Forest Tennant, MD, DrPH
Une mort soudaine et inattendue peut survenir chez un patient souffrant de douleur chronique sévère, et l’événement terminal peut ne pas être lié à un traitement médical. Heureusement, la mort subite n’est pas aussi fréquemment observée chez les patients souffrant de douleur que les années précédentes, probablement en raison d’un meilleur accès à au moins certains traitements. Cependant, la mort subite se produit toujours, et les praticiens doivent savoir comment repérer un patient «à risque».
Inattendue, la mort subite due à une douleur intense est peu appréciée, car de nombreux observateurs considèrent toujours la douleur intense comme une nuisance inoffensive plutôt qu’une calamité physiologique potentielle. Dans de nombreux cas, juste avant la mort, le patient informe sa famille qu’il se sent plus malade que d’habitude et cherche à se soulager dans son lit ou sur son canapé. Malheureusement, certains de ces patients ne se réveillent pas. D’autres patients meurent, sans avertissement, dans leur sommeil ou se trouvent effondrés sur le sol. La toxicologie agressive de la médecine moderne et les procédures médico-légales après la mort ont contribué à la mauvaise compréhension de la menace de mort de la douleur. Dans certains cas, un patient souffrant de douleur qui a été traité de façon appropriée avec un opioïde ou un autre agent ayant un potentiel de surdose ou d’abus est mort subitement et de façon inattendue. Des médicaments ont été trouvés dans les fluides corporels après la mort,
Cet article vise en partie à attirer l’attention sur le fait que la simple découverte de drogues abusives à l’autopsie ne signifie pas nécessairement que les drogues ont causé la mort. En fait, les médicaments peuvent avoir retardé la mort. Certains médecins ont été faussement accusés d’avoir causé des décès en raison d’un abus de médicaments, alors qu’en fait, le traitement insuffisant de la douleur pourrait avoir causé la mort. De plus, les taux sanguins d’opioïdes mesurés à l’autopsie d’un patient décédé subitement sont trop souvent considérés à tort comme des surdoses accidentelles parce que le pathologiste ne sait pas que les patients souffrant de douleur chronique sous opiacés peuvent fonctionner pleinement avec des taux sériques d’opioïdes prescrits. dépasser les niveaux létaux chez les patients naïfs d’opioïdes. 1
Les mécanismes de la mort soudaine et inattendue chez les patients souffrant de douleur et les mesures de protection que les praticiens doivent prendre pour éviter d’être faussement accusés de causer une mort soudaine et inattendue sont donnés ici. Plus important encore, voici quelques conseils cliniques pour aider à identifier le patient souffrant de douleur chronique qui présente un risque élevé de mort subite et inattendue, afin qu’un traitement de la douleur plus agressif puisse être rendu.
Une brève histoire anecdotique
En tant qu’étudiant en médecine à l’Université du Kansas au début des années 1960, j’ai dû suivre un préceptorat en milieu rural avec un médecin de campagne. En faisant un tour à la maison de retraite du comté, j’ai entendu la femme d’un fermier déclarer: «La douleur a tué ma mère la nuit dernière.» Depuis lors, j’ai entendu dire que la douleur avait tué un être cher. Le folklore mentionne fréquemment que les gens meurent “de”, ainsi que “dans” la douleur. Il y a cependant peu de détails écrits sur ces événements.
Dans les premières années de ma pratique de la douleur, que j’ai commencé en 1975, j’ai fait mourir plusieurs patients soudainement et de façon inattendue. Cela m’arrive rarement aujourd’hui car j’ai appris à «m’attendre à l’inattendu» et à identifier les patients qui courent un risque élevé de mort subite. Au cours des dernières années, j’ai examiné un certain nombre de cas de litiges et de fautes professionnelles de mort subite et inattendue chez des patients souffrant de douleur chronique. Dans certains de ces cas, les médecins ont été accusés de surprescription ou de mauvaise lecture et d’avoir causé un décès soudain et inattendu, même si le patient avait pris des doses stabilisées d’opioïdes et d’autres médicaments pendant de longues périodes. De plus, l’autopsie n’a révélé aucun signe d’œdème pulmonaire (un signe de surdose et de dépression respiratoire). Dans les cas où le médecin a été faussement accusé, la découverte de drogues abusives dans les fluides corporels après la mort a causé la mort d’un membre de la famille.
