMG_1549.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1200" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj9eV7vge53-zFAUVnp9Jrp8LTcCZzobPNa8malESpHqKM1ti1sDUhC8bCzeyo8r4orTuXv6ZNJX2xcj95atylnOuWk54sIttkoQn8ZqmBa3sVh_E4mY_0gXvD0zTACDq-XRes7l1dOILz0/s320/IMG_1549.JPG" width="240" /></a></div>
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<i>12/5/18 - X-ray results from my visit: </i><br />
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<i>1. Right upper lobe bronchiectasis and partial collapse, with probable improvement in aeration since 11/13/2018. </i><br />
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<i> 2. Prior densities in the left lower lung field have also improved.</i><br />
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<i>"Improve..." used twice in one reading.</i>John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com2tag:blogger.com,1999:blog-4878517487148484304.post-37693679457308445102018-11-22T14:19:00.003-06:002018-11-22T14:19:58.892-06:00Happy Thanksgiving!Happy Thanksgiving my friends. I hope this note finds you warm, happy and feeling well loved.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGd6EYNTQOOVJ7WY_kSJT8YjKvra3CNWy00xGsnGGgIZLzs5i6wUl2AdZUqFEQ2BlXvjNbdlooMdjJsNTXMGhqZjjTehTZYMCUmh43GOtWocOHFY-BrMsumUmYxmjDgUGcX9nSWCUyf6dy/s1600/DsnVMYKUwAIytaK.jpg-large.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="628" data-original-width="1100" height="182" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGd6EYNTQOOVJ7WY_kSJT8YjKvra3CNWy00xGsnGGgIZLzs5i6wUl2AdZUqFEQ2BlXvjNbdlooMdjJsNTXMGhqZjjTehTZYMCUmh43GOtWocOHFY-BrMsumUmYxmjDgUGcX9nSWCUyf6dy/s320/DsnVMYKUwAIytaK.jpg-large.jpeg" width="320" /></a></div>
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There is so very much to be thankful for. My Sweetie who shares this chapter of our story, my family for supporting and loving us as they do, for the Lord for blessing us with all of our gifts, and for my donor family for this precious gift of life.<br />
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I am also thankful for you guys, for checking in and being a part of our journey. Thank you all so very much and have a wonderful Thanksgiving and Holiday Season.John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com0tag:blogger.com,1999:blog-4878517487148484304.post-62667146370530749802018-11-14T21:08:00.000-06:002018-11-30T16:29:30.224-06:00My Latest Hospital StayHey all, I know it has been awhile since my last post. Things have been in a bit of flux and I wanted to wait until I got a bit of stability before posting. That's not going to happen, so I might as well post away.<br />
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<a href="https://primaltransplant.blogspot.com/2018/06/update-on-starting-extracorporeal.html" target="_blank">I had mentioned </a>that my Team wanted me to have Extracorporeal Photopheresis (ECP and that UTSW was trying to be a part of a Clinical Study that included ECP for post lung transplant patients in chronic rejection. Well that's not going to happen. We didn't become a part of the study and ECP is not covered by Medicare for this application. <br />
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Events over the past few weeks may make that point moot anyway.<br />
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In late October I had some chest pain on the right side. It kind of felt like pneumonia but only on the right side. My daily Pulmonary Function Test (PFT's) showed my lung function had fallen off a bit. Went in to see the Team and found that the upper lobe of my right lung had collapsed. We left the clinic and headed to the hospital for a bronchoscopy. This was bronch #19 for me, and the roughest of the lot. It was also the hardest my doctor remembers doing. The docs who perform the bronch's are the Team doctors, so we know each other well and can have very honest discussions about what's going on. Getting six biopsies from the upper lobe caused a good deal of bleeding and I woke during the procedure gagging and coughing. On a happy note, the procedure, or the coughing, opened up my lung and things looked good after.<br />
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I was scheduled for a CT the 2nd week of November and a couple of days before the test my chest felt off again. Not as bad as before, but off. The CT showed that my that lobe had collapsed (<a href="https://www.mayoclinic.org/diseases-conditions/atelectasis/symptoms-causes/syc-20369684" target="_blank">Atelectasis</a>) again, so I was off to the hospital on Saturday. Now one really nice thing about being a part of this team is the fact that when you head into the hospital, whether it is to the ER or a routine admittance, they are waiting for you when you get there. So I checked in and whisked up to the 10th floor, our home away from home.<br />
