by Dr. Arvind Chopra
The diagnosis of rheumatoid arthritis (RA) is essentially clinical. A typical picture is that of a woman who is near menopause and develops slowly progressive pain and swelling in small joints of the hands and feet with feeling of stiffness and slowness of body movement( especially in the joints) on awakening in the morning. Other joints that are commonly affected are knees, wrists, shoulders,elbows and ankles. The pattern of joint affection is usually symmetrical. Though neck pain and stiffness often accompanies arthritis, back ache is not a feature of RA. When chronic and progressive, the patients often develop deformities of the joints,especially those of hands and feet. RA is predominantly a woman’s disease but men also
suffer from severe RA and no age is exempt. Uncommonly, the patient complains of small firm nodules (marble size) under the skin near elbows or over hands and feet. It is this kind of a clinical picture that should ring the first bell to announce the disease.
Thus the doctor ought to carefully review the patient’s narration of symptoms and examine the joints for features of inflammation and deformity. The clinical examination must include all systems like cardiovascular, pulmonary and nervous system. Certain blood and X-ray tests are often required. An early disease is often a challenge and several visits
may be necessary before the doctor can be certain of the diagnosis. As an important guidance, patients suffering from multiple joint pain and swelling (called polyarthritis) need to be carefully observed for 6 weeks or so following the onset of disease before making a definite diagnosis of RA. Several viruses (such as respiratory illness, mumps, and hepatitis)
can cause a RA like polyarthritis that completely subsides within 6 weeks or so.
Blood is often tested for erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to measure the extent of disease activity and progression. Routine blood testing may also reveal anemia (low hemoglobin) which can be due to either
nutrition deficiency (especially iron and folic acid) and/or severe RA (effects bone marrow). Several other routine blood tests are ordered to evaluate blood sugar, liver and kidney functions, and lipids (cholesterol) which are relevant to assessing the patient’s general health and look for any other occult disease complication. It is prudent to add that
patients of RA are prone to hyperlipidemia (increased cholesterol) related thickening of blood vessel walls (atherosclerosis) and attendant cardiac and other circulatory complications (ischemic heart disease, strokes). The blood tests are also required to assess the patient’s fitness for medications [ in particular potent anti-rheumatoid drugs like methotrexate, leflunomide, sulfasalazine and the newer biologic agents (such as rituximab, infliximab and tocilizumab]. It is prudent to remember that though RA is predominantly an arthritis, it is actually a systemic disorder that can also uncommonly affect
other body systems such as lungs and nerves.
Rheumatoid factor (RF) antibody and cyclic citrulline peptides antibody (anti-CCP antibody) are often present (over 70%) in blood/serum of RA patients. Presence of RF and anti-CCP strengthen the diagnosis. RF is generally the preferred test and
can be easily carried out in all laboratories. Anti-CCP is a more expensive test but provides a stronger diagnostic clue especially when the clinical picture is not typical. Certain other antibodies like ANA (antinuclear antibody) are also tested to screen other related complex rheumatic disorders. ANA can be infrequently positive in patients with RA but in an atypical clinical situation would need to be followed by more specific blood antibody tests ( such as antids DNA and anti nuclear RNP) to exclude complex rheumatic disorders (like lupus and mixed connective tissue disease). It must be borne in mind that several antibodies like RF and ANA are also present to a limited extent (under 10%) in normal healthy people and several other systemic disorders. These antibodies ought to be tested with care and expertise in standardized labs. Often the
techniques are complex. While reporting these antibodies, labs must indicate their quantitative values, type of method used and controls. Finally, none of these antibodies are a substitute for a good clinical evaluation of RA by a competent doctor. Do not rush into making a diagnosis based only on the presence of these antibodies. A clinical correlation is mandatory. Though there are few genetic tests that indicate susceptibility and severity of RA (such as HLA DR typing), they have not been found useful in routine clinical practice. Also, genetics may differ in different ethnic populations.
