Health Care and the Warm Fuzzies

Health Care and the Warm Fuzzies

You’ve undoubtedly seen the commercials on TV for healthcare insurance.  I call them the “warm fuzzies,” since that’s the feeling they hope to exude.  The actors are smiling, deliriously happy, content and thrilled with their coverage.

Let’s step back a bit and take a realistic look at what happens.  Today, I had an appointment with my cardiologist.  It was made 6 months ago.  I know this because he expressly set up a 6-month follow-up with me.  He’d also made an appointment for some tests which I’d had a week ago.  I received a call last week from the doctor’s office, reminding me of my appointment.

I arrived, signed in and had a seat.  After a moment the lady at the front desk called my name.  It seems there was some question about my appointment.  The staff was missing a referral.  I explained the date had been made months ago and I’d even received a reminder from this office within the last week.  “But we don’t have a referral from your primary.”

I decided to call my internist to find out if they could send a referral.  The receptionist said she’d check on it and put me on hold.  While the “elevator music” was entertaining, after several minutes I decided to call back.  The receptionist explained the person that takes care of referrals was not in.  I’ve seen a note in my internist’s office that there is a 5-day wait on referrals.  I can understand last minute requests need to be discouraged.  On the other hand, I was standing in the cardiologist’s office waiting for my appointment.

I explained to the staff that I could not get the referral.   They were checking with the insurance company and finally offered to have me set up another appointment.  By this time, 45 minutes had passed.  My frustration was palpable, my blood pressure had risen and rather than have a cardiac event in the office, I left.

Once home, I called the insurance company — those people whose biggest thrill in life is to make me deliriously happy.  The member engagement individual attempted to reassure me as she explained what is at best a convoluted system.  When I make an appointment, like this one, 6 months in advance, I have to remember to have my internist send a referral.  However, she can’t do that 6 months out, because it will expire after 3 months.  That’s right folks, I have to wait 3 months and then have my primary doctor send a referral.  My headache was increasing.

I have CVD, a diagnosis that isn’t going away anytime soon.  One might even say it’s a chronic condition.  It’s vital that I see a cardiologist at least once or twice a year.  Apparently, my health insurance company knows better than my doctors, the American Heart Association, and the AMA.

My next call was to my internist.  I explained I needed a referral so I could make an appointment with my cardiologist.  “We need to have the date of the appointment.”

“I don’t have an appointment yet.”

“But we need the date before we can do the referral.”

OMG.  There appears to be a conspiracy.  The medical establishment has decided to do me in.  Mind you, they are all very polite.  If anyone was losing it, it was me – not them.  They all told me how they regretted my plight, but as the words, “I’m sorry….” were uttered, a pause trailed off as if they knew to add the word “but” would indicate their total lack of empathy.

It was time to call the cardiologists office.  I spoke with someone briefly, explaining what had happened.  He put me on hold for a few minutes and then said, the first appointment we have with your doctor is in July.

“Do you not understand he wanted to see me today, six months ago?  Maybe 3 months more won’t hurt, or on the other hand, maybe I’ll be dead by then.”

“I’m sorry, let me check further.”  When he returned to the line, he said he was going to do some more work on this and would call me again in the afternoon.  “Let me see if I have all your information…Oh, I just realized today is your birthday.”

“Yes, it is.  And so far today, the medical establishment seems to be determined it will be my last!”

My 9:45 am appointment has long since passed.  I received a call from the cardiologist’s office.  I have an appointment on May 23rd.  I’ve contacted my internist with the date so a referral can be prepared.  The insurance company assured me that I can verify everything online.  The time is 5 pm.  What a fantastic way to celebrate a birthday.

Like George Bush, I remember a kinder, gentler time, when you could just make an appointment with a doctor and go see him or her.  But now we have warm fuzzies — that only exist in your mind.

 

BODY LANGUAGE

BODY LANGUAGE

The definition of body language is, “the process of communicating nonverbally through conscious or unconscious gestures and movements.”  But, I’m thinking of something different.  I’m here to discuss how your body speaks to you.  If you are sick, your body might ache, and your temperature rise.  These are straightforward messages from your body.  However, sometimes, the language is more subtle.  Let me tell you a story to illustrate what I mean.  It’s Martin Luther King’s birthday, 2016 about 12:39 am.

