Category: Personal

140 keV Gamma “Ray” Bone Scans…

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My rate of emission of 140 keV photons is now down to lower levels, five radioactive half lives after injection. The concentration has been reduced by biological elution and the radioactivity by decay. It was interesting to read how few suppliers there were for 99mTc. Yesterday, she only injected a few millilitres of tracer.

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I have been reading up and watching videos on the interpretation of bone scans, I can probably note metastatic lesions, depletion in tracer localisation due to prothesis, fractures (old and new), areas of bone formation and depletion. It might be interesting to see what my damaged cervical spine looks like and if my “broken” ribs from rugby can be seen.  Osteophytes are evident on my thoracic spine and near my Titanium pin. The Diffuse Idiopathic Skeletal hyperostosis (DISH) is probably still growing and could localise tracer. {I had a full body scan.} This, if seen, can be cross referenced with an upcoming CT scan.

There could be plenty in my scans for a nuclear medicine professional to discuss with her younger colleagues.

I meet some of the diagnostic criteria for polycythaemia (probably secondary). If it is the malignant form this may interfere with bone cycling in the marrow and could appear in the scintigraphy. There are a few suggestions in the literature to use nuclear medicine to detect this. But it is not common practice.

I guess the single-photon emission computed tomographic (SPECT) images might show something like this below. My hip arthritis is much worse than in the X-ray or CT images below. It does not look like a whole lot of extra knowledge comes from the SPECT data for the hip.

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Dunn’s view of (A) right and (B) left hips of a 48-year-old male patient presenting with left hip pain only. Single-photon emission computed tomographic images shown in (C) anterior and (D) posterior coronal views display more uptake (black arrow) along the superolateral aspect of the acetabular roof on the symptomatic left hip compared with the asymptomatic right hip (white arrow).

Clin Orthop Relat Res. 2008 Dec 17;467(3):676–681

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What might however be interesting is what tips up in the rest of the body scan. The pain in my lower and mid lumbar spine has been explained in different ways by different doctors.  There might be clues as to what is going on.

I guess what I do not want to see is evidence for primary bone cancer or metastatic disease. The main diagnostic differentiation of the latter is a disordered or “random” appearance of tracer localisation. Metastatic disease is incurable and often terminal.

I have joked that I could re-train as a radiographer or a nuclear medicine operator. But you know what they say about old dogs.

It is weird, I feel very up in the air, with little or no idea if/when I will get to see the data. Something which could change the direction of life is hanging ill-defined in the aether. I am in a kind of limbo.

I wonder if people who prescribe scans have ever had to wait and hang like this…

Maybe it should be a compulsory part of training…

Pandora, what does two plus two equal?

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“A bone scan or bone scintigraphy is a nuclear medicine imaging technique used to help diagnose and assess different bone diseases. These include cancer of the bone or metastasis, location of bone inflammation and fractures (that may not be visible in traditional X-ray images), and bone infection (osteomyelitis).

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The most common radiopharmaceutical for bone scintigraphy is 99mTc with methylene diphosphonate (MDP). Other bone radiopharmaceuticals include 99mTc with HDP, HMDP and DPD. MDP adsorbs onto the crystalline hydroxyapatite mineral of bone. Mineralisation occurs at osteoblasts, representing sites of bone growth, where MDP (and other diphosphates) “bind to the hydroxyapatite crystals in proportion to local blood flow and osteoblastic activity and are therefore markers of bone turnover and bone perfusion”.”

From Wikipedia

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I have not long returned from the Nuclear Medicine suite at Yves Le Foll hospital Saint Brieuc. The pretext from my bone scan was to look at where there might be inflammation in my right femoral head / neck and hip prior to an operation. The first orthopaedic surgeon, who prescribed the scan, suggested that it might be done with an Iodine radio-tracer. That is not for bones. He became a little flustered when questioned and pressed on the subject. The second orthopaedic surgeon questioned why he might even order such a test. It seemed incongruous to him.

Nobody in France has yet mentioned the C word! Looking in Pandora’s box can have unexpected results. They could be doing a “Basil Fawlty”.

At the end of my scan today the operatives in the control room were all looking intently at my images, pointing and talking animatedly. Before the scan they did not help me onto the scanner table, after it they were very helpful with the dismount. The images changed behaviour. I was not privy to my gamma ray “only fans” content which had them talking. The secretary suggested that I will get the results in a letter at some unspecified time in the future. The results will go to the first orthopaedic surgeon and my GP.

The following outcomes are possible:

1)  The results simply show osteo-arthritic frictional inflammation in the bony tissues. What I call the pepper mill effect. In which case I will get the results through the post and I can take a good scooby at them myself.

