It's only been 3 months, stop complaining...

Well, I'm back. My extended absence can be blamed on various reasons, but I'll just chalk it up to a general lack of time and energy.

From all accounts, our ICU billing issue has been resolved. I didn't want to really start ranting before because the physician's group was trying to work with us to get United to pay their proper fees, rather than reaching into our wallet. I wanted to bite my tongue on the off chance that things would go our way, and as luck would have it they did. Crisis averted.

Zach has been doing "fair" I guess. We stopped giving him Topomax (anti-seizure) about a week and a half ago and started giving him Levsin (treats stomach issues). It was working well up until yesterday when Zach had a couple of bad shaking incidents. Other than those he has been more alert, eating better, and doing better with physical activities. I guess we will have to wait and see how things go from here. In other news I gave Zach a much needed haircut. I don't know how he feels about it, but most people have said it turned out well. I'm sure they're just humoring me. When I was actually cutting Zach's hair I was trying to figure out which Johnny Depp character I was channeling - Edward Scissorhands or Sweeney Todd.

As for the rest of the crew...

Josh is three days away from turning 11. It's hard to believe I'm old enough to have an 11 year old son, but it's the truth. A pool party is planned for Sunday. Josh wants you all to know the party is at capacity, however you can all still feel free to send him gifts. He is a big fan of cash. Us parents have covered the gift thing by buying him a new leopard gecko. This one is a male named "Tang" because he is a "Hypo Tang" genetic morph. (3 guesses as to what color he is). Since Josh's other gecko (Spot) is a female, I guess there is a chance of offspring. We'll cross that road at a later date I guess.

Brandon is rapidly approaching 4 years old. Of course if he doesn't watch his little attitude, he may not live that long. (Just kidding) His favorite pastimes are watching whatever show happens to be playing on Nick Jr. (He's a big fan of the Dora-Diego-Kai Lan-Wonderpets programming block), playing/fighting with Josh, dragging his toys into the living room, throwing tantrums, and trying to stretch bedtime out as long as possible. Whoever coined the phrase "terrible twos" probably didn't have a child that lived to the age of 3, or they surely would have re-thought that phrase.

The wife and I are doing as well as can be expected I guess. Nothing major to report on that front.

Guess I'll close for now. Hopefully I'll be a little more prompt with the next update...

We owe what?

Greetings faithful readers.

Today NPT brings you a discussion of a topic that has become a recent thorn in my side - balance billing.

For those of you unfamiliar with the term, it goes like this... You visit a doctor outside of your insurance plan's "approved providers". The doctor takes whatever payment the insurance company provides and then bills you for the difference. Seems fair and simple except for....

Let's say you have a medical emergency and visit the local hospital (part of your insurance plan) for treatment. You are seen by an ER doc who sends you for x-rays which show you need emergency surgery. The surgery is performed and after it is done you need to recover for a couple of days in ICU.

After discharge, you thank god for your insurance because the only cost you have to pay is for the deductable.

Whoa, not so fast there Bud.

A few weeks later you get bills from the ER docs (not part of your plan), the radiologist who read the x-rays (not part of your plan), the surgeon (not part of your plan), the anesthesiologist (not part of your plan), and the ICU physicians (not part of your plan). They have all gotten their payments from the insurance company for "out of network" benefits and are looking to you for the balance.

So much for an "in-network" hospital if none of the doctors you actually see there are "in-network".

So, in our case everything from Zach's surgery was covered by insurance except for the attending physicians in the ICU unit, who are not part of our "network". There is a battle brewing between us, United Healthcare, and this physicians group.

There are so many nuances in this whole issue to get into, and I'm going to need to break this down into several posts - so stay tuned.

Happy Birthday to Zach

You know, I did an update a couple of weeks ago that seems to have been lost somewhere in cyberspace....

Well, I'll just lump everything together.

Zach finally got his cast off, and is now in a removable brace.  He's also off of the Trileptal.  Life has been much better.  He's got his personality back - no more sitting around all day like a zombie.  He's eating much better, and overall just seems to be much happier.

I think this has much more to do with the change in medication than getting rid of the cast, but I'll take it either way.

