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A Fan of the Sleep Sentry
I have been a type 1 since 1960. In the latest issue of Diabetes Health, featuring the GlucoWatch monitor, I read it with interest. However, I was absolutely shocked to realize the costs. I've been using a Sleep Sentry for at least 10-15 years and it has served me very well.
The Sleep Sentry alerts the user to an increase in sweat, which usually accompanies hypoglycemia. It doesn't require a separate sensor like the expensive, disposable pads that the GlucoWatch requires. The Sleep Sentry was made by Teledyne and runs on batteries and is meant to be worn at night only by insulin-dependent people. I have tried to contact Teledyne on several occasions but have received no reply.
The Sleep Sentry looks like a watch. It has two buttons-one to set it. When it rings, you press both buttons to turn it off.
This is my usual procedure if the alarm on the Sleep Sentry goes off: if my blood sugar is 40_45, I take 50g of carbohydrates, reset the Sleep Sentry and go back to sleep. My wife is also in the habit of listening for the alarm because I am sometimes semi-conscious when my sugar is too low. The Sleep Sentry has saved my life on several occasions. I think I paid less than $175 for the Sleep Sentry in 1986 and it has worked like a charm. I change the battery once a year but I live in fear that I will not be able to get a replacement if and when it breaks down.
It's hard enough being a diabetic without having to incur heavy costs for technology such as the GlucoWatch.
Editor's Reply: Eric Orzeck, MD, can repair your Sleep Sentry for you. He charges an initial fee of $35 to look at it, and if there aren't any lost parts it costs an additional $25 or so to fix. He warns, however, that it may cost more if there are lost parts.
Orzeck is also close to signing a contract to begin manufacturing the Sleep Sentry again. When he bought the rights to the Sleep Sentry in 1983, users probably numbered in the tens of thousands. He expects an initial run of 1,000 units within three months of signing. The new model will probably retail for about $300.
The new Sleep Sentry will have some improved features, including a lighter and better battery life, a thinner aluminum casing, and an adjustable strap that would allow the user to wear the device either on the wrist or around the ankle. Orzeck says some people get more reliable readings from wearing it around their ankle. Wrist or ankle, Orzeck advices that the device has to be snug in order to obtain the best readings. He admits that the Sleep Sentry may not work very well on people who sweat a lot. For more information, contact Eric Orzeck, MD, at 8181 N. Stadium Drive, Suite 200, Houston, TX, or call (713) 799-8585. His fax number is 713-799-8484.
A Frustrated Blood Donor
I have been donating blood for the past four years or so. In July 1998, I switched from insulin injections to the insulin pump, and I love it. When I am asked if I am being treated for anything that requires routine follow-up visits, I usually check "yes." At this point I also tell them that I have insulin-dependent diabetes. This has not been a problem until today, when the woman who collected my blood saw the pump on my waistband. She told me I could not give blood if I was using an insulin pump. I told her that was news to me. At eight different times during the past year and a half I have already donated a gallon of blood.
When the person in charge repeated that as long as I was wearing an insulin pump I would not be allowed to donate blood, I asked to speak to the people who set the donation guidelines. She gave me the phone number of the main Red Cross office in Farmington, Connecticut. Dr. Badon, the person in charge at this facility, spoke to me and informed me that he had set the guidelines and that he would not accept my blood because of the possibility that I might be carrying some transient bacteria that may cause a serious problem for transfusion recipients. Certainly, I don't want to harm anyone with my voluntary act of kindness, but neither do I want to be disqualified from giving blood if there is only a low risk of my carrying a transient bacteria. I believe blood collection centers test the supply prior to using it. There has to be a test that would make it possible for pump users like me to continue to give blood. I ended my phone call with Dr. Badon when he said he made the decisions regarding who could, or could not, give blood.
Please respond as soon as possible with your opinion on this problem and whether or not you feel you may help to bring this situation to light. Thanks for your time.
Beth A. Melzen
Editor: We asked the medical experts at Animas to reply-
I called the Blood Center of Central Iowa here in Des Moines: ANYONE taking insulin CANNOT donate blood; if the patient has diabetes and is NOT taking insulin and "regulated" they are allowed to donate. This is a policy by the FDA. I asked her why-if someone donated it might cause an insulin reaction and then the blood bank would be liable or the patient receiving the blood might get too low or too high a blood glucose from the blood. It has nothing to do with the insulin pump.
