Via MacMadame -
When asked why they get a restrictive surgery, such as the sleeve, over a malabsorptive surgery such as RnY or a DS, many people point to the need to take vitamins and possible issues with malnutrition. Definitely, if you don't absorb everything you consume due to an intestinal bypass, your risks of problems caused by malnutrition go up. But that doesn't mean someone with a restrictive-only surgery has no chance of experiencing a problem brought on by not getting enough of certain nutrients.
In my own case, my issues have all been with protein.
My protein and albumin levels were adequate pre-op. Nothing to write home about, but at least within what is considered normal ranges. My protein was at 6.9 (the acceptable range is 6.4 to 8.2) and my albumin was 3.7 (3.2 to 4.7). I also had Vitamin D in the toilet at 32 (normal range is 45 to 100) and issues with calcium and potassium due to taking HCTZ for high blood pressure.
I have been able to solve my issues with calcium, potassium and Vitamin D by a combination of supplementation and getting off the HCTZ. But my protein levels have not been as cooperative.
Over the past 1.5 years, my albumin has ranged from a scary low of 2.9 to a "high" of 3.7. It seems to have settled into the 3.5-3.7 range at this point. And, yes, that is considered normal. But it's the low end of normal. I'd be happier to be in the middle of the range, especially if my protein is also at the lower end of normal.
Speaking of protein, mine dropped to 5.7 (!) at 7 weeks post-op, then climbed up to a whopping 6.1 at 3 months out and .... stayed there for over a year. This is while I was taking in 125 to 135 g of protein a day on average, I should note.
Also, I consume around 2000 calorie a day. So shouldn't I be getting pretty much all of the necessary nutrients from food? Yet my labs are good, but not fantastic. I am taking 2x the adult dose of a multivitamin every day and 1500 mg of calcium from supplements, 50,000 IU of Vitamin D3 every Monday, and .... my labs are okay. I had really hoped to cut down to 1000 mg of calcium a day and 1 multivitamin now that I'm eating the supposed daily average. But I don't see anything in my one year labs to justify dropping back on what I take.
The thing is: our bodies are made up of complex systems that interact on every level. You can't cut out part of an organ and not expect there to be consequences. With a smaller stomach, I now have less intrinsic factor than I used to and less stomach acid (especially since I'm on Prilosec). Also, my stomach empties slightly faster than normal. I also have much less ghrelin, aka the hunger hormone. While most of this is not going to cause big problems, it's not like it won't have any impact at all.
For me, having less ghrelin has been a blessing as has having less stomach acid. My GERD is mostly gone, easily controlled by taking a PPI, and my hunger is slightly under normal levels. But it appears that having a smaller stomach and faster stomach emptying means that I am not absorbing as many nutrients out of my food as I was pre-op, probably because the food is not as broken down when it hits my still intact intestines.
That means I have to keep taking all my supplements and it also means I have to be extra careful about my protein intake.
So, it's not just those with RnY and DS who have to worry about their labs and their nutrition. We all do.
We made it successfully between enrollments and we are now insured. All hell can now break loose. KIDDING. MORE THAN KIDDING.
I had missed my last blood work appointment, and bumped it to today. Here's to hoping I have some iron in my blood. It's been a long time since my last infusion - three months or so - so I may need another.
Last time we checked, I had low normal HCT and HGB and I had actually increased my Ferritin (iron stores) level to, I think, 11? (I am typically between 3 and 5, which is super low.)
If I don't need an infusion, I think I may start tanking up on oral iron supplements, there are so many I can try, and it might be a good time to give it a solid attempt with no metal dripping in an IV bag for a good long stretch. I never took anything repeatedly since starting infusions -- doctors had said NOT to -- to measure the effectiveness of the Ferrlecit and Dextran.
Here's to healthier blood.
Update - I'm not anemic. Woot. My hematocrit and hemoglobin were NORMAL.
My iron stores, ferritin, are still in the toilet at 7. The hematologist didn't even suggest a follow up. I guess this means, I'm going to attempt to take iron supplements, play doctor and work on getting my own iron stores up.
In fact, she was more concerned that my blood sugar was low during the draw. LOL. I didn't even know.
NEW YORK (Reuters Health) - Weight loss surgery can help you lose weight, but it's also likely to leave you unable to absorb iron, a new study suggests: Iron deficiency is a common problem after stomach bypass surgery to treat severe obesity -- and standard iron supplements may not be enough to prevent it in some patients.