So, like the headline says, Zach turned 9 yesterday.  Because he likes to be in water, Mom booked him a swimming party.  Of course the skies of South Florida were full of the natural event known as "crap look at all that freaking lightning".  Never fear though, mom knows better about our weather patterns - so the party was booked at the British Swim School, an indoor facility.  Zach spent about 2 hours in the heated pool, and looked like he had a great time.  He was joined by an assortment of family and friends, and all the kids looked like they had a really good time.  Some of the adults (humble narrator included) who weren't in the pool got to find out up close just how much humidity can be given off by a pool heated up to about 90 degrees.  It felt much cooler outside the building, which if you have never experienced summer afternoons in South Florida is somewhat like sitting on the surface of the sun while trying to breathe through a wet towel.

Still though it was a great party, sweating off a few pounds won't do me any harm.

In other good news, Janine passed her state exam to become a school administrator, and has submitted her final work in her final class for her master's degree.  So, by the end of the month she should be on track to getting an AP job.  Of course it is mandatory that I mention that she kept up a 4.0 GPA in grad school while working full time, raising the 3 boys, and dealing with all of Zach's medical issues.  So those of you out there reading - don't try the "I'm too busy excuse" to not go back to school...

Janine's school where she works did very well on this year's state exams.  Since becoming the "Reading Specialist/Leader/Coach/whatever they call it this year", the school has gone from a "D" school to this year marking their fourth "A" ranking in a row.  Congrats to the kids for doing well, and the staff for buying in to the program.

Well, I'm out for now.  Hopefully I'll have a nice report on a getaway Janine and I are planning for this weekend - sans kids.  Yes, just the two of us.

I just realized...

That I haven't updated you all on the wonderful happenings in our lives.

Let's see, umm... well uh, now that I think of it there hasn't been all that much wonderful to report.

In the "general" news category, Zach has still had some issues.  When he went a couple of weeks ago to be fitted for his brace, they removed his cast and discovered some really nasty skin ulcers on his back.  They were in a spot that there was no way for us to see, so we have no idea how long they had been developing.  Janine took Zach to Dr. Joffe who checked out the ulcers, and decided that they weren't too serious (they looked serious to me, but I'm a little less experienced than he is), and had us apply a disinfecting solution to them 3 times a day. (We're still doing this actually)  He put Zach in a new cast with a hole in the back where the sores are so they can heal.  Once that is done, he can be put in the brace.  We're looking forward to that.

Zach has still been having seizure-like episodes.  However, they aren't seizures - the 24 hour EEG he had after having a major not seizure that required us to call 911, and for him and his mother to spend a night in a complete hell hole says so.

The details:  Last Tuesday Zach was scheduled to go to Broward General Hospital for a 24 hour EEG.  This isn't our regular hospital, but it is where our neurologist is on staff.  Monday night after dinner, Zach started having one of his episodes.  It started out as they usually do, but progressed until it was pretty severe.  At one point his breathing started to get all strange, so we thought it was a good idea to call the paramedics.  By the time they arrived, he had almost returned to normal, but because he (like all Hunters boys) has a restricted airway - the paramedics thought it best that he be brought to the emergency room as a precaution.  Now considering that he was due to be in Broward General in the morning anyway, we asked if he could be taken there.  Unfortunately, the ambulance wasn't allowed to transport that far, and had to take us to Memorial West.

Now, West is part of the Memorial system - which is the hospital group where Most of Zach's other doctors are on staff, where he gets his infusions etc.  We like the Memorial system.  West isn't as good in our opinion as Regional - but at least all of Zach's records are available and his doctor's have access to him.  We hoped that since he was there that we could get the 24hr EEG done, and avoid going to Broward General.  Yea - no. 

The on-call neuro (who saw Zach when he was in ICU when he was first diagnosed with "seizures") didn't want to admit him because he was being followed by another doctor, and he didn't know his history.  Janine called Dr. Benke to see if he could help, but despite his efforts, none of the staff neurologists would admit Zach.  (Dr. Benke was less than thrilled by all accounts.)

After the ER doctors consulted with Dr. Epstein (our regular neurologist), it was decided to have Zach transported to Broward General via ambulance.  He and Janine got into the room there at about 3:00 AM Tuesday morning.

After taking the other boys to school, I headed over to the hospital.  Let's just say Broward General's idea of a children's hospital is nothing like Memorial's idea.  Not even close.  I could not have been less impressed.