Définition et cause Les
décès inattendus chez les patients souffrant de douleur chronique se produisent généralement à la maison. Parfois, la mort est dans un hôpital ou un centre de désintoxication. L’histoire de ces patients est plutôt typique. La plupart sont trop malades pour quitter la maison et passer beaucoup de temps au lit ou sur un canapé. La mort survient souvent pendant le sommeil ou lorsque le patient se lève pour aller aux toilettes. Dans certains cas, la famille rapporte que le patient a passé une quantité de temps extraordinaire sur les toilettes juste avant l’effondrement et la mort. Une mort soudaine et inattendue peut cependant se produire n’importe où et n’importe quand, lorsque des patients souffrant de douleur sont décédés de façon inattendue et ont soudainement été retrouvés au travail ou en voiture.
Les spasmes coronariens et / ou les arythmies cardiaques entraînant un arrêt cardiaque ou une asystolie sont la cause apparente du décès dans la majorité de ces cas, car aucune pathologie macroscopique conséquente n’a été retrouvée à l’autopsie. 2-5 Un arrêt cardiaque instantané semble expliquer un collapsus soudain ou la mort pendant le sommeil. Peut-être que la constipation et la tension pour passer les selles peuvent être des facteurs de contrainte cardiaque, car certains patients souffrant de douleur meurent pendant la défécation. Une septicémie aiguë due à une insuffisance surrénale et à une immunosuppression peut être à l’origine de certains décès soudains.
Deux mécanismes de mort cardiaque
La douleur intense est un stress horrible. 6,7 Les poussées douloureuses aiguës ou chroniques provoquent chez l’axe hypothalamo-hypophyso-surrénalien la production de glucocorticoïdes (cortisol, prégnénolone) et de catécholamines (adrénaline et noradrénaline) dans le but de contenir biologiquement le stress. 8,9 Les catécholamines ont un effet de stimulation puissant et direct sur le système cardiovasculaire et entraînent une tachycardie sévère et une hypertension. dix Les taux de pouls peuvent généralement atteindre plus de 100 battements par minute et même atteindre plus de 130 battements par minute. La tension artérielle peut atteindre plus de 200 mmHg systolique et plus de 120 mmHg diastolique. En plus de la libération de catécholamines surrénales, les poussées de douleur provoquent une hyperactivité du système nerveux autonome et sympathique, qui ajoute une stimulation supplémentaire à la tachycardie induite par les catécholamines et à l’hypertension. Les signes physiques d’hyperactivité sympathique autonome, en plus de la tachycardie et de l’hypertension, peuvent inclure mydriase (pupille dilatée), transpiration, vasoconstriction avec extrémités froides, hyperréflexie, hyperthermie, nausées, diarrhée et vomissements.
And this is an funding danger worth taking.
What’s up, this weekend is pleasant designed for me, for the reason that this moment i am reading this impressive educational paragraph here at
my house.
Hi there! I’m at work surfing around your blog from my new
apple iphone! Just wanted to say I love reading through
your blog and look forward to all your posts! Keep up the fantastic work!
A person essentially help to make seriously articles
I might state. This is the very first time I frequented your website page and thus far?
I amazed with the analysis you made to make this actual
post extraordinary. Great process!
Fantastic site. Plenty of useful information here. I’m sending it to
several buddies ans additionally sharing in delicious. And obviously, thanks on your effort!
This design is spectacular! You certainly know how to keep a
reader entertained. Between your wit and your videos, I was almost moved to start my own blog (well,
almost…HaHa!) Excellent job. I really enjoyed what you had to say, and more than that,
how you presented it. Too cool!
Hi there outstanding blog! Does running a blog similar to this take
a lot of work? I have very little knowledge of coding but I
was hoping to start my own blog in the near future.
Anyway, if you have any ideas or techniques for new blog
owners please share. I know this is off topic but I simply needed to ask.
Many thanks!
Piece of writing writing is also a fun, if
you know after that you can write or else it is complicated to write.
When some one searches for his essential thing, thus he/she desires
to be available that in detail, so that thing is maintained over here.
Hello just wanted to give you a quick heads up.
The words in your content seem to be running off the screen in Safari.
I’m not sure if this is a format issue or something to do with web browser compatibility but I figured I’d post to let you know.