Researchers found that among 67 Chilean women who had undergone the most common form of weight-loss surgery, 39 percent developed low blood counts, also known as anemia, within 18 months of surgery. That anemia was most often due to a deficiency in iron, which the body needs to produce healthy red blood cells that carry oxygen.
In contrast, less than two percent of the women had been anemic before surgery, the researchers report in the American Journal of Clinical Nutrition.
It's well known that nutritional deficiencies are a risk after the type of surgery examined in the trial, known as Roux-en-Y gastric bypass, the most common and most effective form of weight- loss surgery for severe obesity.
The procedure involves stapling off the upper portion of the stomach to create a small pouch that restricts the amount of food a person can eat at one time. The surgeon also makes a bypass from the pouch that skirts around the rest of the stomach and a portion of the small intestine, limiting the body's absorption of nutrients.The new findings suggest that impaired iron absorption, rather than reduced iron intake, is the major cause of long-term deficiency after gastric bypass, according to the researchers.
Tests done six months after surgery showed that, on average, women were absorbing just one-third of the iron from food that they had before surgery.
What's more, their absorption of iron from supplements showed nearly as great a decline. And many women became deficient in iron despite taking supplements after surgery, according to the researchers, led by Manuel Ruz of the University of Chile in Santiago.
All of the women in the study were put on vitamin and mineral supplements after surgery, though not all took iron pills. Those who did were prescribed 18 milligrams per day -- the standard recommended iron intake for women younger than 50.
That amount, Ruz and his colleagues write, appears "largely insufficient to prevent iron deficiency and iron deficiency anemia."
The researchers say that some patients may need to take newer, more readily absorbed iron formulations, or receive infusions of the mineral rather than pills, to prevent a deficiency.
According to the American Society for Metabolic & Bariatric Surgery, about 220,000 Americans had some form of weight-loss surgery in 2008, with gastric bypass accounting for the majority.
SOURCE: American Journal of Clinical Nutrition, September 2009.
NAAC Review Published: September 15, 2009
The two types of bariatric procedures most often performed in Europe are adjustable gastric banding (AGB) and gastric bypass (GBP). The use of bariatric surgery has demonstrated long-term effectiveness on weight loss and comorbidities, including three recent studies, which used restrictive and malabsorption procedures, with findings of decreased mortality several years following the bariatric procedures. Gastric bypass, an irreversible restrictive and mildly malabsorptive procedure, is more efficient than AGB, a purely restrictive and reversible procedure, on weight loss and comorbidities. However, GBP potentially induces more nutritional deficits, compared to adjustable gastric binding. Adverse effects of bariatric surgery are not uncommon, but less is known about nutritional complications of bariatric surgery. In the present study, the authors prospectively compared the prevalence of nutritional deficiencies after AGB and GBP procedures.
I haven't felt right lately, I've been super-forgetful, clumsy and generally feeling stoopid. Enough so that I felt it necessary to get an urgent visit with the PCP this morning. (Many of those symptoms point to a medication problem, I don't want to mess around.) I was already having memory and cognitive problems, I have for a long time, but it's increased.
I didn't call, I just walked in to see if they had any available appointments, and they squeezed me in. (Although, I have to mention, that any time that's ever happened, that I have been "squeezed in" -- the offices are empty. But I do appreciate it.)
The doctor sent me to get blood drawn, she's checking my current state of anemia, metabolic panel, vitamin levels, thyroid and my seizure med level. I told her that SOMETHING is not right. Something is out of balance. I am off kilter, more than my usual. Here's to hoping something IS off kilter, or you can set me up in that special Alzheimer's Unit now.
No seriously, you don't get it. I walked in to drop off the baby at school today and a former co-worker of Mr's was there. She said, "Hi! How are you?" I HAD NO IDEA WHO SHE WAS. She's been IN MY HOUSE. Mr. has only been in the new job for what, a month? I knew that I recognized her, but I could not place her. She likely thought I had lost it.
Add that to the general feeling of askew in my body? Good times.
It could be worse.
Alongside me, a woman my age, being escorted out of a van with full head protection on.
It could be worse.