The room was tiny - there wasn't even really room for the two of us to sit down.  We had the joy of there being another patient in the room with Zach.  That itself was fine, except for the fact that this particular patient was having some pretty severe psychotic issues.  Being the parent of a medically involved child, I have sympathy for other parents in a similar situation.  This child would go from moments of normal behavior to screaming fits with some really "colorful" language.  He would randomly throw objects or keep hitting the nurse call button.  Lovely.  He really should have been in an isolation room.  Not just for the safety and peace of his roommates, but to give the poor kid some privacy and dignity.  I wouldn't want my kid to be some kind of public spectacle like this kid was.

Did I also mention that I didn't see the nurse wash her hands when entering or leaving the room?  Good thing there isn't some highly contagious form of the flu going around.

The nurse also got on my nerves by trying to tell me how to give Zach a dose of Trileptal.  She brought the dose in an oral syringe and couldn't understand why I needed a spoon to give it to him...  Her: "It's easier if you just give it to him in the syringe."

            Me: "We can do it your way and he'll spit it out, or we can do it the same way we do it twice a day - every day of his life, and he'll take it without any problem.  Which do you want me to try?"

Note to medical professionals - You may be highly intelligent, have attended the best medical schools in the country,  graduated with highest honors, and have more "medical" knowledge than I.   However, when it comes to my child I am a goddamned genius. Please don't make me prove you wrong.

Okay, off the soapbox.

Anyway, Zach spent the day and night hooked up to the EEG.  He didn't have any major episodes - probably because he had one the previous night.  He had a small one with dinner, but after looking at the recordings Dr. Epstein doesn't feel they are "seizures" - well at least not in the sense he originally thought.  He has decided to take Zach of the Trileptal and have him try Topomax instead.  It deals with a different type of seizures in a different way, and may be more effective than the Trileptal was.  Since we started weaning Zach off of the Trileptal he has been more alert and happier, so at least we have that to cheer about.

In other news, Josh got his braces off - which he is quite thrilled with.  He has to wear a retainer at night, but other than that his teeth are good to go.

Our baseball season ended last weekend with a loss in the first round of the playoffs.  Given the fact that we lost our first 11 games before going undefeated the last month, this would go down as "a long season".  Josh played really well though, so it's all good I guess.

We took a quick weekend vacation to Orlando so Janine could attend a workshop to get ready to take the state school administrators exam.  She went to the workshop on Saturday and the men went to Seaworld.  Janine joined us in a return to Seaworld on Sunday, and we all had a pretty good time.

The next weekend Janine took the exam.  She doesn't have the results yet, but I am sure that she did fine.  She is scheduled to graduate with her master's degree next month. (A few months early)  Once she graduates and has her passing grade on the exam, she will be ready to work as an administrator.  Well - get paid as an administrator at least.  She's been doing a lot of administrative work for years, now it's time to actually have that job title.

Well, I guess that's all that's going on for now.  Catch you later.

All cracked up

Since the cast change a couple of weeks ago, Zach has been obviously been in some discomfort. A good bit of this we blame on his stomach issues. However we've also been pretty sure that his cast is a bit too tight as well.

So, yesterday after his infusion we too Zach to see Dr. Jofe, who agreed with us that it looked too tight. His solution was to split the cast from under each armpit all the way down to the waist, then to tape the halves together. This allows the cast to flex and expand a little while still protecting Zach's back.

The actual cutting of the cast scared the crap out of Zach. Literally if you know what I mean.

Well, we eventually got that mess cleaned up and we were on our way. Zach seems to be a little more comfortable now thankfully. He is going to see Dr. Tucker this afternoon to follow up with his "digestive" issues.

I'm still trying to figure out what motivates a doctor to want to specialize in the poop field?

I can imagine the converation when the med school students are sitting around discussing their future plans...

"I love kids, I'm going to be a pediatrician!"
"I'm interested in the heart, I'm going to be a cardiologist!"
"Poop! I love to deal with poop!" (This is the point where his friends decide to sit just a little further away from him...)

Anyway, Dr. Jofe is going to be taking Zach out of the cast and putting him in a brace in a few weeks. (Yea!) Hopefully that will make life better.

What a gas

Well, I think we may have found the cause of Zach's recent problems - gas.

We had noticed, and his physical therapist had mentioned that Zach has been burping lately. Seeing as though he has never done this before, I started to think that prehaps it is severe pain from gas that is causing his episodes and his lack of appetite.