One need not test synovial fluid from a joint to diagnose RA but the same is useful to exclude infections (in particular tuberculosis in our country). On similar grounds, arthroscopy (a surgical procedure used to examine joint and perform some
limited surgery) is not required to diagnose RA but can be a useful tool to carry out a synovial tissue biopsy in rare instances of a difficult to diagnose chronic affection of a single large joint (usually knee).What is the role of X-Rays? One need not take an X-Ray of every painful joint. Radiological changes of significance often take time to show. Initially, an X-Ray may only show soft tissue swelling of a joint which can be anyway appreciated better by the eye, and further evaluated on clinical examination. However, X-Rays of hands and wrists are important in RA and may begin to show changes consistent with the diagnosis as early as 6-8 weeks after the onset of the disease. A critical finding in the X-Ray is that of early joint damage which is often reported as ‘erosion’ near the joint margin. Erosive arthritis is always a serious finding because it invariably means a severe disease which is likely to be progressive and lead towards early joint deformities. A normal XRay of a painful joint does not exclude the possibility of RA. X-rays can also be helpful in monitoring the progression of disease and joint damage over time. X-Rays would also be required when surgical correction is being considered. In atypical clinical situations, usually marked by affection of fewer large joint (usually lower limb) involvement and back aches, X-Rays of the spine and pelvis are often taken to exclude inflammatory disorders of the spine/axial skeleton (such as ankylosing spondylitis).
There are several other radiology imaging modalities which are infrequently indicated and required but can be crucial to diagnosis (including that of RA complications) in certain difficult clinical situations. Sometimes when a patient continues to suffer from joint aches and pains without showing any clear cut clinical evidence, a radioactive bone scan can show evidence and extent of arthritis which helps in the overall diagnosis. MRI and CT scan can show great anatomical detail of an affected joint especially with reference to complications and need for surgery. MRI scan is of outstanding value with
regards to diagnosing chronic back ache and other disorders of spine and sacroiliac joint (hall mark of ankylosing spondylitis like disorders). Osteoporosis (thinning of bones) is an important accompaniment and or complication of RA which can be due to age,menopause, poor physical activity and drugs (especially steroids). Bone mineral density (BMD) is
measured by DEXA (a radiology imaging machine somewhat similar to CT scan) to diagnose osteoporosis. Newer techniques in ultrasonography are now being made available to quickly diagnose early arthritis and joint damage in RA and other
inflammatory disorders.
In conclusion, the diagnosis of RA needs much care, attention and expertise from the doctor. A wrong diagnosis, which is not too infrequently seen in my referral practice, leads to unfortunate psychological stress and avoidable finance losses.
Every investigation carried out must be supported by good clinical reasoning and interpreted in a clinical context. RA is a lifelong disease which requires careful selection of several drugs to treat and regular supervised medical care and monitoring. Therapy often requires changes. Sometimes, the disease is progressive despite optimum therapy. All this would
mean, that patients of RA need repeated investigations to ensure good control of disease and timely detection of complications. Patients must try and understand the logic and reasoning of carrying out the investigations required to make a proper diagnosis of RA. And it is equally important, that doctors make themselves responsible to explain to the patients as to why so many investigations are required? Effective management, which includes diagnosis and treatment, of RA actually begins when the patient first steps into the doctor’s room. Diagnosis is never a one point event. It is actually a
continuous process of confirmation, monitoring and fine tuning so as to relieve the patient of the suffering. RA is no exception.
Please let me know if you’re looking for a author for your weblog. You have some really great posts and I believe I would be a good asset. If you ever want to take some of the load off, I’d really like to write some articles for your blog in exchange for a link back to mine. Please blast me an e-mail if interested. Kudos!
I was extremely pleased to find this website. I wanted to thank you for your time due to this wonderful read!! I definitely appreciated every little bit of it and I have you book marked to see new stuff on your web site.
Simply wish to say your article is as astonishing. The clearness for your publish is simply cool and i can think you are a professional in this subject. Well with your permission allow me to seize your RSS feed to stay up to date with forthcoming post. Thank you one million and please continue the gratifying work.
This information is invaluable. Where can I find out more?
Incredible points. Outstanding arguments. Keep up the amazing work.
Yes! Finally something about %keyword1%.
Unquestionably believe that which you stated. Your favorite justification appeared to be on the net the simplest thing to be aware of. I say to you, I definitely get irked while people consider worries that they plainly do not know about. You managed to hit the nail upon the top as well as defined out the whole thing without having side effect , people can take a signal. Will likely be back to get more. Thanks
This design is spectacular! You obviously 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!) Wonderful job. I really enjoyed what you had to say, and more than that, how you presented it. Too cool!