The layout look great though! Hope you get the problem solved soon. Cheers
Now it is time to choose your specific investments.
My brother recommended I might like this blog.
He was totally right. This post actually made my day. You cann’t imagine just how much time I had spent for this information! Thanks!
This design is incredible! You most certainly know how to
keep a reader entertained. Between your wit and your
videos, I was almost moved to start my own blog (well, almost…HaHa!)
Fantastic job. I really enjoyed what you had to say, and more than that,
how you presented it. Too cool!
Thanks in your curiosity in Funding Recommendation.
bookmarked!!, I really like your website!
Consider investments that provide immediate annuities.
With havin so much written content do you ever run into
any problems of plagorism or copyright violation?
My site has a lot of exclusive content I’ve either created myself or outsourced but it appears a lot of it is popping it up all
over the internet without my authorization. Do you know
any solutions to help reduce content from being ripped off?
I’d truly appreciate it.
Schwab Clever Portfolios invests in Schwab ETFs.
Hey I am so happy I found your blog page, I really found you by accident,
while I was searching on Askjeeve for something else, Anyways I am here now and would just like to say kudos for a remarkable post
and a all round interesting blog (I also love the theme/design),
I don’t have time to look over it all at the moment but I have
saved it and also included your RSS feeds, so when I have
time I will be back to read a lot more, Please do keep up
the superb work.
Right away I am going away to do my breakfast, after having
my breakfast coming again to read more news.
Nice blog! Is your theme custom made or did you download it from somewhere?
A theme like yours with a few simple adjustements would really make my blog jump out.
Please let me know where you got your theme.
Appreciate it
I am sure this post has touched all the internet users, its really
really good post on building up new blog.
WOW just what I was looking for. Came here by searching for
ig
Hiya! I know this is kinda off topic nevertheless I’d figured I’d ask.
Would you be interested in trading links or maybe
guest writing a blog article or vice-versa? My blog covers a lot of the same topics as yours and I feel we could greatly benefit from
each other. If you happen to be interested feel free to shoot me an e-mail.
I look forward to hearing from you! Wonderful blog by
the way!
I am in fact thankful to the owner of this site who has
shared this enormous paragraph at at this place.
A monetary advisor is your planning partner.
Monetary advisors business is individuals enterprise.
I am no longer sure where you’re getting your information, however great topic.
I needs to spend some time studying much more or figuring out more.
Thank you for excellent information I used to be searching for this info for my mission.
Oh my goodness! Impressive article dude! Thanks, However I am going through problems with your RSS.
I don’t understand the reason why I am unable to
join it. Is there anybody else having identical RSS
issues? Anyone who knows the solution can you kindly respond?
Thanks!!
Good day! I could have sworn I’ve been to this
blog before but after reading through some of the post I realized it’s
new to me. Anyways, I’m definitely happy I found it and I’ll be book-marking and checking
back frequently!
Hi, I desire to subscribe for this weblog to take
latest updates, therefore where can i do it please help.
Hi, I think your blog might be having browser compatibility issues.
When I look at your website in Safari, it looks fine but when opening in Internet Explorer, it has some overlapping.
I just wanted to give you a quick heads up! Other then that, wonderful blog!
Wow! This blog looks just like my old one! It’s on a completely different subject but it has pretty much the same layout and design. Excellent choice of colors!
Great post! We are linking to this great post on our site.
Keep up the good writing.
Hi there i am kavin, its my first occasion to commenting anyplace, when i read this piece
of writing i thought i could also create comment due to this sensible piece of writing.
Schwab Intelligent Portfolios invests in Schwab ETFs.
Think about investments that offer fast annuities.
Hi, i think that i saw you visited my blog thus i came to “return the favor”.I’m trying to
find things to enhance my web site!I suppose its ok to
use a few of your ideas!!
Keep on working, great job!
I’m really loving the theme/design of your site.
Do you ever run into any web browser compatibility problems?
A few of my blog visitors have complained about my website not operating correctly in Explorer but looks great in Opera.
Do you have any recommendations to help fix this problem?
Good blog you have here.. It’s difficult to find high-quality writing
like yours nowadays. I seriously appreciate people like you!
Take care!!
A financial advisor is your planning companion.
Investors do pay direct and indirect prices.
Take into account investments that supply instant annuities.
And that is an investment threat price taking.
Appreciate the recommendation. Will try it out.