I awoke in extreme pain.  I had a toothache.  It’s the kind of pain you feel when you require a root canal.  I got out of bed, walked into the kitchen and got a drink of water.  As I wandered around the house, the pain began to subside.  I was exhausted and asked myself, “Did I really feel that?”  I finally convinced myself it was my imagination and went back to bed.

A few hours later, the pain returned.  I’ve undergone a root canal, and I know the pain doesn’t come and go.  I was also aware that when having a heart attack, one can experience referred pain.  Instead of feeling pain in your chest, it can be in your head, neck, arms, or back.  I figured I’d better check this out — and I did.  I went straight to Dr. Google.  I looked up angina.  There’s stable and unstable angina, the latter indicating a heart attack.

Not having graduated from medical school, but considering myself an excellent diagnostician, I determined I did NOT have a heart attack.  Mind you, I had just read on the Mayo Clinic site that unstable angina occurs even at rest (I was asleep) and often is unexpected.

My doctor’s office would be open in a couple of hours, and I decided to call her.  In the meantime, I took a shower, dressed, and worked in my office.

I explained to the receptionist I believed I might be having angina.  The doctor got on the phone and asked for my symptoms.  I told her what had occurred and she said, “Go to the Emergency Room.”

I countered with, “Well, I thought I’d just come to your office.”

“I don’t have time to drive you to the ER.  Go to the hospital … and don’t drive yourself.”

After some blood tests, chest x-rays, and EKGs, a young ER doctor came to the room I was in and said, “You’ve had a heart attack.”  Quite frankly, he looked to me to be about 19.  What could he possibly know?  Apparently, more than I.  Within minutes a very tall cardiologist walked in and said, “You’ve had a heart attack.  We won’t know the severity until you have a cardiac catheterization.”

Ten hours had passed since I felt the first pain.  Also, I’d experienced fatigue, another symptom of a heart attack.  What did I do as I was having a heart attack?  I went back to bed, diagnosed myself, worked in my office, and yes, took a shower!  Had my occlusion been in a different artery, those decisions could have been fatal.

Like many victims of a heart attack, I looked at the event and my quick recovery and figured, that’s it — I’m well.  I actually thought, “Is that all there is to a heart attack?”  What I didn’t consider is the cause and effect aspect.   The heart attack was fixed with a stent. However, the underlying cause, cardiovascular disease, was still with me.

Almost one year to the date of my event, I was exercising more rigorously than usual in Cardiac Rehab when I began feeling some pressure in my jaw.  No pain, just pressure.  I stopped and asked someone to take my blood pressure.  It was elevated from exercise, but nothing concerning.  So I continued my routine.  As I was leaving, I mentioned what had happened to a nurse.  She said to call my doctor.  I did and was told to come right in.  My doctor, in turn, called my cardiologist and within a week I was back in the cath lab.

I had somehow avoided a second heart attack.  However, my Left Anterior Descending Artery  (a/k/a WidowMaker) was 95% occluded.  This event was potentially worse than the earlier heart attack.

Your body speaks to you.  I pretty much ignored my first cardiac encounter.  Fortunately, even though the second message was much more subtle, I listened.  Quick action saved my life.

Here are my rules to live by.  First, listen to your body.  Second, know your numbers:

Blood Pressure:  The new “Normal” is less than 120/80

Triglycerides:  Normal is less than 150mg/dl

Cholesterol:  LDL less than 70 (it was 100); HDL more than 40

Third, get some exercise.  You don’t need a gym.  Go for a walk in the park or if the weather is not conducive, go to a mall.  The American Heart Association recommends 30 minutes of exercise daily.

Oh, and if you’re still smoking, STOP!

Our bodies speak to us when something is wrong, in a language that is sometimes confusing or subtle.  In our busy worlds, we tend to ignore the message or pull a Scarlett O’Hara saying, “I just can’t think about this now.  I’ll think about it tomorrow.”  But here’s the rub: tomorrows aren’t guaranteed.

Editors Note:  This was a speech given at Miracle Mile Toastmasters on March 7, 2019.

 

Fred & Ginger Had Rhythm, Do You?

Fred & Ginger Had Rhythm, Do You?

We’re talking about circadian rhythm.  From the Latin circa (around) and diem (day), circadian rhythm is any biological process that displays an endogenous, entrainable oscillation of about 24-hours.  These 24-hour rhythms have been widely observed in plants and animals (including we humans).  So, while we all have an inert rhythm – why don’t we “dance” to it?