Charlene Freeman, RN, CDE, CPT
Manager Clinical Services
This is obviously the first time I've ever encountered someone with this particular problem (can't say I even know many patients with diabetes who donate blood, let alone wear a pump). First, the reader should be highly commended for her altruistic efforts; the nation's blood supply is in constant shortage and threatens to become an even scarcer source as the FDA imposes stricter criteria for acceptance of suitable blood donors. Most recently in late 1999, the FDA passed a moratorium banning any person who originated from or visited the United Kingdom during 1980 to 1996 to donate blood out of fear that such people may be unknowing carriers of the infectious agents presumed responsible for causing bovine spongiform encephalopathy (or "mad cow" disease as we recognize it). Such a ban by conservative estimates depletes the blood donor pool by an approximate 10%.
A person living with diabetes certainly seems like a suitable donor so long as they pass the same stringent screening tests applicable to all persons who wish to donate. This includes getting screened for carriage of the human immunodeficiency virus or various forms of viral hepatitis. Blood before donation is also subjected to screen for exclusion of infections with bacterial agents that may prompt illness in the person on the receiving end.
This brings us to your question. While I am unclear myself about the prejudice against pump-users for donating blood (as opposed to other diabetics), the American Red Cross and Dr. Baran may be citing concerns about an increased carriage rate of Staphylococcus species in people who have diabetes. Staphylococcus species (Staphylococcus aureus and epidermidis) is an extremely common bug that usually poses no harm to the people who carry it (and a lot of people do carry it). Nearly 30% of the entire population at large is probably walking around with an innocent strain of the bacteria in their nares or on their skin. However, for people who are living in an immunocompromised state (whether it be from AIDS, chemotherapy treatment, prolonged hospitalization, multi-organ failure, or organ transplantation), Staphylococcus can cause life-threatening infections including: pneumonia, septic shock, and meningitis. It turns out as well that the population of people who need blood products most are those immunocompromised people whom I just mentioned.
There is also growing concern of a multi-drug resistant strain of Staphylococcus aureus that can usually only be treated by one or two antibiotics. These resistant strains are becoming increasingly prevalent in nursing homes, hospitals, and even the community and pose great danger for people who are already ill.
You are entitled to find out more about the so-called "restrictions" that have been mentioned to you about insulin-pump users donating blood. The American Association of Blood Banks (www.aabb.org) is probably a great first place to find your specific question answered as you can easily reach one of their authorities by phone or email. If the concern does pertain to passage of Staphylococcus, I don't see much utility in such a policy professed by Dr. Baran to exclude the donation of blood ONLY from insulin-pump users. Insulin-pump users have no increased carriage rate when compared with people who use more conventional means of insulin delivery (van Faassen I, et al. Carriage of Staphylococcus aureus and inflamed infusion sites with insulin-pump therapy. Diabetes Care 1989 Feb;12(2):153-5).
Again, this is a policy with which I am not too familiar. It may have only recently been adopted to curtail the already substantial morbidity to which patients who require blood products are subjected. In the meantime, enjoy the liberation and rejoice in the glycemic control that your newly found insulin pump has provided for you.
MD and medical consultant for Animas
Calling for a Different Approach
I offer the following example from our ongoing discussion on non-compliance: Several years ago we reviewed the importance of glucose monitoring with a group of patients with type 1 diabetes and then verbally suggested how many times per day they should test. We then asked them to send the records to us in a specified time period. Only 20% complied with our verbal contract. We then repeated the exercise with another group, only this time we formally wrote down the conditions (a written contract) and then the physician and the patient both signed it. The response rate, or compliance to the written contracts, more than doubled to 48%. Here, compliance is a good word, but the outcome was still less than optimal and persuaded us that the development of a comprehensive system approach to chronic care is imperative. While patients have rights, they also have responsibilities just as do the professional members of the team.
Donnell D Etzwiler, MD,
Founder and President Emeritus of the International Diabetes Center,
Clinical Professor Emeritus of the University of Minnesota,
Sharing Diabetes Health with Your Doctor
I thank you so much for all that I have learned and all the information I get from Diabetes Health. My copies are passed to my doctor so we are both learning more.
A Reader Finds Fault with Needle Maker
Diabetes Health is the top publication in its field and the only one I read anymore. Keep up the good work.