I was able to find good advice from your blog articles.
Thank you to your curiosity in Investment Advice.
Traders do pay direct and oblique prices.
And this is an funding danger price taking.
Monetary advisors business is individuals business.
Monetary advisors business is individuals business.
A monetary advisor is your planning partner.
I have read some just right stuff here. Certainly
value bookmarking for revisiting. I surprise how a
lot attempt you place to make the sort of wonderful informative site.
A monetary advisor is your planning companion.
Monetary advisors enterprise is people enterprise.
Thanks for your interest in Funding Recommendation.
When someone writes an paragraph he/she maintains the
thought of a user in his/her brain that how a user can know it.
Thus that’s why this paragraph is great.
Thanks!
A financial advisor is your planning partner.
It’s fantastic that you are getting thoughts from this piece of writing as well as from
our argument made here.
I’m not sure why but this site is loading extremely slow for
me. Is anyone else having this issue or is it a problem on my end?
I’ll check back later and see if the problem still exists.
Thanks for your curiosity in Funding Advice.
Monetary advisors business is people business.
I was wondering if you ever thought of changing the page
layout of your website? Its very well written; I love what youve got to say.
But maybe you could a little more in the way of content so people
could connect with it better. Youve got an awful lot of text
for only having one or 2 images. Maybe you could space it out better?
And this is an investment risk price taking.
And this is an funding risk value taking.
Schwab Clever Portfolios invests in Schwab ETFs.
A financial advisor is your planning companion.
Have you ever thought about writing an e-book or guest authoring on other websites?
I have a blog based on the same ideas you discuss and would really like to have
you share some stories/information. I know my visitors would enjoy your work.
If you are even remotely interested, feel free to shoot me an e mail.
Investors do pay direct and indirect prices.
What’s up, after reading this awesome post i am too happy to share my experience here with mates.
Thanks in your curiosity in Investment Advice.
This is true for investment advice as properly.
Consider investments that supply rapid annuities.
Schwab Intelligent Portfolios invests in Schwab ETFs.
And that is an funding danger price taking.
Thanks on your interest in Funding Recommendation.
Wow that was odd. I just wrote an incredibly long comment but after I clicked submit my comment didn’t appear.
Grrrr… well I’m not writing all that over again. Anyway, just wanted to say wonderful blog!
All sorts of investments come with certain risks.
I love your blog.. very nice colors & theme. Did you design this website yourself or did you hire someone to do it for you?
Plz answer back as I’m looking to create my own blog and would like
to know where u got this from. thanks a lot
This design is incredible! You most certainly know
how to keep a reader amused. Between your wit and your videos, I was
almost moved to start my own blog (well, almost…HaHa!) Fantastic
job. I really enjoyed what you had to say, and more than that,
how you presented it. Too cool!
The other day, while I was at work, my cousin stole my iPad and tested to see if it can survive a forty foot drop, just so she can be a youtube sensation.
My apple ipad is now destroyed and she has 83 views. I know this is entirely off topic but
I had to share it with someone!
Now it’s time to choose your specific investments.
Traders do pay direct and indirect prices.
Consider investments that provide fast annuities.
Schwab Intelligent Portfolios invests in Schwab ETFs.
Schwab Intelligent Portfolios invests in Schwab ETFs.
excellent submit, very informative. I ponder why the
other experts of this sector don’t notice this.
You should continue your writing. I am sure, you’ve a huge readers’ base already!
Now it’s time to pick your specific investments.
Now it’s time to decide your specific investments.
All types of investments include certain risks.
And that is an funding danger price taking.
Consider investments that provide instant annuities.
All sorts of investments include sure dangers.
Way cool! Some very valid points! I appreciate you
writing this post and the rest of the website is also very good.
I’m not sure where you’re getting your information,
but good topic. I needs to spend some time learning more or understanding more.
Thanks for wonderful info I was looking for this information for my mission.
Now it is time to choose your specific investments.
Good day! Do you use Twitter? I’d like to follow you if that would be ok.
I’m definitely enjoying your blog and look forward to new posts.
Schwab Clever Portfolios invests in Schwab ETFs.
What’s up i am kavin, its my first occasion to commenting
anyplace, when i read this post i thought i could also make
comment due to this good article.
This is true for funding recommendation as nicely.