In the suprachiasmatic nucleus of the brain, we have a “clock,”  which governs when we sleep and rise, taking (in part) its cues from light sources to govern our 24-hour day.  Doctors Michael Roizen and Michael Crupain suggest in their new book, “What to Eat When,” this biological rhythm affects our digestion and hormonal levels,  and it dictates when it’s best to exercise and to eat.  In fact, they propose that “when we eat, is just as important as what we eat.”

Two weight loss studies conducted by Dr. Jakubowicz, of Tel Aviv University, include the effects of circadian rhythm.

In a 12-week study, 93 obese women, were divided into two groups.  The objective for all was to lose weight on a 1400 calorie per day diet consisting of moderate-carb and moderate-fat intake.  The food consumed was the same, except that one group’s breakfast was composed of 700 calories, lunch 500 calories, and dinner 200 calories.  Group 2 did the reverse, 200 calories at breakfast, 500 at lunch and 700 at dinner.

Everyone lost weight.  The big breakfast group lost an average of 17.8 pounds and 3 inches off their waistline. The big dinner group lost 7.3 pounds and 1.4 inches off their waistline.  The more abundant breakfast group also showed significantly lower levels of ghrelin (often referred to as the hunger hormone), and a decrease in insulin, glucose and triglyceride levels.

In another study, 193 obese, non-diabetic adults participated in a 32-week study.  Again, they were divided into two groups.  Men had 1600 calories per day, women 1400 calories.  One group had a low carbohydrate diet with a 300 calorie breakfast; the other was high in both proteins and carbohydrates and always included a dessert for breakfast.  This meal came in at 600 calories.  After the study, the group with the big breakfast lost, on average, 40 pounds more than their peers.  Part of the problem for the low carb, small breakfast group was the participants didn’t endure denial well for 32 weeks.  As mentioned in an earlier post, when faced with deprivation, one can sometimes become depraved.

While the Israeli studies results are compelling, they are supervised diets, and I wouldn’t advise something so drastic without direction from a professional.

In urban America, our days are filled with work, school, and other activities.  We leave homes at different times, not having breakfast as a family unit.  During the day, there is work, school, after-school activities, and appointments.  Our calendars are full.  At the end of the day a family, hopefully, can sit down as a unit for what is usually their largest meal.  Complicating our lives, even more, is the control technology has over us.

So I asked myself, “how can I incorporate a better “when” into my diet day?”  I figured this would be a relatively easy process.  I  was wrong.  Even following the book’s four guidelines can be problematic.  I get up early and have a substantial breakfast (which includes fat, protein and whole grains) by 8 am.  I plan lunch between 12 and 1 pm.  Dinner is my smallest meal, and I try to eat it between 5 and 6 pm.  This is fairly compatible with the guidelines.  However, keeping a consistent mealtime schedule is not as easy as I’d thought.  It’s here the adage, “make plans and life happens,” comes in to play.

The doctors also discuss what to eat when you’re experiencing stress or grief, how to handle health issues and other everyday life challenges that arise.  Importantly, they do speak to “mindful” eating.  Enjoying a meal without phone or text interruption, and eliminating television programming while dining is recommended.

There is science to aligning our circadian clock with our hunger clock.  Do you want to figure out how you can incorporate the “when” into your day?  Read “What to Eat When.”  Some suggestions may be easier to integrate into your life than others, but there is no doubt, better positioning the two rhythms can be beneficial to your well-being.

 

 

 

 

 

 

 

 

 

NAVIGATING THE DIET MELANGE

NAVIGATING THE DIET MELANGE

This is the time of year when diet companies and weight loss plans, make promises to transform you — producing a better, fitter, and more amazing you.  Many suggest these remarkable changes will occur almost overnight, with little or no effort.  As with anything in life, if it sounds too good to be true, it probably is.  I decided to do some research.  Every year U.S. News & World Reports puts out a list of the best diets.  I checked out those top rated.  Here is a link to the article:  https://health.usnews.com/best-diet/best-diets-overall.

The left-hand column of the article provides ways you can customize a diet.  There are rankings (kinds of programs), or you can modify the type of regime, as well as specific preferences you desire.