Now, a complaint. The "They can be used only once" blurb by an unknown manufacturer of needles is the lousiest, dirtiest bit of commercialism I have yet seen in any diabetic publication. As any of us who are on a budget know, we use a needle as long as it will go in comfortably. This used to be six or seven times but just recently I notice that four uses is about maximum. My conclusion is that the manufacturer is no longer coating the needle with silicone or is doing something to force us to use it only once. The pictures of the highly magnified needle point are ridiculous-stainless steel does not look that way after sticking it into soft flesh, and if it does I would like to know the brand so I can buy some other. We diabetics (at least after living 38 years with diabetes as I have) are not stupid and I am fed up with the barrage of ads for every high-profit item ever created for a diabetic.
To all people with diabetes: don't let any of these ads or articles scare you into buying anything. Use your common sense and don't be afraid to question your doctor.
Penn Valley, California
When Humalog Pools Under the Skin
My 12 -year-old son has had diabetes for two years now. He has been on the pump for the last year and only uses Humalog. Although, his insulin to carb ratio has gone from one unit of Humalog for 25 carbs to one unit of Humalog for 10 carbs (which he is now taking), he still only needs 1 unit of Humalog to lower his blood glucose to 130. I don't understand why his insulin to carb ratio has changed so much, and yet his insulin resistance hasn't.
My other question is: Although his endocrinologist disagrees with me, I feel that Humalog can pool beneath the skin in his thigh where his site is and can be effective longer than the 4 hours that they say Humalog is effective for. I have noticed that sometimes there is a lump in his thigh after an injection when his blood sugars are high. He rubs it until there is no longer a lump, and without taking any insulin, his blood glucose level drops within the next four hours. So, do you think that Humalog can remain effective for more than 4 hours if it is pooled (stored) beneath the skin?
Thank you. You have been very helpful to us.
Brooklyn, New York
The Discussion Continues on Medical Tattoos
My 12 year old son has diabetes, and trying to get him to wear any type of medical alert bracelet or necklace met with extremely limited success. Last fall he asked if we could "Just get a tattoo on my arm, that way I won't lose it." Thinking this might be a good solution I spoke with nurses in our local ER and they agreed. However, we have been unable to obtain a tattoo in this state (New Hampshire), or any of our neighboring states because the law states that one must be over 18, even with parental consent, to be tattooed. While I understand the intent of the law, and under any other circumstance would not want my child to have a tattoo, I see truly believe that a tattoo might well be life saving for a person with a life threatening disease. Please, if you have any suggestions on how to obtain a tattoo for medical reasons please e-mail me.
In a recent column you wrote about use of a tattoo as medical identification for diabetics, and asked for input from medical personnel about this practice. I am a neurologist, and my wife is a type I diabetic for 33 years, diagnosed when she was 18 months old. Here's my two-cents on this topic.
In my opinion, the tattoo is a good idea, but I think a bracelet is still best of all. Here's why.
Your tattooed friend is correct that medical personnel will probably see the tattoo on his chest. My concern would be about non-medical emergency personnel responding to an emergency in the field.
For example, police officers are often first on the scene of an accident, and although they are trained in giving first aid, they may not look on your friend's chest to see the tattoo. They almost surely would notice a bracelet, however.
I also wonder about type I's with hypoglycemic reactions that cause them to behave strangely, but not lose consciousness. As you know, hypoglycemic reactions may sometimes consist of aggressive or bizarre behaviors that superficially may resemble intoxication with alcohol or other drugs. Again, police responding to someone behaving strangely may notice a bracelet and think of medical evaluation before the person's condition deteriorates further.
I can imagine other situations where this might come up. For example, your friend was flying with you on an airplane. Flight crews are trained in emergency first aid, but in the case of a suddenly unconscious passenger, I bet they would think first of things like heart attack and stroke before diabetes. Similarly, a combative or disoriented passenger might be considered intoxicated or psychotic when really all he needs is a little sugar.