So, a few days ago we started giving him Gas-X before meals. Since then, he hasn't had any major "episodes", and is starting to eat normally again. The Miralax is also starting to do its thing - too well at times...

Life is much better, but MPS still sucks.

Here's how things are going in our world....

It's been rough.

Zach had his cast change done last Monday. Due to a scheduling mix-up Dr. Kaufman was not available to sedate him. Although that probably had nothing to do with it, Zach had issues with the anesthesia he was given. The procedure itself went fine, but during recovery there were issues with his heart rate dropping. Apparently he was in too deep of a sleep. They got an IV with some sugar water flowing into him, and that apparently woke him up enough to keep his heartrate up.

He was sent home that afternoon, but slept the rest of the day and night - not waking up until Tuesday morning.

When he did wake up, he went into one of his "episodes". The full body shaking, screaming etc. Janine and I decided that these episodes had gone long enough, and decided to get to the bottom of it ASAP.

We were able to get an appointment to see Dr. Tucker who is a pediatric gastroenterologist for that morning, and with Dr. Epstein our neurologist for that afternoon.

Armed with a video of Zach's episode we headed off to Dr. Tucker's office. After examining Zach and seeing the video, he felt that Zach wasn't having a seizure in the typical sense. He felt that it may be a reaction to pain, and that the pain may be related to his stomach in some way. Most likely constipation in some manner. (Ever since his operation this has been an issue.)

He didn't feel an obstruction in the bowels, but had us take an x-ray Thursday while at ERT just to rule it out. Dr. Tucker told us to have Zach take the adult dose of Miralax to hopefully get his system moving. He also told us to try to get Zach to drink 4 bottles of Ensure a day to try to fatten him up a bit. (He's dropped a good amount of weight since surgery.)

Of course Zach has no desire to drink 4 bottles of anything. Since surgery, it has been really hard to get him to eat. I assume it has something to do with his stomach issue. Hopefully it's just constipation, and not something harder to diagnose like reflux.

At our visit with Dr. Epstein he viewed the video as well and did not feel Zach was having a "seizure". He couldn't be 100% sure without actually having him hooked up to a EEG at the time it happened though. He also felt that some sort of gastric issue could be the cause. His suggestion was to keep Zach on his anti-seizure medication for now, and see if by giving the Miralax, we are able to get the "episodes" under control. If that's the case, then we can take Zach off of the anti-seizure medication.

Of course this doesn't really address the suspicion I have that the anti-seizure medication may be part of the cause of the stomach issue. It's the only new medication he is on since the surgery. Aside from being in the cast, there is nothing "different" that I can think of that would cause Zach to not want to eat. The only logical choice is either the cast or the medication is upsetting his stomach. Which do you think would be more likely?

I really hope the Miralax does Zach some good soon. It's gotten to the point where I am worried that he is not eating enough to support his body. He's already really thin, he doesn't have any more weight to lose. I don't want to see him with some kind of feeding tube, but I'm afraid that if we can't get him eating soon that will end up happening. Depressing.

Have I mentioned MPS sucks.

Update time

Here's all the news that's fit to print...

Zach is doing as well as can be expected. He seems to have adjusted to his cast finally. Of course it is going to need to be changed in the next two weeks or so. Hopefully the new one will be similar enough to this one so that he won't notice a difference. We're hoping for him to be placed into a brace, rather than a cast, at some point - but he probably isn't ready for that yet.

Zach has been standing up and walking with assistance, which is a really good sign. He is still up on his toes though. I think we are going to wait until summer to get his ankles casted, but that's up in the air for now. Once that is done, he should be able to walk flat footed again.

In other news, Josh's baseball season is upon us. I've taken the plunge and am the head coach for the team this season. We've managed to lose our first two games by a combined score of 25 to 8, but hopefully we'll get it turned around here sometime soon. On the good side of things we can't get much worse! It's all improvement from here on out...

We took the kids to the Renaissance Fest last weekend. It's quite an umm..... experience. Brandon was a bit freaked out at first because everyone is in costume, and there is a ton of activity going on. He eventually got over it and seemed to have a good time. I actually felt bad for some of those people in costume because it was about 85 degrees out. (In mid-February - gotta love the South Florida weather.) The was even a guy walking around in a full suit of armor. I'm thinking that guy had to be really hating life that day.