Thank you for the auspicious writeup. It in fact was a amusement account it.
Look advanced to far added agreeable from you! However, how could we communicate?
What’s up, just wanted to say, I enjoyed this article. It was practical.
Keep on posting!
And this is an investment risk value taking.
This is true for funding advice as nicely.
Heya i’m for the primary time here. I came across this board
and I in finding It really helpful & it helped me out much.
I’m hoping to provide something back and aid others like you aided me.
It’s perfect time to make a few plans for the future and it’s time to be happy.
I’ve learn this publish and if I may just I wish to recommend you few attention-grabbing things or tips.
Maybe you could write subsequent articles regarding this article.
I desire to learn even more issues about it!
Hi there, always i used to check weblog posts here early in the morning, since i like to gain knowledge of more and more.
I’m really enjoying the design and layout of your website.
It’s a very easy on the eyes which makes it much more pleasant for me
to come here and visit more often. Did you hire
out a developer to create your theme? Great work!
What i don’t understood is if truth be told how you are
not really much more well-liked than you might be right
now. You are so intelligent. You know therefore significantly with regards to this matter,
produced me individually believe it from a lot of numerous angles.
Its like women and men aren’t involved except it’s one
thing to accomplish with Woman gaga! Your
own stuffs great. At all times care for it up!
Hello there! Do you use Twitter? I’d like to follow you if that would be okay.
I’m definitely enjoying your blog and look forward
to new updates.
What’s up, this weekend is pleasant for me, for the
reason that this time i am reading this great informative paragraph here at my home.
Thanks for your personal marvelous posting! I truly enjoyed reading it, you can be
a great author. I will be sure to bookmark your blog and definitely
will come back in the foreseeable future. I want to encourage continue your great
posts, have a nice weekend!
Greate article. Keep writing such kind of info on your
blog. Im really impressed by your blog.
Hello there, You have done a great job. I will certainly digg it and for
my part recommend to my friends. I am confident they will be benefited from this
website.
Just want to say your article is as astonishing.
The clearness on your post is just spectacular and i could suppose you are
knowledgeable in this subject. Well together with your permission allow me to grab your feed to keep
up to date with forthcoming post. Thank you a million and
please carry on the rewarding work.
You can definitely see your enthusiasm within the work you
write. The arena hopes for even more passionate writers like you who aren’t afraid to mention how they believe.
At all times go after your heart.
Just want to say your article is as surprising. The
clarity in your post is simply excellent and i could assume you are an expert on this subject.
Well with your permission let me to grab your RSS feed
to keep updated with forthcoming post. Thanks a million and
please carry on the gratifying work.
Magnificent web site. Lots of useful information here.
I’m sending it to a few buddies ans also sharing in delicious.
And obviously, thanks on your sweat!
Thank you for the auspicious writeup. It if truth be told was a amusement account it.
Glance advanced to more added agreeable from you! However, how could we
communicate?
Hey there! I just wanted to ask if you ever have any problems with hackers?
My last blog (wordpress) was hacked and I ended up losing many months
of hard work due to no data backup. Do you have any solutions to protect against hackers?
whoah this weblog is great i like reading your posts.
Keep up the good work! You understand, lots of people are
searching round for this info, you can help them greatly.
A financial advisor is your planning associate.
Very nice article. I definitely love this site.
Stick with it!
Hi there! This blog post could not be written any better!
Looking through this post reminds me of my previous roommate!
He always kept talking about this. I’ll forward this article to him.
Fairly certain he’ll have a very good read. I appreciate you for sharing!
Hey there! I just want to offer you a huge thumbs up for your great information you have
here on this post. I will be coming back to your website for more
soon.
Aw, this was an incredibly nice post. Spending some time and actual effort to
make a very good article… but what can I say… I put things off a whole lot and don’t
seem to get nearly anything done.
Pretty! This has been an extremely wonderful post.
Thanks for supplying these details.
Great post. I was checking continuously this blog and I am impressed!
Very helpful information specially the last part :
) I care for such info much. I was seeking this particular info
for a very long time. Thank you and best of luck.
If some one needs to be updated with newest technologies
therefore he must be pay a quick visit this site and be up to
date all the time.
Hi, I do think this is an excellent website.
I stumbledupon it 😉 I will return yet again since I bookmarked it.
Money and freedom is the best way to change, may you be rich and continue to help others.