The other medical concern I have about any tattoo is the potential to contract a disease. I'm sure that many tattooers are scrupulously clean, but there is the potential for transmitting dangerous blood-borne disease from any invasive procedure such as tattooing. The risk of transmitting HIV is probably quite low, provided that even minimal sanitary standards are followed. More worrisome is the potential for transmitting hepatitis B, C, and E, which are much more common diseases, and thus more likely to be spread; unfortunately, they are quite serious, and often deadly. There are also relatively uncommon conditions like transmissible spongiform encephalopathies that could be contracted from a tattoo. Although these conditions are probably not very prevalent in the population, the fact that their infectious particles (called prions) cannot be destroyed by routine methods of disinfection makes them of somewhat greater concern. Once contracted, there is no cure, and the infected patient rapidly deteriorates from progressive brain degeneration. In my opinion, all of these make any elective invasive procedure not worth the risk.
My wife and I have talked a great deal about emotional reactions to diabetes. I think my grasp of the kinds of emotional issues diabetics deal with is as good as a non-diabetic can hope for. I understand why some people don't want to display stigmata that label them with the disease. But I do think it's important to give the diabetic person every possible advantage for that one critical situation we all hope will never happen: you are low or otherwise ill, and cannot tell anyone what you need. In that setting, seconds count, and the most obvious and accessible form of identification may save precious time.
When it came to medical identification for my wife, I admit that I lobbied hard for the bracelet. But I also told her truthfully that the decision was hers, and that I would support whatever she wanted to do so long as she carried or wore a medical alert token of some kind. She chose the bracelet, and now it has become such a regular fixture, she doesn't even notice it.
Hope you find these comments useful. If you wish to publish any of this, feel free to edit, summarize, or paraphrase as you see fit.
Garrett Riggs, Ph.D., M.D.
Gaining Access to Past Issues of Diabetes Health
I noticed that on page 9 of the January 2000 issue you were able to reply to an inquiry by reprinting material first published in your magazine in 1996. I have been a long-time subscriber but I rarely save articles-my filing skills would make that a useless pastime. Do you have any systematic way of recalling articles from earlier issues, for instance, a searchable data base with access via the internet? As I grow older, lots of health-related topics that I once passed over become important personally. It would be nice to know that I could browse in your archives.
Silver Springs, Maryland
Editor's reply: Thanks for your letter. We are working on this already. Your reasons for wanting it make it that much more important. We'll let you know in the magazine when it will be available on our Web site.
Some Kudos from Our Readers
I am a Pediatric Clinical Nurse Specialist who works with all the newly diagnosed children and families with diabetes in our area. I provide each of the parents with a subsription form to this newpaper because I find it is very layperson-friendly with good medical information as well as good consumer information.
Lynne Braxton, RN, MSN
Clinical Nurse Specialist/Pediatrics
Greenville, North Carolina
I just wanted to take this opportunity to thank you for such an informative magazine. I was diagnosed with Type 2 in April at the age of 47. My husband, who is a pharmacist, immediately suscribed to a couple different diabetes journals. Yours is my favorite and the one I take the most interest in. I often find articles I wish my doctor could read. Thank you again.
I am a RD/CDE with Cigna Healthcare of Arizona. I recently became acquainted with Diabetes Health. I want to congratulate all of you on your success in designing an interesting and informative magazine. I teach diabetes classes and I plan to use material from your magazine (and make a plug for subscribing to it as well). I have learned a great deal from articles and I like the style of writing; the language is understandable and not too clinical. Also, the information is cutting-edge.
Keep up the good work!
Dr. Schwartzbein's Diet Works
I am a male type II diabetic and after going on Dr. Schwartzbein's diet as outlined in her book "Dr. Schwartzbein's Principles," I cut my oral agent in half (to only 500 mg daily of glucophage ) and lowered my HBA1c from the low to mid 7's to under 6.0 and lowered my cholesterol by 30 %.
The most profound dietary change I actually adopted is simply limiting my carbohydrate intake to 40 grams or less for each meal and 15 grams for snacks. I exercise four to six hours per week or my carbohydrate limit would be lower.
She advocates limiting carbohydrates while increasing protein and fat intake. Patients on the diet don't even count fat grams or total calories. They only count carbs.
The real surprise in her book was the notion that the liver when confronted with high insulin and glucose levels from excess carbohydrate intake converted the blood sugar to cholesterol. It seems to be true.
If I limited my carbohydrate intake to the meager 15 grams per meal and 8 grams per snack recommended for diabetics I could even stop the one Glucophage pill per day routine. However, my personal physician is reluctant to allow even a short test period. The debate will continue.