Now, if you work there and have to dress in costume I can understand it. That's your job. What I can't understand though are the freaks that don't work there, but dress up in the costumes anyway. Are they trying to fit in better? Show their dedication to late 15th century Europe? C'mon people - that's like wearing a Mickey Mouse costume when you visit Disney World. No - the people working there don't think you're cool because you have "Renaissance" clothes to wear. They think you're a dork. Oh yea, they aren't impressed by the "Olde English" accent you are trying to use while ordering your frozen lemonaide either.

Never a dull moment...

Up until last night, the past week went fairly well for Zach.

He was eating fairly well, and seems to be adjusting to wearing his cast. He was back at school, and life has been getting back to its normal routine. (Well, normal for us at least.)

Then, just as we are getting settled to watch the SuperBowl, Zach started having what may (or may not) have been a seizure. He was shaking uncontrollably, hyperventilating, and his body temperature had shot up. After about 3 minutes we gave him a dose of Diastat per his neurologist's instructions, and called 911.

The friendly members of the Miramar Fire Rescue Department showed up within a few minutes and whisked away Zach and Janine to Memorial West. I followed a few minutes later.

By the time the ambulance arrived at the hospital, the shaking had pretty much stopped. We all spent the next 6-7 hours in the ER while trying to figure out if this actually was a seizure, if it was a seizure - what was the cause, was the Dilantin not working, why the remote control for the television I was watching would only allow you to cycle UP through the channels - even if you JUST WANTED TO GO BACK ONE DAMN STATION, and should his medication be changed?

Alas after a battery of tests, and much cursing at the remote on my part, we came away with not too damn much info. The neurologist wanted to switch his anti-seizure medicine, and we were sent off into the night (well, morning really) with prescription in hand.

We were in luck in that the nearest 24 pharmacy was only a couple of minutes away. Of course their computer system was down so they couldn't fill the prescription. Just our luck. Off we go to another pharmacy. When we get there we find out that Zach needs something like 120 cc of this medicine a month. However it is only dispensed in a 240 cc bottle. This doesn't seem like a big deal except for the fact that the insurance company won't pay for any more than a month at a time. Well, that and the medicine is about $200 a bottle without insurance. The pharmacist called the ER docs, but they basically said we were stuck because that was what the neurologist ordered and they couldn't change it... Now, realize this is all happening at about 2 in the morning. We decided that since Zach had been given a 12 hour dose in the hospital at about 12:30 that this could just get sorted out in the morning. (well, later in the morning)

As it stands, Janine was going to make some calls this morning to see what to do next. I haven't heard from her yet, so I assume nobody has been dumb enough to piss her off so far. Once she gets this medication thing taken care of, I'm going to have her try to find out why some moron would design a remote control that only allows you to switch the channels in one direction.

There's no place like home

Well, after more than a week of living in the PICU of Joe Dimaggio Children's Hospital, Zach finally came home Tuesday night.

After alternating nights at the hospital for that week, it's safe to say that both Janine and myself were quite sleep deprived. No matter day or night, there is always the same amount of activity going on in the PICU, and because the glass is so heavily tinted, there was little sunlight to be seen. Put that together for a few days and you really have no idea what time it is, or if it is day or night. Zach wouldn't really ever sleep for more than a few minutes at a time, which didn't make things any easier.

At one point after looking at the clock at seeing it was 9:30 I actually asked the nurse if it was AM or PM. It was really freaky there for a while... If they ever need actors to play the part of Zombies in a horror movie, they could do the casting right in the local PICU - wouldn't even need to use much makeup.

There are a million things that went on while Zach was there, but it would take forever to write, so I'll give it to you in a brief format...

After surgery Zach slept, then couldn't sleep, then wouldn't sleep, had a seizure (maybe), had another, got put on anti-seizure medicine, slept, itched, itched some more, slept, itched, itched some more, got some medicine for the itching, slept, itched, got more anti-itch medicine, slept, couldn't poop, got medicine to make him poop, didn't poop, got an enema, got another enema, still didn't poop, got more medicine to make him poop, pooped, pooped, really pooped, wow look at all the poop, slept, woke up, didn't sleep, got arm splints to stop him from itching, hit various people with the arm splints, got more anti-itch medicine, slept, woke up, complained about the arm splints, learned to itch face while wearing arm splints, got his cast, pooped some more, ate a small bit of food, pooped again, man where is all this poop coming from, got discharged.