Post writing is also a fun, if you be acquainted with after that you can write otherwise it is complex to write.
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. Anyway, just wanted to say superb blog!
Its like you read my mind! You seem to know so much about this, like you wrote the book in it or something. I think that you could do with some pics to drive the message home a bit, but other than that, this is great blog. An excellent read. I’ll definitely be back.
I pay a visit day-to-day some web sites and websites to read articles or reviews, except this weblog gives quality based posts.
Its like you read my mind! You seem to understand so much approximately this, like you wrote the ebook in it or something. I feel that you could do with some p.c. to force the message house a bit, however other than that, this is great blog. A great read. I’ll definitely be back.
What a data of un-ambiguity and preserveness of precious experience about unexpected feelings.
What i do not realize is in fact how you’re now not really a lot more well-favored than you may be right now. You are so intelligent. You understand therefore significantly in relation to this topic, produced me in my opinion believe it from so many various angles. Its like men and women don’t seem to be fascinated unless it’s something to accomplish with Woman gaga! Your personal stuffs excellent. Always take care of it up!
This design is steller! 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!) Great job. I really enjoyed what you had to say, and more than that, how you presented it. Too cool!
This design is wicked! You obviously 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!) Great job. I really enjoyed what you had to say, and more than that, how you presented it. Too cool!
If some one needs expert view concerning blogging and site-building then i propose him/her to pay a visit this weblog, Keep up the good job.
What’s up, its nice article regarding media print, we all understand media is a impressive source of data.
I’d like to thank you for the efforts you have put in writing this blog. I am hoping to view the same high-grade blog posts from you in the future as well. In fact, your creative writing abilities has motivated me to get my very own blog now 😉
Please let me know if you’re looking for a article author for your site. You have some really great posts and I believe I would be a good asset. If you ever want to take some of the load off, I’d really like to write some articles for your blog in exchange for a link back to mine. Please blast me an e-mail if interested. Cheers!
What i do not realize is actually how you’re not really a lot more smartly-favored than you may be right now. You are so intelligent. You realize therefore significantly relating to this matter, produced me in my opinion consider it from numerous numerous angles. Its like men and women don’t seem to be fascinated unless it’s something to accomplish with Lady gaga! Your own stuffs great. Always maintain it up!
For newest news you have to pay a visit world-wide-web and on world-wide-web I found this site as a best web site for most recent updates.
Pretty nice post. I just stumbled upon your blog and wanted to say that I have really enjoyed browsing your blog posts. In any case I’ll be subscribing to your feed and I hope you write again soon!
I am extremely impressed with your writing skills and also with the layout on your blog. Is this a paid theme or did you customize it yourself? Either way keep up the nice quality writing, it’s rare to see a nice blog like this one nowadays.
My programmer is trying to persuade me to move to .net from PHP. I have always disliked the idea because of the expenses. But he’s tryiong none the less. I’ve been using Movable-type on a variety of websites for about a year and am nervous about switching to another platform. I have heard great things about blogengine.net. Is there a way I can transfer all my wordpress content into it? Any kind of help would be really appreciated!
Excellent blog you’ve got here.. It’s hard to find good quality writing like yours these days. I seriously appreciate people like you! Take care!!
Hey very interesting blog!
Wow, that’s what I was looking for, what a data! present here at this webpage, thanks admin of this website.
This post is in fact a nice one it helps new net viewers, who are wishing for blogging.
I really love your site.. Very nice colors & theme. Did you create this web site yourself? Please reply back as I’m looking to create my very own website and would like to know where you got this from or what the theme is called. Thanks!
Hello just wanted to give you a quick heads up. The text in your post seem to be running off the screen in Ie. I’m not sure if this is a format issue or something to do with web browser compatibility but I thought I’d post to let you know. The layout look great though! Hope you get the problem resolved soon. Cheers
Greetings! This is my 1st comment here so I just wanted to give a quick shout out and tell you I genuinely enjoy reading through your blog posts. Can you suggest any other blogs/websites/forums that deal with the same subjects? Thanks!