P.S. I ordered the In-Charge fructosamine meter I saw advertised in your magazine and it is an excellent tool to stay in control since it gives you a one to two week average blood sugar result. That is much more useful data than the random or fasting instantaneous glucose levels from normal meters.
Huntington Beach, California
Re: "Just what is a healthy diet for a person with diabetes?"
Editor: One of our readers has responded to a letter from Karen McDonald, published in our January 2000 issue. Ms McDonald felt that people with diabetes should not feel obliged to eat from all the food groups if some of the foods are not of benefit to them. She singled out carbohydrates as a culprit for people with diabetes and suggested that a diet of proteins, fruits and vegetables would be a healthier choice.
I was concerned that there was no Editor's response to Ms. McDonald's letter. I was left with the feeling that her comments supporting the latest diet fads was the correct diet for people with diabetes.
Although I am not a dietitian, I hope that a dietitian will respond to Ms McDonald's comments on her ideas of what a healthy diet for diabetes is. While foods that are high in fiber from the vegetables and fruit group are healthy for people without kidney problems, from all that I have read, high-protein diets are hard on the kidneys, lead to calcium loss in the bones and to increased incidence of heart disease which causes 70% of deaths among people with diabetes. It is portion sizes and balance that help us keep our blood sugars in better control because almost all foods turn to sugar before it can be used by the body.
I have had diabetes for 37 years and within the last few years have gone toward a vegetarian diet. I have been able to bring my lipid panel into an excellent range and I try to keep my blood sugar in control through exercise and the correct amount of insulin.
An Answer to Deborah L. Moore on Animal vis-a-via Pump Therapy
Deborah Moore's letter was extremely encouraging. I would hope that my case would be so easy. Every type of human insulin I tried would work just fine for about 3 weeks. But then it would go haywire. To control my levels, I gradually increased my dosage. My dose would double and even triple.
I have been disheartened by many medical professionals who believe they know it all and want to offer a pat answer to my needs. I certainly need [a doctor] who can observe me and my responses and find a new solution. After all I have been through, I am afraid of trusting someone who won't listen to me.
I have gotten a video and received information about the pump. I'm willing to try but it would be a complete change in my therapy and regimen and still there would be no guarantee of success because the immune rejection that I seemed to have to both human and pork insulins could make pump therapy ineffective for me. I'm open to change, but messing with insulin can be life-threatening and my diabetic history from day one has never fit the textbook profile of the diabetic model.
Santa Ana, California
P.S. I did get my bovine insulin from the U.K. and I'm under control with a great HbA1c. At the moment I'm enjoying the respite. Perhaps when my tide turns again there will be newer and more promising options available to me.
Editor: The U.K. company Ms. Vernier referred to in her letter is CP Pharmaceuticals. Their toll-free number is 011-800-667-55555.
Other Properties of Alpha Lipoic Acid
There was an article on page 41 of the January 2000 issue of Diabetes Health relating to alpha lipoic acid. I suggest you do an additional literature search on this subject as there are other important properties of alpha lipoic acid that were not mentioned.
For example, it inhibits glycosylation of proteins and therefore can reduce the incidence of many diabetic long-term complications. It also increases insulin sensitivity even in slim, type 1 diabetics who are not insulin-resistant. It should also be pointed out that while large doses are necessary to achieve many of the effects, the water-soluble version is effective in much lower doses. Inhibiting glycosylation of proteins usually reduces levels of A1c in people who take this product and means they can no longer use A1c results as an indication of average blood sugar.
Richard K. Bernstein, MD, FACE, FACN, CWS
Mamaroneck, New York
A Formula for Frequent Fliers
I was delighted to read your January issue and the article from Mr. Charles Swanson of Fremont, California. I too have been diabetic and insulin-dependent for 53 years, having been diagnosed in October 1947 at the age of 17. Otherwise, I have been in good health with excellent vision and no other ill effects which I am extremely grateful for. Over the years I have always been very brittle with glucose readings ranging from 40 to 200. I have had some earlier bouts with hypoglycemia after switching from pork and beef insulins to human insulin. However, since going on Humalin and Humalin N combinations I have eliminated most reactions with only some very minor ones. This plus having a fantastic wife for 45 years has kept me in very good health.