Study suggests the womb may be key to breaking cycle of fat, diabetes
"Obese women who manage to shed excess pounds before becoming pregnant may be able to break the cycle of inherited weight problems and pass along better health to their children, a new study shows.
Researchers found that children were less likely to become obese if their mothers lost significant weight through obesity surgery before becoming pregnant, according to an upcoming study in the Journal of Clinical Endocrinology & Metabolism. The children with the surgically slimmed mothers also looked to have a lower risk of heart disease and diabetes.
âWeâve shown that when the mother loses weight prior to becoming pregnant, the kid does not become obese,â said Dr. John Kral, study co-author and a professor of surgery and medicine at the State University of New York Downstate Medical Center in Brooklyn.
Other studies have shown that obese moms are more likely than slim women to have obese children, Kral said.
And the health risks associated with obesity are well-documented for both moms and babies, said Dr. Dominic Marchiano, an assistant professor of obstetrics and gynecology at Pennsylvania Hospital in Philadelphia.
But until now, it was unclear exactly how to break the cycle.
Steeped in sugary womb
The new results shift some of the blame for childhood obesity from genes and the home environment to the conditions a fetus encounters as it matures in the womb.
Factors in the uterus might affect how a kidâs genes function later on, Kral said. For example, obese mothers often have blood sugar levels that are too high.
âAnd that can leave the kid marinating in sugar as he develops,â Kral said âBut itâs not only that. There are many other substances in the amniotic fluid of an obese woman that can affect the developing offspring.â
Kral and his colleagues studied 111 children from Quebec City, some of whom were conceived before and some after their moms had weight-loss surgery. The kids ranged in age from 2 to 26.
The 49 moms in the study had a procedure called biliopancreatic diversion, or BPD.
That surgery directs food to bypass part of the small intestine and also makes the stomach a little smaller. The resulting weight loss is mainly due to the fact that people absorb fewer calories, Kral said, adding that studies have shown that people with BPD continue to eat significantly more than people who are naturally lean. This suggests that what the moms ate later on, during their babiesâ childhoods, wasnât the difference; instead, it was likely their actual weight loss.
The women in the study had lost an average of 36 percent of their body weight and had kept the weight off for about 12 years. They also had experienced improvement in their cholesterol and blood sugar levels.
Kral and his colleagues counseled the women to hold off on conceiving until they had achieved their desired body weight. When the women did become pregnant, they were given supplements to make sure that their babies didnât miss any important nutrients, Kral said.
When the researchers compared children conceived before and after a momâs weight loss surgery, they found startling results: post-surgery babies were smaller, though not underweight, and they were three times less likely to become severely obese as they grew up.
The children born to thinner moms also appeared to be healthier overall, with lower insulin resistance and cholesterol levels, signs of a reduced risk of diabetes and heart disease.
And these results were the same when the researchers limited their analysis to children who were siblings: 25 of the 49 moms had children born both before and after their surgeries.
What was most striking, Kral said, was that you could break a familyâs cycle of obesity by getting the mom to lose weight.
Further, Kral said, it really doesnât matter how the moms drop the pounds. The results are expected to be the same if a mom loses weight through dieting instead of surgery.
These new results may give those contemplating pregnancy another incentive to slim down, Marchiano said. âWe always recommend that women lose weight prior to conception â but not while they are pregnant,â he added. âThis may help with motivation as women think about the weight destiny of their children.â
I especially like the visual of the fetus marinating in sugar.
I'm actually an experiment in progress, with three pre-WLS babies and one post WLS baby.
Does the post WLS kid stand a better chance of not becoming obese? Environment be damned, will she be better off than the first three? I do wonder sometimes.
My post WLS child didn't marinate in sugar, in fact, I was seriously hypoglycemic throughout her development. I actually wondered if she would be negatively effected due to my health post WLS. For a while, I thought she might be born with some type of abnormality, either from the constant hypoglycemia, anemia or another vitamin issue. She, of course, is now nearly three and fine, but I did wonder!
An old pal from my AOL days is looking into weight loss surgery, and sent these questions over. I know they look like things I've answered a hundred times before, but you know what? Answers change over time as I grow with this body. I know she wants the truth, and I am not in the business of selling surgery.
How long ago did you have your surgeryâ¦.
- April 5th, 2004.
- I felt like sheer death for a few days, I have fond memories of the ride home from Boston. NOT ANOTHER BUMP, YOU ASSHOLE! O-o But not SO awful that I couldn't waddle through the store within those same days.