2) There is a long delay during which a conflab occurs. I do not get the results in a timely fashion, some other follow up plan is hatched. Something needing to be followed up has been found.

3) I get a telephone call to tell me bad news. I am being followed for elevated prostate specific antigen and have had colon cancer. There are anomalies in my blood work.

4) The results arrive in a tardy fashion with bad news therein, before anyone contacts me.

This is what the Canadian Cancer Society says:

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Société canadienne du cancer

La scintigraphie osseuse aide les médecins à diagnostiquer et à évaluer différentes maladies et affections osseuses. On peut y avoir recours pour:

  • trouver un cancer des os ou déterminer si un cancer présent dans une autre région s’est propagé aux os;
  • aider à diagnostiquer la cause ou à déterminer l’emplacement d’une douleur osseuse inexpliquée;
  • aider à diagnostiquer des fractures osseuses qui ne sont pas évidentes à la radiographie;
  • voir jusqu’où le cancer s’est propagé;
  • trouver des lésions osseuses causées par une infection ou d’autres affections osseuses;
  • savoir si le traitement du cancer est efficace ou pour faire un suivi.

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Obviously, they are going to have a cancer bias. My gut feeling is that people are not being 100% straightforward with me. My gut feelings are often with substance. The French can beat around the bush so to speak.

Waffle, moi?

Whatever the outcome, knowing what the data says does not change the actual physical plane reality. It does / might affect how things move on from here…

It is out of my hands; I can do nothing…

We shall see…

When Professor Google Does Not Know…

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Something weird is happening at Eurofins the lab which analyses the blood tests. On Saturday they sent me the results of my alpha-1 antitrypsin survey. This came back normal, so there is no genetics causing a suppression. Yesterday evening they resent me the results twice!! This kind of thing is not normal, so it caught my attention.

The really weird thing is the low parathyroid hormone level.

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“Hypoparathyroidism is the combination of symptoms due to inadequate parathyroid hormone production (PTH) (Hypo-parathyroid-ism).  This is a very rare condition, and almost always occurs because of damage or removal of parathyroid glands at the time of parathyroid or thyroid surgery. This bears repeating: When people have too little parathyroid hormone (PTH), it is almost always because they had thyroid or parathyroid surgery and all four parathyroid glands were removed or injured.”

Source parathyroid.com

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I have the low hormone level BUT not the reduced calcium levels. I used to get cramps and have had neuropathy in my fingers. This neuropathy being probably down to the cervical spine injury ~2008 and the hernias therein. Calcium levels are however normal.

I have asked Professor Google about the PTH low Calcium normal using different sets of key words. He/she/it does not have much to say on the subject. There was one case of a Māori woman with similar numbers. It was weird enough to ask the laboratory to check the parathyroid hormone data. It was not wrong. They made a “special” report.

The endocrinologist may yet comment.

Using the above logic it perhaps makes sense to re-test the hormone level.

Because I am asymptomatic, this does not seem like a big deal. It could be a harbinger of problems yet to come. The hormone level is low; it has not dropped the calcium yet…

Like me it is a bit of an anomaly an outlier. The question is, is it safe to ignore and chalk up as just one of those things or does it need further investigation?

When You Just Know

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I have started the process of looking around for an alternate orthopaedic surgeon. I have secured a provisional appointment. I just know that should I follow through, this it is going to open a can of worms. In principle a second opinion is “allowed”. In practice it can put noses out of joint, cause gossip and stoke rivalries. I can stop it. I am going to sleep on it. But the moment I tip up for an appointment I will have to explain myself. There will be uncomfortable feelings on both sides. It will not be smooth and I will be the problem, not anyone else. I am also a foreigner now, too. I do not have citizenship and my right to stay expires in a few months’ time, March.

Way back when I lived near Farnham, I had a GP doctor who was athletic-skinny. He had a pro-forma crib sheet for calculating BMI. It was issued by the Ministry of Truth. He calculated mine and proceeded to lecture me from his soap box about the need to lose weight. Even though I was not officially obese back then. I asked him to show me my extra body fat. He could not. He said that people can be fat on the inside. Whatever that means, those were his literal words, fat on the inside. I showed him my large biceps and claimed muscle mass but he persisted. I then said that I had recently read an article in the BMJ about how raw BMI data was often over interpreted in general practice medicine. His back was up and he was affronted.