This is very interesting, You are a very skilled blogger. I have joined your feed and look forward to seeking more of your magnificent post. Also, I have shared your web site in my social networks!
A fascinating discussion is worth comment. I do think that you ought to write more on this topic, it might not be a taboo subject but usually people do not discuss such topics. To the next! Cheers!!
Правильный мужской эромассаж Москва – тайский салон
Thank you for another great article. Where else may just anyone get that kind of information in such a perfect method of writing? I have a presentation next week, and I am at the look for such information.
No matter if some one searches for his essential thing, so he/she needs to be available that in detail, so that thing is maintained over here.
Way cool! Some very valid points! I appreciate you writing this article and also the rest of the site is extremely good.
Greetings! This is my first visit to your blog! We are a collection of volunteers and starting a new initiative in a community in the same niche. Your blog provided us valuable information to work on. You have done a marvellous job!
Very nice article, just what I needed.
Heya i’m for the first time here. I came across this board and I find It truly useful & it helped me out a lot. I hope to give something back and help others like you helped me.
Hello! This post couldn’t be written any better! Reading this post reminds me of my old room mate! He always kept talking about this. I will forward this article to him. Pretty sure he will have a good read. Thank you for sharing!
My programmer is trying to persuade me to move to .net from PHP. I have always disliked the idea because of the expenses. But he’s tryiong none the less. I’ve been using Movable-type on several websites for about a year and am nervous about switching to another platform. I have heard great things about blogengine.net. Is there a way I can transfer all my wordpress content into it? Any kind of help would be really appreciated!
I don’t even know how I ended up here, but I thought this post was good. I don’t know who you are but definitely you are going to a famous blogger if you are not already 😉 Cheers!
An interesting discussion is worth comment. I believe that you ought to write more on this issue, it might not be a taboo subject but generally people don’t discuss such topics. To the next! Cheers!!
Nice blog here! Also your website loads up fast! What host are you using? Can I get your affiliate link to your host? I wish my website loaded up as fast as yours lol
Amazing blog! Do you have any suggestions for aspiring writers? I’m planning to start my own website soon but I’m a little lost on everything. Would you advise starting with a free platform like WordPress or go for a paid option? There are so many choices out there that I’m totally confused .. Any recommendations? Appreciate it!
Good day! Do you use Twitter? I’d like to follow you if that would be ok. I’m undoubtedly enjoying your blog and look forward to new updates.
Hello there! I could have sworn I’ve been to this blog before but after browsing through some of the posts I realized it’s new to me. Nonetheless, I’m definitely pleased I discovered it and I’ll be bookmarking it and checking back regularly!
It is appropriate time to make a few plans for the longer term and it is time to be happy. I have read this submit and if I may I want to recommend you few interesting things or advice. Perhaps you could write next articles relating to this article. I wish to read more things approximately it!
I’m really enjoying the design and layout of your site. It’s a very easy on the eyes which makes it much more enjoyable for me to come here and visit more often. Did you hire out a designer to create your theme? Outstanding work!
What a stuff of un-ambiguity and preserveness of precious knowledge regarding unexpected feelings.
It is perfect time to make a few plans for the longer term and it is time to be happy. I have read this post and if I may I want to recommend you few fascinating things or advice. Perhaps you could write next articles relating to this article. I want to read more things approximately it!
Appreciate the recommendation. Will try it out.
Hi there to all, the contents present at this site are really awesome for people experience, well, keep up the nice work fellows.
Superb blog! Do you have any hints for aspiring writers? I’m planning to start my own site soon but I’m a little lost on everything. Would you suggest starting with a free platform like WordPress or go for a paid option? There are so many choices out there that I’m totally confused .. Any ideas? Many thanks!
Really no matter if someone doesn’t understand after that its up to other people that they will help, so here it happens.
This is my first time visit at here and i am in fact impressed to read all at alone place.
Wow, awesome blog layout! How long have you been blogging for? you make blogging glance easy. The whole glance of your web site is fantastic, let alonewell as the content!
Yes! Finally something about %keyword1%.
Im not that much of a online reader to be honest but your blogs really nice, keep it up! I’ll go ahead and bookmark your site to come back in the future. Cheers
Hey very interesting blog!