Have you achieved your goal, or at least
most of itâ¦.
- No, never. My goal is disgustingly low, considering my height, so, no. I've never touched it. I "should" be between 115-130 something pounds, and I've never gotten beyond 149. 149 lbs is a good weight for me, and when/if I ever have plastic surgery, it's damn small and good enough. I hit that weight and rebounded to 170 and got pregnant. During pregnancy I hit 210 lbs. I have been playing in the range of 155-170 lbs since then and it's the most difficult NOW to change.
- Simply stated, no. I did not know enough of the "could happens." If I could "go back and do it all over again," I would, but likely pick a different path. I can't give you advice. I can't tell you what to do. But if you were my sister? I'd probably say, gastric banding. Yeah, it's slower loss, and yeah it's got higher regain rates, but it is a teaching method that can WORK, and won't cause mal-absorption and the issues that come from rerouted innards.
Positives from surgery over the yearsâ¦..
- Nearly 100% success in the weight loss department, actually, my surgeon's goal for me was 175. So, there, I did it. 320 - 149 - 210 - 155 - 170. Overall, being smaller works for me. Sad, but true, you get treated better as a normal-sized person, doors are held for you, drinks are bought for you -- and so on.
Negatives from surgery over the yearsâ¦..
- For ME: Dehydration, kidney stones, weight loss stalls, gas of DEATH, food issues, food intolerances, dumping, late dumping, diarrhea, severe constipation, severe reactive hypoglycemia, neurological symptoms, vitamin deficiency, severe anemia, vertigo, seizures.
- For Mr. MM: Dehydration, severe pain in blind stomach requiring re-admit and scoping, constipation, food intolerances, dumping, late dumping, diarrhea, reactive hypoglycemia, sometimes severe, the worst powerful gas on EARTH and bowel distress often
- For Grandma Mr MM: Strictures, bradycardia, low protein levels, anemia, very severe constipation, severe vertigo requiring meds and therapy, dumping, and lots of complications with post-WLS plastic surgeries.
- For Mr. MM's Sister: Problems with slow weight loss, and assorted similar complaints.
How hard is it to stick to the
- The diet is easy as pie in the beginning. You are FORCED into it. There is NO way to cheat. Starvation works. It's not until 9+ months or closer to 24 months that the real problems start regarding food demons. By the time you can eat normal small meals, you have had better dealt with the food issues and emotional eating, or you're on the road to regain without a doubt.
New! New to me, anyway, a chewable iron tablet that doesn't taste like licking the inside of a Spaghetti-os can! Not that I know ANYTHING about things like that. Please say hello to:
Iron-deficiency anemia is a common complication of gastric bypass and is more pronounced in menstruating females. There is also a risk of other micronutrient deficiencies, such as vitamin B12 and calcium deficiencies.
- Product - Building Blocks 30mg Chewable Iron
- Via - www.bbvitamins.com Direct at http://www.bbvitamins.com/ProductDetails.aspx?productID=138
- Price - $10.50 per month
- Pros - Tastes really good, breaks down into a sweet berry sugar-like consistency, no aftertaste, no icky mouth!
- Cons -
- Rating - Pouchworthy, MM.
Even if you never took a single vitamin in your life: If you're having weight loss surgery you must take vitamin and mineral supplementation after your procedure. Get used to it.
Malabsorptive procedures such as biliopancreatic diversion or mixed restrictive/malabsorptive procedures (eg, Roux-en-Y gastric bypass) can result in serious nutritional problems when patients do not take required supplements after surgery. Vitamins and minerals that are commonly deficient in this circumstance include vitamin B-12, calcium vitamin D, thiamine, folic acid,iron, zinc, and magnesium.
From Bariatric Times, in regards to RNY Gastric Bypass Surgery -
The general recommendations are:
â¢ Chewable, liquid, or powder multivitamin containing RDA levels of iron and zinc taken daily.
â¢ Sublingual B12 (500â1,000mcg) once per week, IM injection (1,000mcg) once per month, or nasal gel or B12 patch (1,000mcg) once per week; increase based on follow-up labs.
â¢ Chewable, liquid, powder, or lozenge 1,000 to 1,500mg calcium citrate with vitamin D in divided doses; increase based on follow-up labs.