When I started on my weight loss journey, I had 2 objectives:  1) Lose weight and 2) Not ever have another heart attack.  To be honest, there is no guarantee of the second goal. The reality is I have cardiovascular disease (CVD).  After my myocardial infarction (MI), stents were inserted, and it resolved an immediate problem.  It did not take away the CVD.  For me, this is a good-news, bad-news scenario.  The bad news is I could experience (and almost did) another cardiac event, the good news is I have learned and continue to learn how to listen to my body and take better care of it.

The top 3 diets overall, at U.S. News were:  1) The Mediterranean Diet, 2) The Dash Diet, 3) The Flexitarian Diet.  In all 3 plans, you do the shopping at your local market  — there are no premade meals to buy.  While they all recommend fresh fruits and vegetables, you might consider frozen vegetables, which are generally harvested in their prime and quick-frozen.  Be sure you get the veggies without sauces, butter, etc.  Plant-based proteins are advocated (legumes, beans, nuts), but you don’t have to give up lean meat.  There are hundreds of recipes available online and cookbooks dedicated to all 3.

I was listening to Dr. Jen Ashton, the Chief Health and Medical Editor, and Chief Medical Correspondent for ABC News and Good Morning America, discuss the finding from U.S. News.  In addition to being a physician, Dr. Ashton received a Master’s Degree in Nutrition from Columbia University in 2016.  Credentials in nutrition are a rarity among physicians.  One thing Dr. Ashton emphasized is that any diet has to be “sustainable.”  If any program is not easy to follow you will likely give up.  All 3 of these diets are easy to follow.

Since a primary reason for researching diets was because of my concern over heart health, I feel compelled to mention the Ornish Diet, which tied for #1 with the Mediterranean Diet in the Heart Healthy category.  A preeminent difference between this and the Mediterranean Diet is that it is incredibly restrictive with the use of oils (even unsaturated), foods containing cholesterol, animal products, etc.  The plan emphasizes stress management and exercise in addition to diet.  Both are essential to maintaining a healthy heart.

While I don’t follow it flawlessly, my diet most resembles the Mediterranean Diet.  Hell, I am Italian after all.  Of course, if you look at the European portion of the Mediterranean Sea, it encompasses Greece, Italy, France, Turkey, and Croatia — all with different kinds of cuisine.  Yet they all share a similar pyramid.  All meals include the base (this is where most of your food will come from) encompassing fruits, grains, vegetables, beans, nuts, legumes, seeds, along with herbs and spices.  Next up on the pyramid is fish and seafood.  These you have at least 2 times per week.  Next up is poultry, eggs, cheese and yogurt which you have in moderate portions daily to weekly.  The tip of the pyramid contains meats and sweets — these foods, of course, are in limited quantities.

There is one other thing we must consider when discussing the Mediterranean Diet.  People from that region, do not hop in the car to go to the mall or market.  They walk just about everywhere or ride bikes (how un-American).  In other words, they are not couch-potatoes, they are active.  Don’t expect to lose weight, if you aren’t moving.  Think at least 30 minutes a day of moderate to vigorous exercise.  If you’ve been inactive, start off incorporating physical activity 3 days a week, increasing your workout as you can.

So there you have it.  The top diets, according to U.S. News.  There are more.  Under best weight loss diets, you can find Weight Watchers, Volumetrics Diet; Best Fast Weight Loss Diets gives us HMR Diet, Atkins Program and Keto Diet; Best Commercial Diets include Jenny Craig and Nutritarian.  OMG, it goes on and on.

There are additional charges to join many of the Weight Loss and Commercial Diet Plans, plus monthly fees.  Some have group meetings, meetings with counselors (or a combination of both) and some are available online You need to choose what works for you.  Prepared food can be purchased directly from the company or at your local market, reducing preparation time for the user.  Just remember Dr. Ashton’s advice, whatever you select, IT MUST BE SUSTAINABLE.

Early on I tried Weight Watchers and dropped it because while it offered portion control and a pretty healthy approach, I didn’t know how many macro and micronutrients I was getting per meal or per day.  Was I getting too many carbs, too much fat?  It simply didn’t follow the lifestyle of a control freak.  However, others swear by it and if it’s working for you, stick with it.

Finally, I judge my diet results, not on a number on the scale, nor a dress size.  I look at my waist size (more on this in a future post) and most importantly on lab results, and maintaining healthy blood pressure.