Добро пожаловать на сайт онлайн казино, мы предлагаем уникальный опыт для любителей азартных игр.
I’ve read some good stuff here. Definitely value bookmarking for revisiting. I wonder how so much attempt you put to create such a wonderful informative site.
Онлайн казино радует своих посетителей более чем двумя тысячами увлекательных игр от ведущих разработчиков.
Онлайн казино отличный способ провести время, главное помните, что это развлечение, а не способ заработка.
В нашем онлайн казино вы найдете широкий спектр слотов и лайв игр, присоединяйтесь.
This post will help the internet people for building up new webpage or even a blog from start to end.
Quality articles or reviews is the key to attract the viewers to visit the site, that’s what this website is providing.
Why users still use to read news papers when in this technological world everything is existing on net?
Thank you for the auspicious writeup. It in reality used to be a amusement account it. Glance complex to far brought agreeable from you! By the way, how can we keep in touch?
Hello! I’ve been following your web site for a long time now and finally got the bravery to go ahead and give you a shout out from Lubbock Tx! Just wanted to mention keep up the excellent job!
Ищете надежного подрядчика для устройства стяжки пола в Москве? Обратитесь к нам на сайт styazhka-pola24.ru! Мы предлагаем услуги по залитию стяжки пола любой сложности и площади, а также гарантируем высокое качество работ.
строительство снабжение
С механизированной штукатуркой стен от mehanizirovannaya-shtukaturka-moscow.ru ремонт становится не только быстрым, но и качественным. Попробуйте самостоятельно, вы не разочаруетесь!
I got this site from my pal who informed me regarding this website and now this time I am visiting this site and reading very informative posts at this place.
At this moment I am going to do my breakfast, later than having my breakfast coming yet again to read additional news.
Quality posts is the important to be a focus for the users to pay a visit the web site, that’s what this website is providing.
Hi! I realize this is somewhat off-topic but I had to ask. Does running a well-established blog like yours take a massive amount work? I’m completely new to operating a blog but I do write in my diary everyday. I’d like to start a blog so I will be able to share my experience and thoughts online. Please let me know if you have any suggestions or tips for new aspiring bloggers. Appreciate it!
Обеспечьте своему жилищу идеальные стены с механизированной штукатуркой. Выберите надежное решение на mehanizirovannaya-shtukaturka-moscow.ru.
Simply want to say your article is as amazing. The clearness in your post is simply cool and i can assume you are an expert on this subject. Well with your permission allow me to grab your RSS feed to keep up to date with forthcoming post. Thanks a million and please continue the rewarding work.
I am sure this article has touched all the internet users, its really really pleasant article on building up new website.
What’s up friends, good piece of writing and nice arguments commented here, I am actually enjoying by these.
Link exchange is nothing else but it is simply placing the other person’s webpage link on your page at appropriate place and other person will also do same in favor of you.
If you are going for best contents like I do, only go to see this site every day as it offers quality contents, thanks
My relatives all the time say that I am wasting my time here at net, but I know I am getting experience daily by reading such pleasant articles.
Hey There. I found your blog the use of msn. This is an extremely smartly written article. I will be sure to bookmark it and come back to read more of your useful information. Thank you for the post. I will definitely comeback.
This is very interesting, You are an excessively professional blogger. I have joined your feed and sit up for looking for more of your fantastic post. Also, I have shared your site in my social networks
I visited several web pages but the audio quality for audio songs present at this site is really excellent.
Hey I am so happy I found your web site, I really found you by mistake, while I was browsing on Google for something else, Anyhow I am here now and would just like to say thanks a lot for a incredible post and a all round enjoyable blog (I also love the theme/design), I dont have time to read through it all at the minute but I have book-marked it and also included your RSS feeds, so when I have time I will be back to read much more, Please do keep up the fantastic jo.
I was able to find good info from your blog articles.
Great goods from you, man. I’ve have in mind your stuff prior to and you’re simply too wonderful. I really like what you’ve obtained here, really like what you’re stating and the way by which you assert it. You are making it entertaining and you still take care of to stay it smart. I cant wait to read far more from you. This is actually a wonderful website.
This article is really a nice one it helps new net users, who are wishing for blogging.
My brother suggested I might like this blog. He used to be totally right. This publish actually made my day. You cann’t consider just how much time I had spent for this information! Thank you!