It’s genuinely very complicated in this full of activity life to listen news
on Television, thus I simply use web for that purpose, and get the
hottest news.
Amazing blog! Is your theme custom made or did you download it from somewhere?
A theme like yours with a few simple adjustements would really
make my blog stand out. Please let me know where you got your design. Many
thanks
WOW just what I was searching for. Came here by searching for ig
Monetary advisors enterprise is people enterprise.
This is true for investment recommendation as effectively.
Quality articles or reviews is the secret to be a focus
for the users to go to see the website, that’s what this website is providing.
Investors do pay direct and oblique costs.
Greetings from Ohio! I’m bored to tears at
work so I decided to browse your blog on my iphone during lunch break.
I enjoy the info you present here and can’t
wait to take a look when I get home. I’m amazed at how quick your blog loaded
on my cell phone .. I’m not even using WIFI, just 3G ..
Anyhow, awesome site!
First of all I would like to say fantastic blog!
I had a quick question which I’d like to ask if you don’t mind.
I was curious to know how you center yourself and clear your mind prior to writing.
I have had a tough time clearing my thoughts in getting my ideas out.
I truly do enjoy writing but it just seems like the first 10
to 15 minutes are wasted just trying to figure out how to begin. Any suggestions or tips?
Kudos!
I always used to read article in news papers but now as I am a user of internet so from now I
am using net for content, thanks to web.
Thank you for the auspicious writeup. It in fact was a
amusement account it. Look advanced to more added agreeable from you!
By the way, how could we communicate?
All sorts of investments come with certain risks.
Take into account investments that offer instant annuities.
All sorts of investments include certain dangers.
Investors do pay direct and indirect prices.
Now it is time to choose your particular investments.
Thanks to your interest in Investment Advice.
That is true for investment advice as well.
Traders do pay direct and oblique costs.
This is true for investment recommendation as well.
A financial advisor is your planning partner.
When someone writes an post he/she retains the thought of a user in his/her brain that how a user can know it.
So that’s why this piece of writing is perfect. Thanks!
It is not my first time to visit this web page, i am browsing
this website dailly and take good facts from
here everyday.
Hi, I check your blog daily. Your writing style
is witty, keep doing what you’re doing!
Hey exceptional blog! Does running a blog similar to this take
a large amount of work? I have virtually no expertise in computer
programming but I was hoping to start my own blog soon. Anyways, if you have any recommendations or techniques for new blog
owners please share. I understand this is off subject nevertheless I just
wanted to ask. Many thanks!
I absolutely love your blog.. Great colors & theme. Did you build this web site yourself?
Please reply back as I’m looking to create my very own site and want to know where
you got this from or what the theme is named. Appreciate it!
After I initially left a comment I seem to have clicked the -Notify me when new comments are added- checkbox and now whenever a comment is added I recieve 4 emails with
the exact same comment. Is there a way you are able to remove me from that service?
Thank you!
Great web site you have got here.. It’s difficult to find excellent writing like yours these days.
I seriously appreciate individuals like you! Take care!!
Wow that was strange. I just wrote an really long comment but after I clicked
submit my comment didn’t show up. Grrrr… well I’m not writing all that over again. Regardless, just
wanted to say excellent blog!
Hi there colleagues, nice article and pleasant urging commented here, I am genuinely enjoying by these.
This information is worth everyone’s attention. When can I find out more?
Wow, marvelous blog layout! How long have you been blogging for?
you make blogging look easy. The overall look of your site is fantastic, let alone the content!
Thank you, I’ve just been looking for info about this subject for a
while and yours is the best I have came upon so far. However,
what concerning the conclusion? Are you positive in regards
to the supply?
It is not my first time to go to see this site, i am visiting this site dailly and obtain good facts from here all the time.
A group of white supremacists interrupted an author discussion Saturday at
the popular Washington, DC bookstore Politics and Prose.
Do you have a spam issue on this website; I also
am a blogger, and I was curious about your situation; we have
created some nice procedures and we are looking to exchange strategies with others, why not shoot me an e-mail
if interested.
You could certainly see your enthusiasm in the work you write.
The arena hopes for even more passionate writers like you who
aren’t afraid to mention how they believe. At all
times follow your heart.
Thanks for sharing your thoughts. I really appreciate your efforts and I will be waiting for your next post thank you once again.