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To make a long story shorter. We tried <a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/intermittent-positive-pressure-breathing" target="_blank">Intermittent Positive Pressure Breathing</a> (IPPB), BiPAP, CPAP, an incentive spirometer and the <a href="https://www.nationaljewish.org/treatment-programs/medications/airway-clearance-devices/acapella-choice" target="_blank">Acapella </a>(flutter) device. We also did IV antibiotics and another bronchoscopy. And once again, I'm unique. The team hasn't seen a post transplant lung collapse like this without a physical cause. We also couldn't get it re-inflated. So I'm back in the comfort of my own home, on a 60 mg Prednisone taper and three weeks of oral antibiotics. I'm also using the incentive spirometer and the Acapella.<br />
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I'm feeling good, and my Pulmonary Function Tests (PFT's) are a bit better than prior to the hospital stay.<br />
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Just another paragraph in <a href="https://primaltransplant.blogspot.com/2018/04/the-next-chapter.html" target="_blank">this chapter</a> of my story. An interesting one to be sure, and one that hopefully helps my team with future patients. This paragraph has to include my CT (with contrast) from the hospital:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiLlLFtBSgyO6FTY1vGy0IRz-74euehHvz2Aiemv9C1cFuDM4SSPE0XooPQf_oiG9hGi8pXKnXbCYxccaxdZmASq4LqBNXiqtnqO8El_zrUDNIAb40Tlw01eb5Z8kk4FIAUtQi-0yIzplcp/s1600/56366328243__8791883D-CECE-4519-911F-523268C74B5B.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1200" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiLlLFtBSgyO6FTY1vGy0IRz-74euehHvz2Aiemv9C1cFuDM4SSPE0XooPQf_oiG9hGi8pXKnXbCYxccaxdZmASq4LqBNXiqtnqO8El_zrUDNIAb40Tlw01eb5Z8kk4FIAUtQi-0yIzplcp/s320/56366328243__8791883D-CECE-4519-911F-523268C74B5B.JPG" width="240" /></a></div>
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<blockquote class="tr_bq">
IMPRESSION: </blockquote>
<blockquote class="tr_bq">
1. Redemonstration of complete collapse of the right upper lobe, no definitive endobronchial lesion identified. </blockquote>
<blockquote class="tr_bq">
2. Grossly unchanged multifocal groundglass opacities in the bilateral lower lobes. Findings may represent infection/aspiration. </blockquote>
<blockquote class="tr_bq">
Chronic allograft lung disease is also on the differential.</blockquote>
My next annual VQ scan will be interesting.<br />
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<i>Edit:</i> I forgot to include the leading 'best guess' as to what happened. Back in April I u<a href="https://primaltransplant.blogspot.com/2018/04/the-next-chapter.html" target="_blank">nderwent a Thymoglobulin treatment</a> that dropped my T cells down to < 25 cells/ul. That is very low. To help prevent a serous fungal infection, I took <a href="https://www.pfizermedicalinformation.com/en-us/patient/vfend" target="_blank">Vfend</a>, a potent anti fungal for 6 months. Vfend has a large effect on how my body metabolizes Prograf, a major anti rejection drug. When transitioning off of Vfend, the Prograf level in my body dropped low, this may have triggered a rejection event. Imaging does indicate that my chronic rejection is progressing. John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com0tag:blogger.com,1999:blog-4878517487148484304.post-46947193814143549032018-08-07T18:31:00.001-05:002018-08-07T18:31:50.297-05:00Going to Ball Games... and stuff"...why must you live out those songs that you wrote."<br />
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Hank Jr's been rolling thru my mind of late. Like Hank, I'm often questioned about some of the things I do when going out and about with my Sweetie. I like to share our activities on social media, and that sometimes get a "what the heck' reaction from friends and family.<br />
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For instance, we went to a Rangers game last month. Now the ballpark in Arlington is an open ballpark and at first pitch it was 107 F. Later in the game I posted this on Facebook:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgc9E-SiLJe4hX4nXhEdfa30X6Y5UqXYS_IZMq81IX6tq_7YZkU2qy4ym6iqkZOOBWN6sgVmDFUBISiBYD22K9TvYcw8KBT1Rc2qxwTs86F1jHRlS8hMW_AIEypPJvimPsFmT_1fOZ_Y3X1/s1600/fullsizeoutput_a15.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="883" data-original-width="1298" height="217" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgc9E-SiLJe4hX4nXhEdfa30X6Y5UqXYS_IZMq81IX6tq_7YZkU2qy4ym6iqkZOOBWN6sgVmDFUBISiBYD22K9TvYcw8KBT1Rc2qxwTs86F1jHRlS8hMW_AIEypPJvimPsFmT_1fOZ_Y3X1/s320/fullsizeoutput_a15.jpeg" width="320" /></a></div>
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I have to admit, that was a rough evening for me. So here I am, in the middle of a chronic lung transplant rejection, with a very severely suppressed immune system, going out in a very public place during a heat advisory. Why?<br />