I was very pleased to discover this great site. I wanted to thank you for your time for this wonderful read!! I definitely liked every bit of it and I have you book-marked to check out new things on your blog.
I’ve read some just right stuff here. Definitely value bookmarking for revisiting. I wonder how so much attempt you put to create one of these magnificent informative site.
Hi there, I found your web site via Google even as searching for a comparable topic, your web site got here up, it looks good. I have bookmarked it in my google bookmarks.
Не упускай возможности испытать свою удачу с Lucky Jet – самой популярной игрой на 1win.Получай максимум удовольствия и выигрывай великолепные призы с Lucky Jet – выбор профессионалов в мире азарта.
Hi, i think that i saw you visited my weblog so i came to return the favor.I am trying to find things to improve my site!I suppose its ok to use some of your ideas!!
Hiya very nice blog!! Guy .. Beautiful .. Superb .. I will bookmark your blog and take the feeds also? I am satisfied to seek out numerous useful information here in the submit, we’d like develop more strategies in this regard, thank you for sharing. . . . . .
Ridiculous quest there. What occurred after? Thanks!
you are actually a good webmaster. The web site loading speed is incredible. It kind of feels that you are doing any unique trick. Moreover, The contents are masterpiece. you have performed a magnificent task in this matter!
Hmm it seems like your website ate my first comment (it was extremely long) so I guess I’ll just sum it up what I had written and say, I’m thoroughly enjoying your blog. I as well am an aspiring blog blogger but I’m still new to the whole thing. Do you have any suggestions for inexperienced blog writers? I’d certainly appreciate it.
Thank you for some other wonderful article. Where else may just anyone get that kind of information in such a perfect way of writing? I have a presentation next week, and I am at the look for such information.
I have been surfing online more than three hours nowadays, yet I never found any fascinating article like yours. It’s pretty worth enough for me. Personally, if all website owners and bloggers made good content as you did, the internet will be much more useful than ever before.
Thank you for the auspicious writeup. It in fact was a amusement account it. Look advanced to far added agreeable from you! By the way, how can we communicate?
Great post.
Thanks for a marvelous posting! I definitely enjoyed reading it, you are a great author. I will be sure to bookmark your blog and will eventually come back someday. I want to encourage you to continue your great writing, have a nice morning!
When someone writes an article he/she maintains the thought of a user in his/her mind that how a user can know it. Thus that’s why this article is great. Thanks!
Excellent article! We will be linking to this great article on our site. Keep up the good writing.
Truly no matter if someone doesn’t know after that its up to other users that they will help, so here it happens.
Thanks for sharing your thoughts on %meta_keyword%. Regards
Hi there, always i used to check blog posts here early in the break of day, since i love to gain knowledge of more and more.
Hey there, I think your blog might be having browser compatibility issues. When I look at your blog in Ie, 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, amazing blog!
Your means of explaining everything in this post is actually nice, all be able to effortlessly know it, Thanks a lot.
Great post.
Your means of describing everything in this piece of writing is truly good, all be able to easily understand it, Thanks a lot.
Hello there, I think your website may be having browser compatibility issues. When I look at your site in Safari, it looks fine however, if opening in Internet Explorer, it has some overlapping issues. I simply wanted to give you a quick heads up! Other than that, fantastic blog!
This is very interesting, You are a very skilled blogger. I have joined your feed and look forward to seeking more of your fantastic post. Also, I have shared your web site in my social networks!
I am in fact thankful to the owner of this website who has shared this great piece of writing at at this place.
An impressive share! I have just forwarded this onto a coworker who had been doing a little research on this. And he in fact bought me lunch simply because I found it for him… lol. So let me reword this…. Thank YOU for the meal!! But yeah, thanx for spending time to discuss this issue here on your website.
I think this is one of the most significant information for me. And i’m glad reading your article. But wanna remark on few general things, The website style is perfect, the articles is really excellent : D. Good job, cheers
I have read so many articles about the blogger lovers but this piece of writing is truly a pleasant post, keep it up.
I’m not sure where you are getting your info, however good topic. I needs to spend a while learning more or working out more. Thank you for fantastic information I used to be looking for this information for my mission.