â¢ Some programs may also recommend a separate daily B-complex or thiamine.
In addition, some post ops may require additional iron, especially menstruating women, we're very prone to post RNY anemia. And according to your follow-up blood work, vitamin supplementation levels may need to be tweaked from time to time.
Take your vitamins. If you were able to go through massive surgery, you can take a vitamin. I don't want to hear, "But they're all like, icky! I totally can't take them because I GAAAAAG."
Take. Your. Vitamins. Your blood, brains, nerves, eyes... they'll all thank you. I mean it.
After weight loss surgery, vitamins are imperative, from my experience, you're not allowed to skimp. I am not a nutritionist - nor a doctor - listen to them - however I think vitamins are important. This is why I am on this mission - to try every. single. vitamin. out there made for the bariatric post op.
This morning I receive a menu for the cafeteria.
(There's a video within the article that shows her distress. Please watch it.)
SIGH. Although, I get it.
The 2002 surgery led to chronic malnutrition and anemia. As the pounds melted away, so did her life.
With a sunken face and protruding collar bones, she is too weak to work and spends most afternoons on the couch wrapped in a blanket.
She has thoughts of giving up, but wants to be there for 12-year-old daughter Megan and 19-year-old son Dustin.
"It's not acceptable leaving me like this," said the 103-pound Krueger, who at 38 looks closer to 50. "I've gone to doctor after doctor and basically they don't help me."
So. I have written on all of my medical charts that I am "allergic" to iron in the form of Dextran or Infed. The new hematologist gave me a test dose today, after much discussion last week, because my long-term iron storage levels, or "Ferritin Levels" (Currently at 3) are so low, and have been for so.freaking.long. that...
"Why shouldn't we give it another try?"
"What, OMGZ what?!"
Yeah. I took the allergic medication.
anaphylactoid reactions are serious and unpredictable, IV iron dextran
should be used only when iron deficiency anemia cannot be treated
adequately with oral iron" -JAMA
Woot. I tried HARD not to feel an itch. I overthought it. I was like, THERE IS AN ITCH RIGHT THERE AND OH MY FREAKING GAWD I FEEL IT AND I AM GOING TO GO INTO SHOCK RIGHT THIS VERY MOMENT!! I felt a little bit gross for a moment, and then my arm felt heavy and achy, but then, I was okay again, and back to my normal seizure-medicated self.
I had been receiving Ferrlecit, which is given instead of Dextran or Infed, but it didn't seem to raise my iron storage levels at all. My ferritin levels have always been 5 or under. I admit, I have been not good about following through with infusions, but I have had more infusions than more RNY patients out there.
The hematologist seems to think that if I survived this big dose of iron that should have made me shoot into orbit with itch, I'll be running a marathon by next week.
If this does not work, I will melt down pots and pans and eat them.
Why infusions? Why can't you just take pills, Beth?
Parenteral Iron Repletion Therapy-
Therapy for iron deficiency anemia includes treatment of its underlying cause and restoration of normal hemoglobin concentrations and iron stores. This can be accomplished by oral or parenteral administration. Although the oral route is preferred, clinical situations exist where the parenteral route is indicated:
- Intolerance or non-compliance to oral iron preparations.
- Lack of effect of oral iron therapy.
- Malabsorption of oral iron, e.g. due to gastrointestinal disease or surgery.
PS. My bloodwork from last week - BETTER - my B12 with no injections - was good! Nothing stood out in the basic CBC other than the iron.
The new hematologist seems great. She's got an awesome personality, she's funny and warm. It's actually more funny though - when I went in there - I am brand new never met the woman - and she says:
"You didn't have a gastric bypass or anything, right?"
LMFAO. The nurse is all, "Read the chart."
She looked half-mortified for a moment.
Apparently young, otherwise 'healthy' younger women make up a large portion of a hematologists caseload. Every hematologist I meet tells me stories about people who've had gastric bypass and gotten sick.
My first hematologist basically inferred that I chose to "do this to myself" (have the bypass and get sick) when I first went with my blood level at 23. Initially I was pissed when I heard that. But. I got over it.
My blood draw from the end of November was decent.
My anemia was borderline, not so bad at all, my ferritin (long term iron stores) are always the toilet, but HCT and HGB were low normal, which is where it is all the time, even with IV iron treatment.