I just knew that we would never get on and for our mutual benefit it would be better for me to have another GP. I saw him a few times before I changed practice and each meeting was fractious. He is a human being, so was I. I have rarely had a reaction like this from a woman. I concluded that possession of a penis played a role in interpersonal dynamics. I am not insecure about the average size of mine, physically and metaphorically. I don’t have a whole bag of chips on my shoulder.

The caveat here is that my perception could be skewed. I perceive that I have an uncanny knack of putting people’s back up especially when they deem themselves superior, more expert, to me. I can be more frank than some like or can handle. I am just being me. I am not trying to wind them up or belittle them. I get what I perceive of as bad reactions.

In general I know when I have the early stages of a bronchial infection. I report to a GP doctor and quite rightly because there is not enough cack in the lungs, they do not initially prescribe an antibiotic. I just know in many cases I will be back soon when the cack gets cacky enough for antibiotics. They have a process to go through to limit over prescription. I just know that I have to wait until a certain severity of illness presents. They are doing their job, that is all. It is possible that I might wait too long one day.

I had a bad clash of personalities with my cancer “care” nurse a decade ago. She had severe mother superior tendencies and I met her dogmatism head on. This made collecting my results from her an unpleasant thing which I came to dread. Rather than looking forward to her support, I would dread the meetings. I asked them to send my carcinoembryonic antigen (CEA) results by email. They refused. If anything went wrong it would have to be very wrong indeed before I would reach out to my allocated cancer care nurse. I never did. I just knew that the best thing was to switch hospital care teams. It sounded simple and I could offer the reason of enhanced proximity.

However I opened a can of worms. Every time I went for a colonoscopy or to follow up blood in the faeces, they wanted to know why I had changed teams. They kept pressing me. They seemed obsessed with gaining this information. I gave the same answer that they were closer, which was true but incomplete. On a number of occasions the chimney sweep insisted that the blood was from piles. I just knew that was not the case. So we had to have an examination for piles before he agreed to a sigmoidoscopy. I don’t particularly like having endoscopes shoved up my arse but there was no way of avoiding his adamant insistence that it was piles. I just had to let him go through his process. He had all the power and I wanted to find out if I had a new cancer or a recurrence of the old one. I was not anxious I wanted data. People can see anxious when need for data manifests.

Sometimes I just know when the best thing is to drop something and walk away. It is for everyone’s benefit. Even If I am inconvenienced it can be better just to let things lie, leave them well alone.

A while back someone trying to be clever said that I was a part of the equation as to why things were not working out. I simplified his equation by removing a variable, me. I don’t know how well the equation worked out after that…If I was a/the problem at least they had the possibility of moving forward unencumbered by me.

This feeling that I am a/the problem according to others has presented multiple times in this life and it has resulted in a walk away or a door slam on more than a few of these.

If I am the problem I want to simplify things…

I just know when people are seeing or are starting to see me as a/the problem.

Maybe they are right and it is always me…

It is just one of those things…

Narziß und Goldmund – Quantum Superposition State

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Finding “The Glass Bead Game” and Herman Hesse was a pivotal moment for me. In Knecht, the Magister Ludi, I found someone who innately sensed interconnectivity, the flow of consciousness and how one idea or theme intertwined others. His “lives” spoke direct to me. Finally I did not feel quite so absolutely weird. The scale of concept was vast and hugely refreshing. Someone on the planet was wired a little like me, though far more eloquent and expressive.

Like Magnus Pym and Bern, “The Perfect Spy”, had captured and conveyed a little of what it was like for me to have traversed life. His fiction more complex than mine. Yet I recognised the chameleon into which I once morphed for safety and to blend.

But it was with Narziß und Goldmund that I learned in the courtyard at Mariabronn of my own duality superimposed into a superposition state. There I sensed something of my monastic pasts and my reckless wild child. Initially I felt more Goldmund, later Narziß. The coefficient of the latter in my superposition sate is higher, when time averaged. I saw in this duality the autobiography of Hesse and his delicate and nuanced verbalisation. The sense of friction but not conflict, of phase and of interplay.

In a way each of my blogs are / have been by way of a glass bead game, only making sense to me. They are a way of arranging things like a sand Mandala, waiting for the brush of diaspora onto wind.

And again I am back with Narziß und Goldmund, wondering what fate may have left in store. Are there adventures left or is a retreat deeper into cloister on the cards…

Self-Diagnosis – Avoid Cannibalism

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The internet is awash with medical, pseudo-medical and dietary advice. It is very easy to ask Dr Google, Nurse Edge or Prof DuckDuckGo for advice and thereby arrive at a diagnosis. No doubt this may drive the medical profession up the wall, but on occasion it might be useful. I am able to research things thoroughly without arriving at a firm self-diagnosis. I don’t have a favourite disease, nor a goal I am aiming at. There is no bucket list of maladies. Looking through a list of rare diseases I found this one, which is quite specialised, no need for fava beans and a nice Chianti.