That's it in a nutshell.

Did I mention that while Zach was in surgery, I got a call from the marathon people because the Miami Herald wanted to do a story on Josh? He was going to be the youngest runner this year. It killed me to tell the guy that we were not going to be doing the race. I know that given everything we have been through the past couple of weeks that I at least am in no shape to run. Still though, it would have been great to get our story in the paper. The guy I spoke to from the race said to get in touch with them if we are going to do the race next year and they will help with some publicity for NPT, so I guess it's not a total loss.

Quick surgical update

I only have a few minutes, but here's how things are going...

The surgery went well for Zach. It took about 3 hours for the procedure itself, and there weren't any real complications.

The recovery was rough for Zach for the first day. The doctors had trouble getting the right mix of sedatives and painkillers that would keep him comfortable, but I think they have it worked out now.

Zach had two seizures early yesterday (Tuesday) morning. Nobody is sure why. It's probably related to the surgery/pain/stress that he is going through. However it could just be MPS. In any case, he is on anti-seizure medication for now, and will probably continue on it once he goes home.

This morning (Wednesday) he is running a temperature of about 103. His blood work isn't showing any infection though. Janine was told this sometimes happens in fusion cases, and may just be the way the body reacts to the rods along the spine. The doctors don't seem too concerned about it yet. I'll know more when I get over to the hospital this afternoon.

'Tis the season for giving...

Blood that is.

In preperation for his surgery on the 12th, Janine and I had to donate blood in case Zach has a need for it.

Now, due to a rather unfortunate incident involving a lady at the Red Cross donation center that I still to this day refer to as "Nurse Pincushion", I have not donated blood since I was about 20 years old.

I got some giggles from the questionaire I had to fill out before making the donation. One of the questions asked if I had ever or had "sexual contact" with someone who took money, drugs or other payment for sex since 1977. Now, I'm pretty sure on the money and drugs thing - the thought that I am talented enough in that field to actually get paid for it is quite laughable come to think of it. Since I've been married for quite some time, I've never had a need to pay for sex. (Beg for it perhaps...)

Still though there is that "other payment" issue.... Does that mean if a guy takes a girl out on a date to a nice resturant and they end up doing the deed later on that evening? Or is that not "payment". These are the things that go through my head while I'm sitting there waiting on the nurse to enter my information into her computer. Obviously there are more pressing issues I should be spending my time thinking about, but that's just how my mind works.

As part of the whole donation routine, they give you a "mini-physical" of sorts. My blood pressure was 126/84. Not great, not horrible. Actually, it's usually at least 10 points lower than that, so I'm not really concerned. Pulse was 62 which I'm quite pleased with. It was closer to 90 before I started on the exercise bike.

When you donate blood, they also test your cholesterol level. I had to log in to the blood center website to get those results a couple of days ago. Considering that I'm not known for my healthy eating habits (Damn pizza - why can't I quit you!), I wasn't really looking forward to these results. I was expecting a number in the mid 200's. Enough to send me off to Lipitor land. I was actually paranoid enough about it to look up some of the anti-cholesterol drugs out there.

Did you know Lipitor has "accidental injury" listed as a side effect? As in "People who take this drug are at a higher risk of getting hit by a bus". I'm not sure how they measure that, but it's good to know. Crestor does not list "accidental injury" as a side effect, so that's obviously the one to go with. I'm an expert on "accidental injuries", I don't need any help in that department.

So, imagine my surprise when I logged in and found that my cholesterol is only 182. Safely in the good range. I'll chalk it up to genetics. I didn't get a good/bad level breakdown, but overall it's not that bad.

So on to the bad news...

Due to Zach's surgery, we have decided not to run the half-marathon on the 25th. There are just too many unknowns at this point to allow us to really dedicate the time needed to the race. We'll revisit the idea for next year. However, we have decided to enter into a few of the local 5K events. It's a long story, but Josh actually jogged over 5K on concrete, wearing baseball cleats after a 2 hour practice in about 30 minutes. Given ideal conditions I think he could probably shave close to 10 minutes off that time. We'll have to see how it goes.

I'll update on Zach's surgery as things progress.