Everything else was actually fine aside from my low Vitamin D. B12 was normal. Protein normal, nothing out of range, and a full panel was drawn, as I asked - begged for. Nothing in the panel was out of range that SHE saw. Good. I did not get a copy. But, it was old.
(Though, I am going to make for DAMN SURE that the bariatric doctor I see on Friday checks every. little. detail. since I am looking for a trigger for my neurological problems. There are many trace elements than can be tested.)
*Because, right after I wrote this? I had a complex partial seizure.
We took a new draw, of course, and set up a iron infusion for next week.
Before I get into it, let me remind you, I got new PCP a few weeks ago locally. (Because, I have not seen my PCP's office - with the ONE YEAR WAIT for a physical, and the other crap I was dealing with.) I went to her for some stat blood work because I felt "off."
I swear to you I AM NOT A HYPOCHONDRIAC.
I HATE THAT I FEEL AT ALL "OFF."
I never GO any doctor. I avoid. I have been calling and leaving voice-mail messages for a a couple weeks now. That translates to what, three or four calls. I just want to know what my vitamin levels are. Simple enough. I guess not.
Anyway - remember how I told you I got the opportunity to speak with Dr. Jacques?
She sent this along:
And just so that you KNOW - I BOLD-FACED MY ISSUES:
I do hope that you contact Dr Sasha Stiles at Tufts, and I am working on one additional referral for you. Her is some information on nutrient deficiencies that can cause seizure:
Deficiency: Deficiency causes seborrheic dermatitis, glossitis (swollen
tongue), and cheilosis (cracked corners of mouth), and, in adults, can
cause depression, confusion, EEG abnormalities, and seizures. Seizures,
particularly in infants, may be refractory to treatment with
- Normocytic, microcytic, or sideroblastic anemia can also develop - you need to have this checked and ruled out. The test is serum PLP and/or and EAST test.
- Vitamin D deficiency can lead to seizure when it causes hypocalcemia, hypomagnesemia or both. You should have all three evaluated: 25-OH-D, serum corrected calcium and red blood cell magnesium. A PTH test would also be appropriate.
B1 and B12 deficiency have been documented to cause seizure disorders â
though not incredibly commonly. I would recheck both. Make sure B12
is above 400. I would also check folate. Tests would be serum
thiamine, serum B12, and red cell folate.
- Several of the B-vitamin deficiencies can cause sensitivity of light as
well, especially if they impact the optic nerve. In addition,
deficiency of Vitamin A or zinc (or both since they can occur together)
can cause photophobia.
She suggested I get in to see a Dr. Stiles who is now practicing at Tufts, where I had my RNY. The woman on the phone who took my information was a little confused as to why I would want to see this doctor - five years post operatively.
"You've had the surgery already?"
"So, why do you want to see the doctor?"
I said I was having some "complications." She asked, "like?"
I rattled off that I had various deficencies, anemia, hypoglycemia, seizures, yadda, yadda yadda and, um, my teeth are rotting.
She said, "Your teeth are falling out?" (Like she didn't believe me.)
That happens with severe Vitamin-D deficiency, but I don't think she heard my other stuff, but I did not really want to discuss it, so I just said, "Yep, can I have an appointment?"
January 2nd. PLEASE let this doctor listen to me and do some GOD DAMNED TESTING. I want to be healthy. I want my brain back.
I have a new PCP visit tomorrow. My SIL is taking me, and although I hate to drop bombs on new doctors, guess what? I am going to, because I am going feeling like shit.
I know there is something wrong, perhaps it's my blood catching up with me. (I am guilty of missing my iron infusions, the last two months. They haven't helped increase my blood anyway, BUT, I did miss them entirely and I am probably paying for it now.)
I feel sort of like I did when I was knocked up, I feel like Anemia Girl again. Not only that, but I have pain, actual pain in my muscles or joints, I can't tell where it's coming from. Is this the Vitamin-D deficiency? Perhaps. I didn't know that Vitamin-D deficiency had any real physical "I can feel this" symptoms, and I would hate to read anything into it, but, damn, if it's not related, there's something wrong.
I'm going to beg for a stat CBC. The doctor is going to think I am crazy, because they just don't do that. But, it's a necessary evil. I have a feeling my blood has tanked and I may need to get poked sooner than later. Just send me home with a bag of A-, I'll be alright.