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Kuru

Awareness: There’s no known Kuru awareness group or dedicated day.

Discovery: Occurring at epidemic levels in the ’50s and ’60s, it was eventually discovered by Daniel Carleton Gajdusek, whose research won him the 1976 Nobel Prize in Physiology or Medicine.

Treatment: There’s no treatment for Kuru, other than the preventative measure of not committing cannibalism.

Symptoms: Tremors and muscle jerks (Kuru is the Fore tribe’s word for ‘shiver’), headaches and arm and leg pain, difficulty walking and swallowing, progressive and severe coordination problems.

Discovered only in a remote region of New Guinea among the Fore tribe and closely related to mad cow disease, Kuru is caused by prions, which is a protein that encourages build-up of abnormal brain tissue that results in irreversible brain damage. 100% lethal, it’s brought on by the consumption of human brains that contain the infection. The Fore tribes practiced cannibalism prior to the 1950’s to preserve the spirits of the dead, but it is now outlawed.

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The prophylactic advice to not commit cannibalism is not too arduous to follow. It should be within the ability of most. I read today that ~75% of Americans are obese. I just cross the threshold for obesity which means that ~70% are more weighty than me. That it is a serious arthritis epidemic in the making. Lardy, lardy.

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People can self-diagnose with all sorts of things including grandeur, omniscience and importance. They may imagine themselves angelic and incapable of the oral phase change of butter. Not all diagnoses are accurate.

Today my results for alpha-1-antitrypsin are in and the result is mid-range and very normal. Which raises a slight question about the low alpha 1 globulin data. I would like to see the error bars on reading a labelled electrophoresis result. My guess is that they could be a few percent. As a technique is does not scream highly quantitative to me.

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Alpha-1 (α1) globulins

Proteins migrating within the alpha-1 region include alpha-1-antitrypsin (constituting about 90% of the band intensity), alpha-1 lipoprotein, alpha-1-acid glycoprotein, and alpha-1 fetoprotein. A haze stain at the leading edge of this band may be due to high-density lipoprotein (HDL).

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The GP may wish further clarification. Up to her, if she thinks I need more tests. The thing making up ~90% in the electrophoresis is normal using a more quantitative method.

Logic suggests that having something iffy with my liver is possible / likely. But I am not yet yellow. One genetic problem has now been ruled out. There is a faint hint on line of some endocrine stuff implicated. We shall see what, if anything, the specialist suggests.

I may hear back from the Rheumatologist next week and it is possible something else needs investigated.

On exactly the ten year anniversary of my arse {colon} cancer operation I get to see an anaesthetist to ensure that I am OK to have a colonoscopy. Some blood / piss tests to measure creatinine may be on the cards….

Ten years ago I was in the GP’s office after a sigmoidoscopy. They has found 11 polyps in the lower part of my colon. I had read that 1 in ten polyps turn cancerous. Given that they has not looked “upstream” I said sampling the probability that often suggested that I may have colon cancer “upstream”. He looked shocked and wanted to reassure me. I was calm and knew the reason behind my statement. A few days later they found more polyps and a T3 cancer.

By the middle of July, just after Bastille Day, I will know the state of my chimney and if there are more polyps {or worse} or not. This sets the clock ticking for the next “gold standard” investigation in due course.

I will be enjoying industrial strength laxative on Bastille Day. There will be metaphorical fire works chez nous. We already have the Sudocrem.

I personally would not diagnose a MOT pass, I would fail my contrôle technique and should probably be kept off the streets to protect other road users…

Challenges – Genetics – Having to Endure – Lama Dorje

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A working hypothesis I have is that because I do not strut about, talk a lot and generally bullshit, people feel that I am need of education by them. Somehow, they are kind enough to bestow the benefit of their grandiose and unsolicited opinion on me so that I, a mere lowly pleb, might learn from their magnificence. So many offer me their opinions. Obviously, I am in dire need of education.

It is a catch 22. Do you let them rabbit on {endlessly} or flash intellect and make them feel more insecure than they already are. I don’t have an answer. Neither works well.

You may infer from the above that I am an arrogant arsehole. Your reflection in the mirror which is me may not reveal my essence.

Given all the tests in a medical sense that I am having its sounds a bit like someone meandering around in search of some kind of elusive diagnosis of sorts. That could be the case. Or it could simply be the generosity of the French healthcare system in action. The tendency for prophylaxis here is higher than in the UK.