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Basically, because my Sweetie wanted to. You see, it was snow globe night at the park, and every time she saw the commercials advertising the give away on television, she said she wanted to go. So we went.<br />
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Something I haven't mentioned here before is that my Sweetie has early onset Alzheimer's. The symptoms of her disease have been progressing for over 3 years. My job is to help her have the best life possible. So yeah... I do stuff I shouldn't, but as John Wayne stated... "A man's got to do what a man's got to do." <br />
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No worries though, I take plenty of precautions. For the game I drank 2 liters of water before going and brought 2 more liters of ice water to the game. We had a cooler and I had my mask. High SPF sunscreen and taking is slow got us through the night. Also, it was a pretty great game. <br />
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We have to live life. I have received a wonderful gift of new lungs, that gift is meant to be shared and enjoyed. Supporting my Sweetie is a blessing that I would not have had without this gift.John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com3tag:blogger.com,1999:blog-4878517487148484304.post-73868097750794375932018-07-12T17:30:00.000-05:002018-07-12T17:30:35.413-05:00Stability, A Goal Worth AchievingMy last visit with the Team turned out very well. For the first time in a good while my Pulmonary Function Testing showed a little improvement. It looks like the Thymoglobulin treatment has put my chronic rejection on hold. UTSW has applied to be a part of the Extracorporeal Photopheresis study that I mentioned <a href="https://primaltransplant.blogspot.com/2018/05/keeping-on-keeping-on-new-treatment-is.html" target="_blank">here </a>and <a href="https://primaltransplant.blogspot.com/2018/05/keeping-on-keeping-on-new-treatment-is.html" target="_blank">here</a> and the Team thinks it would be a good thing if I were to participate. If they get approved, we may start next month.<br />
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Blood pressure has gone up so I've started a BP med (yeah more meds), but cholesterol, A1C and blood sugar are all good to go. The meds are messing with my liver and kidney function, so I have to be sure to get in plenty of water.<br />
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The Thymoglobulin and the addition of an anti-fungal to my daily routine has messed with my immune system so we have to keep an eye on my immunosuppressants. I'm currently taking Valcyte only once/day as white blood cell count (and a few other labs) is a bit lower than what they would like. 2.6 thousand/uL. Good thing we are not in the cold/flu season. <br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg42BW6FhSRkKMOOXoAAqLalO9_hFJkyaGzZ7IhC9fNhWUR1wQaZkIgM_3UAazvfO-kgFtInTs6VCW8XOTs6vMS9TWV4Qd_vDYKpKSXqYw4buGXbK719UhPYKQjofsYcIaI9wcNhLEZkZ-E/s1600/stable+mug.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="600" data-original-width="600" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg42BW6FhSRkKMOOXoAAqLalO9_hFJkyaGzZ7IhC9fNhWUR1wQaZkIgM_3UAazvfO-kgFtInTs6VCW8XOTs6vMS9TWV4Qd_vDYKpKSXqYw4buGXbK719UhPYKQjofsYcIaI9wcNhLEZkZ-E/s320/stable+mug.jpg" width="320" /></a></div>
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Image (and mug) <a href="https://wellesleyequestrian.com/products/we-im-stable-mug?variant=30038604881" target="_blank">found here</a>.</div>
<br />John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com0tag:blogger.com,1999:blog-4878517487148484304.post-24165851418791873112018-06-13T17:50:00.002-05:002018-06-13T17:50:56.578-05:00Update on Starting Extracorporeal PhotopheresisIn <a href="https://primaltransplant.blogspot.com/2018/05/keeping-on-keeping-on-new-treatment-is.html" target="_blank">my last post </a>I mentioned that my Team wanted me to start <a href="https://utswmed.org/conditions-treatments/photopheresis/">Extracorporeal Photopheresis</a> (ECP). It turns out that the Centers for Medicare and Medial Services (Medicare) will only <a href="https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=255" target="_blank">cover this treatment for a lung transplant patient as part of a clinical trial</a>.<br />
<blockquote class="tr_bq">
CMS covers extracorporeal photopheresis (ECP) for the treatment of bronchiolitis obliterans syndrome (BOS) following lung allograft transplantation only when ECP is provided under a clinical research study...</blockquote>
There is <a href="https://clinicaltrials.gov/ct2/show/NCT02181257" target="_blank">one clinical trial</a> that is reported as to not being accepting new applicants. From what I understand, the trial has been extended and that UT Southwestern should become a study center come August. This is the first time that Medicare has denied a procedure. I've gotten used to Part D trying to deny my medications, but procedures is a new one for me. I understand that most private insurances do cover this procedure with peer to peer review, but that does not work with Medicare.<br />