Our obsession with diet has created a multi-million dollar industry, which is difficult to navigate.  We need to have a “buyer beware,” sign out there as we evaluate what’s in our best interests.

What do you do?  How do you measure your success?  There was a lot to this post.  I hope I didn’t discourage you.  Let me know your thoughts.

 

Taking the Die Out of Diet!

Taking the Die Out of Diet!

“Hey, I’m depraved on account I’m deprived.” Dear Officer Krupke, West Side Story

You’ve decided it’s time.  You’ve literally eaten your way through Thanksgiving, Christmas, Hanukkah, and New Year’s.  If that wasn’t enough — you consumed enormous quantities of calories attending all those holiday parties.  You are left with a widening waistline, little or no energy, and quite often a dip in your self-esteem.

When you think of the word “diet,” what comes to mind?  How about:

  1. Low fat (or no fat)
  2. No pasta, no bread, no sweets –NO CARBS
  3. Limited calories
  4. No Alcohol
  5. Salads, salads, salads (OMG, I hate green food)
  6. Gluten-free foods — What the hell is gluten?
  7. Starvation

If you can say “Yes” to one or more of the above, you are in deprivation mode.  Trust me, that inevitably leads to becoming depraved.  An example of this kind of depravity is simple.  I do not like coconut.  I’m not fond of the aroma, the taste, or the texture of those shavings placed on top of desserts.  If I am told I cannot have coconut, I will begin to crave it.  In anticipation of expected deprivation, I become depraved!

Like many of you, I’ve tried so many weight loss plans and had little or no success.  Maybe I lost some pounds, but stop the diet, and they would miraculously reappear.  In surrender, I’d thrown my arms in the air figuring, I’d never win in the diet arena.  As I stated in my previous blog post, what finally got my attention was a heart attack.  This weight problem was no longer a vague idea of looking better, my life was on the line.

My life is so often serendipitous.  It took 2 years to find my primary physician.  Incredibly, she is board certified in obesity medicine and has more than a nodding acquaintance with nutrition.  She provides seminars for her patients which include professional dietitians, psychologists, and physical therapists.  She started me on the path of my weight loss journey.  To date, I’ve said goodbye to 35 pounds.

In addition, I’ve taken on-line nutrition courses through edtogo.com.  This does not make me an expert, but I’ve found some things that have worked for me — and that may work for you.  Perhaps you can share some of your experiences that will help other readers.

There is no “one size fits all” diet out there.  Wish there was — bet you do too.  However, sharing what’s worked and what hasn’t might give someone else a “leg-up.”

The “Food for Thought” section of my blog will include suggestions, ideas, recipes (if from another source, there will be links to them).  I hope you are as excited about this section in my blog, as I.  Let me hear from you.

 

Remembering Cari

Remembering Cari

I was attending my first WomenHeart meeting two years ago.  The meeting was starting, and I quickly found a seat, sitting next to Caridad (Cari).  There were maybe 25 – 30 women present and I wasn’t sure what to expect.  Sometimes, the meetings have speakers or activities, but this evening was dedicated to sharing.  I was to learn that taking the time to listen and learn from other heart patients, is an invaluable tool for all.  As it came time for Cari to share, she started to tear up.  In addition to heart disease, Cari had several other serious health issues.  Having an opportunity to express her problems was difficult, yet she did so with profound dignity.

She told us about her Vision Board. It had words of encouragement, pictures of loved ones, and a photograph of the beach – a place she associated with peace and serenity. The first thing every morning she would look at it.  It would lighten her load and help her start her day with feelings of thankfulness.  At the end of the meeting, I spoke with her and our group leader, Annie, about having a Vision Board party for our WomanHeart group.

In January 2017, we had our VB party.  What a great time.  After working on our boards,  we shared our completed projects with everyone.  Here is Cari with her Vision Board along with Annie de Velasco, Andee Weiner and me.  What a happy moment.

As I look at Cari’s Vision Board, I see pictures of her family and of course her beautiful beach.  Most prominently we find the word, GRATITUDE, something integral to her well-being.

Cari passed away early last week.  In the song, Seasons of Love, from the musical, Rent, we are asked, “How do you measure the life of a woman or man?”  The answer is, “Measure your life in love.”  Cari exuded love.  I am so grateful I had the opportunity to know her, if only for a brief time.