It would be fun to have a list of those 50-plus type 1 diabetics and get together on a local or regional basis to compare notes. My wife and I have travelled extensively since my retirement in 1994, having just returned from a tour of Southeast Asia. I test my blood when travelling up to 9 times a day and have a formula for dealing with time zones and the changes as they occur.
It's a matter of timing in taking the insulin at the right time. In other words, during a normal day when I'm home I take it 3 shots a day at the same times. I've been on insulin for 53 years. I pretty much know, depending on my blood suagr, how much insulin I have to take if I have a rough idea of what I'll be eating.
When we flew from San Francisco to Tokyo, we went across several time zones and of course, on an airplane, they're serving meals two to three times during the flight. I know how long Humalog insulin is going to last. It peaks at about 3 hours for me and it tapers off drastically after 4.5 to 5 hours. Based on that, I'd take the appropriate amount of insulin, usually about 5 units, if I'm going to take an ordinary evening meal. I'll take about 5 units of Humalog because I've already taken Humalin N prior to that. I never change the amount of Humalin N I take-that stays the same no matter what time zone I go through but I do vary the Humalog.
Before I came up with the formula I had a lot of hypoglycemia. I test myself 8 times a day. I always carry food with me, snacks like Gluc-O-Bars and granola bars. It works for me.
I would encourage all diabetics to subscribe to Diabetes Health since there is a wealth of information available in the magazine.
I have one bit of advice to all diabetics: stay in good control because the sooner you start the longer you will live.
St. Paul, Minnesota
Hopes Springs Eternal
Just a few words to let you know I always look forward to the next issue. I am a type 2 diabetic and just found out about it two years ago. My sight was getting bad and the eye doctor told me I should get checked for diabetes or high blood pressure. It turns out I had both and the bad vision was due to advanced retinopathy. My vision was 20/400. I've been having laser surgery for over a year and at least my vision hasn't gotten worse. I'm contemplating a surgical procedure that would get rid of scar tissue. My spirits are good and I know that some day soon they will come up with a cure for my problems. Diabetes Health has already answered any questions I've had. Through diet and exercise (I don't need medication right now), I'm feeling great. My feet and legs have more feeling. By the way, I'm 63 years young and intend to be around for a long time if I can stay away from the jelly beans.
Cartoon was not Funny
In the July 1999 issue, there was a cartoon with this caption: "They gamble on everything. Whoever has the lowest blood sugar wins!"
Not very funny. Sometimes, the person with the lowest blood sugar dies.
Why aren't the editors of DI aware of the dangers of hypoglycemia? Why do you seem blind to the need to control blood sugars? Why don't you live up to the name of the magazine and have interviews with diabetics about controlling blood-sugar levels?
Why does it seem like you don't care? Why does Scott King seem shocked and surprised when one of his relatives does not control her blood sugars and then gets diabetic complications?
Why don't you provide more helpful information instead of filling your pages with industry press releases?
Good Wishes for Carol
Your magazine is my favorite, as it is open to all views and is the only magazine that truly presents all research and articles of anything new for diabetics. I am so grateful that you are published.
Scott, it was in some way an inspiration for me to get back on track with my own diabetes care as I read with sadness about your mother-in-law. I do hope she is improving and shall continue to do so. Like her, I hate to be told what to do, and slowly have been eating all the good foods that are so bad for me. Her story has made me realize how foolish I am behaving. I will definitely take control. I too am 64 and have type 2 about 10 to 15 years.
Thank you so much for the wonderful article and details of "Low Carbohydrate Diets" it told all, and certainly with an open view. When I am on that diet, I do not need any insulin, without it and eating a lot of carbohydrates, I need huge quantities of insulin and I suffer from frequent lows. That surely should tell me something?
Keep up the excellent reporting and again I am thankful you are there for me. I am looking forward to March to once again read what is new.
Laguna Woods, California
Scott, I was very moved by your most recent editorial. Just wanted to let you know we are praying for Carol. We love your magazine. We have tried a number of diabetes magazines through the years and yours is the best. My husband has been insulin-dependent for 47 years. Both our children are also insulin-dependent. My husband has all the complications to one extent or another-heart attack, bypass, eye problems, neuropathy, mini-strokes, and reduced renal function-but we are so blessed that he still works every day, although it is with a great deal of effort and he does struggle daily. Thank you for such an excellent magazine. Let me again assure you of our prayers.