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Good news is that this trial is a research study and not a randomized clinical trial. The procedure works and an RCT would be unethical. <br />
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Thankfully I am relatively stable following my Thymoglobulin treatment, and I have a decent amount of lung capacity remaining, so this isn't as large an issue as it is for others in my situation.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhFRPc5UtIA9q6ICJjpQYQ8y6Pjuo-yXY7Zv19wJoqsXaBeKMMXTzvvQIP7bzPezck218sqNahkDL5T-MJnPcnh6f5SM1_R35KPgOgW9jM9rSWWnMXZV_98Toy2xeicKJYpJ5VuJtuDUham/s1600/lungs.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="315" data-original-width="560" height="180" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhFRPc5UtIA9q6ICJjpQYQ8y6Pjuo-yXY7Zv19wJoqsXaBeKMMXTzvvQIP7bzPezck218sqNahkDL5T-MJnPcnh6f5SM1_R35KPgOgW9jM9rSWWnMXZV_98Toy2xeicKJYpJ5VuJtuDUham/s320/lungs.jpg" width="320" /></a></div>
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Image found <a href="https://www.healthimaging.com/topics/diagnostic-imaging/are-ct-lung-cancer-screening-trial-markers-incorrectly-predicting" target="_blank">here</a>. </div>
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<br />John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com2tag:blogger.com,1999:blog-4878517487148484304.post-26437151330818431892018-05-24T20:57:00.000-05:002018-05-24T20:57:14.069-05:00Keeping on Keeping on - A New Treatment is in My FutureIt's coming on a month and a half (40 days) since <a href="https://primaltransplant.blogspot.com/2018/04/the-next-chapter.html" target="_blank">I was discharged from the hospital</a> after completing my Thymoglobulin treatment. I feel great, and was looking forward to today's visit with the Team. I expected to have confirmation that my lungs were stable and then talk about some kidney function issues that the medications have brought up. Well... turns out that even though my daily spirometry at home is basically, in my optimistic interpretation of the results, stable, I am still experiencing a slow decline in lung function. My in-clinic <a href="https://secondwindstl.org/who-we-are/articles-by-dr-hacheem/lung-function-measurement-after-lung-transplantation/" target="_blank">FEV1</a> (basically the amount of air I can forcibly exhale in 1 second) has dropped from 2.03 to 1.83 liters. Heavy sigh.<br />
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Next on the agenda is <a href="https://utswmed.org/conditions-treatments/photopheresis/" target="_blank">Extracorporeal Photopheresis</a> (ECP). ECP utilizes a machine to remove blood, isolate the white blood cells, then medicate and UV irradiate those cells. The blood and altered cells are then returned. Here is the <a href="https://emedicine.medscape.com/article/1131176-overview" target="_blank">Medscape explanation of ECP.</a> On a very positive note, all of the treatments are out patient. That's important and makes things much easier on us. The outlook following this treatment is also positive. Here is a report from a <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1111/ajt.12155" target="_blank">retrospective study performed at a transplant center in Germany</a> that I found pretty interesting.<br />
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I couldn't find any cool Photopheresis images to share, and I know everybody likes images so here is one from the UT Southwestern ECP page.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6LFBnSIcRNTdpFtgEDEVMgZxj48CRTcznyro1AX7LFXamxr_kGCTp28UkQqq0DmKEjh5xpZI3O3MMLYoQjhgaESZhJJ4ER1J-QIi88HVgL9tAZHp0Cg_p2nawnyvgKDy5XouIbMZHDRsC/s1600/photopheresis.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="333" data-original-width="500" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6LFBnSIcRNTdpFtgEDEVMgZxj48CRTcznyro1AX7LFXamxr_kGCTp28UkQqq0DmKEjh5xpZI3O3MMLYoQjhgaESZhJJ4ER1J-QIi88HVgL9tAZHp0Cg_p2nawnyvgKDy5XouIbMZHDRsC/s320/photopheresis.jpg" width="320" /></a></div>
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My kidneys have been having a very hard time with the meds of late. I started really pushing water intake after my last clinic visit and it has helped. My Creatinine level has dropped to 1.4 mg/dl from a high of 1.75. Creatinine levels for normal kidney function are 0.67 to 1.17 mg/dl, so I do still have a ways to go. It is great news that I am trending in the right direction. Healthy kidneys are an important factor in keeping the potential of a second lung transplant a viable future option.John Rhttp://www.blogger.com/profile/09376217483411918789noreply@blogger.com0