The Quality of Bending Easily Without Breaking!

The Quality of Bending Easily Without Breaking!

A quote by Maynard Webb caught my eye some time ago.  He stated, “Flexibility has become a modern-day value.  But flexibility comes with a cost.”  

It brought me back to a time when a friend and I attended yoga classes.  Rosalie and I were thirty-something, and our instructor was perhaps in her 60’s.  She was amazing!  Just watching the spring in her step, her agility and “stretchiness.” Is that a word?  Whatever!  She had stretchiness!  Watching her was inspiring.  

While I’m not an expert on kinesiology, it’s known that as we age our joints stiffen, and that lovely suppleness of youth is but a memory.  I was experiencing this.

I’m not Elizabeth Gilbert, and it’s unlikely that I will go to an ashram as she wrote about in her book, ‘Eat, Pray, Love.’  But thinking again of my former instructor, it occurred to me going to a yoga class was an excellent idea.  I googled Yoga and found a Hatha Yoga school not too far from my house.  And surprise, a beginners’ class was scheduled to start in one week!

On day one, I found myself with some ladies ranging in age from twenty to perhaps 60 or 70.  We were told some movements tend to be effortless, while others are arduous.  We were assured that if we’d stick with it, we would see improvement.

The first thing we were asked to do was sit cross-legged, while maintaining good posture, with knees bent and opened wide like a book. Sounds easy, doesn’t it?  I watched the others in the class.  Their knees were not only opened wide but almost touching the floor.  Mine were up to my ears.  It was suggested that I sit on some towels, elevating my bum, so my knees appeared to be closer to the floor.  Somehow that seemed like cheating, but at least my “pose” looked more similar to everyone else’s.  Of course, I appeared to be a foot taller than everyone else in the room as well.

We proceeded with several poses.  Funny, I had no recollection of pain during my earlier classes.  Our instructor explained that most of us had spent many years sitting, standing and walking incorrectly.  “As a result, some of these poses may be difficult. But don’t worry, just stick with it.”  Good grief!  I had so many years of lousy sitting, standing and walking to make up for!

And the poses continued:  the mountain, the chair, the triangle, downward facing dog — some more difficult than others.  I don’t recall perspiration dripping down my face in past classes, but I was beginning to feel it now. Thinking back on my earlier experience, we glided almost ballet-like from one position to another.  There was nothing rhythmic in my movements now.   Then we were on the floor again —  I in an un-lotus like pose.  I panicked thinking, “Oh my God, my hips are locking, where is the exit?” 

Perhaps, the instructor saw the look of terror on my face, because she asked us to rise again and that’s when it happened.  When you’re as stiff as I was, getting up can be a challenge.  I didn’t fall, because I was able to catch myself by jamming the second toe of my right foot into the floor.  There was PAIN!  Just as I was about to let out a gasping cry, I saw the sign:

“NO WHINING PLEASE”

“What?  No whining, please?  This place must be run by sadists!

I looked around for an escape.

Our instructor, however, was on to another pose — the ‘Warrior Pose.’  She tried to assist this now wounded warrior by moving my left foot, putting more pressure on the toe on my right foot.  She didn’t understand that I couldn’t do that and breathe at the same time.

The hour was almost over.  The instructor said,“It’s time for the ‘Corpse Pose.’”  CORPSE POSE?  They actually have a designated pose for a dead person?  I figured they were going to put me out of my misery.   Lying on my back, my toe throbbing, I awaited my fate.  Fortunately, the Corpse Pose is a time for meditation.  I would have enjoyed it but was in so much pain, I couldn’t think of anything else.  Then I heard a soft voice say, “Namaste.”  The class had ended.

I hoped my ‘corpse toe’ could be revived.  Too bad there was no video of me leaving the studio.  Limping and appearing to be wearing some kind of body armor, I was the personification of rigidity.

Good old Maynard Webb.  He was right.  Achieving flexibility does come with a cost.  Of course, he was talking about working in the age of the internet.  For me, well it came with a broken toe.  

For my next act, I think I’ll take up Tai Chi.  

Editor’s Note:  You may recall this story from back in 2014.  Last Wednesday, I was asked to fill in as a speaker at Toastmasters.   So reworked the original article to a speech format.  Hope you enjoyed this version.