The “health” finger continues to point at genetics. There is a non-normal make up, perhaps. Maybe I am special, so fucking special, or a creep, or a weirdo.

In my extensive recapitulations there is a recurring theme, “having to endure”. I have had to endure all sorts of things starting with bullying at school(s) and being gossiped about extensively, especially when my back was turned and I was not there. I am not paranoid; I have anecdotal evidence in support of this tendency. People curry favour by gossiping and in the past, they have claimed power by association to me. Those days are long gone.

I have an inkling that the current health drama belongs to the subset of “having to endure” challenges. There is little I can do; I simply have to endure and remain calm.

Śāntideva in the Bodhicaryāvatāra, has a whole chapter on forbearance. Bodhidharma was rumoured to have sat watching a wall for nine years.

Maybe one day instead of enduring I may give both barrels. I doubt many could handle it if I ramped up to 9/10 face to face with them. It would be very intense. Outside of experience.

The other working hypothesis I have is that I am tangentially involved in the drama, schemes and socio-political shenanigans of others. The thing is they are over “there” and I am only truly involved in their illusions. People make shit up; they make a drama out of it and somehow, I am caught up in their imaginations. I am written into their imaginary scripts.

I used to wear black Levi’s 501 jeans for decades. I now wear army surplus combat trousers. This dress makes me look a bit like a pikey prepper. I do not look for one minute like an ex-intellectual or the co-founder of a high technology high power laser company. So people tend, in the first instance, to talk down to me, even worse I do not speak high quality French, God’s only intellectual language. I must therefore be an idiotic stupid moron. They judge a book by their mis-interpretation of the cover. The French are as, if not more, arrogant than the English.

What can you do? Let them rabbit on {endlessly}. There is no point in trying to change their habits or self-opinion.

The wife and I have a joke. If I wore Buddhist robes people would treat me entirely differently. If they saw me thus attired in their dreams, they would find it weird.

“Alan always wore jeans in life!!”

There is a part of me that might order some robes on line and do a TikTok type experiment. Go in jeans to an estate agent one day and in robes the next…

But that would be fucking about…

Is there some as yet unseen diagnoses?

Or am I simply enduring the Gattling gun fire of multiple medical tests and appointments?

The current bet is towards the latter…

Low Parathyroid Hormone – Hypoparathyroidism?

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The results for the three different mutations of HFE gene are in. I don’t have any of these. Which excludes the vast majority of the diagnoses for hereditary haemochromatosis. The footnote from the lab suggests contacting the centre for rare iron related disease in the big university hospital 150 km away. They may just talk with me as an ex-boffin.

I do feel a tad rusty these days, like the tin man my joints could use some oiling.

That means the polycythaemia primary or secondary question is in focus. Is there a malignancy or did my blood just adapt to smoking tabs?

My parathyroid hormone (PTH) is low, it is 26 pg / mL.

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“The iPTH reference interval of a healthy blood donor population was measured as 25.2–109.1 pg/mL (2.7–11.6 pmol/L) at 2.5 and 97.5 distribution percentile. The iPTH reference interval from data stored in the laboratory database was 19.3–112.5 pg/mL (2.0–11.9 pmol/L). Furthermore, 60% of the whole population had prevalently insufficient vitamin D concentration (<30 ng/dL; <75 nmol/L).

Mineri et al., Clinica Chimica Acta Volume 521, October 2021, Pages 1-8.”

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So it is at the rare end of a distribution yet just within the 2.5-97.5 percentile range. It is probably within experimental error out of the range. The error bars on 26 picograms must be big in a small sample!!

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“PTH is secreted primarily by the chief cells of the parathyroid glands. The gene for PTH is located on chromosome 11. It is a polypeptide containing 84 amino acids, which is a prohormone. It has a molecular mass around 9500 Da”

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My results for Calcium and Phosphorus were very normal, this latter statement is a bit weird. Low PTH levels are very rare and usually come with low Calcium levels. That pathway is messed up. Low parathyroid hormone screws with the Calcium concentration and bone turnover.

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Symptoms of hypoparathyroidism

Hypoparathyroidism often starts if glands in your neck are damaged during surgery.

Symptoms include:

  • a tingling or burning sensation in your fingers, toes and face
  • muscle pain, stiffness and spasms

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I have these two but these are caused when Calcium is too low!! So I do not have hypoparathyroidism.

We have another “contradiction” of sorts so the GP has asked advice from an endocrinologist. My guess would be re-test and if the value is still low maybe do something.

I am going to have an Alpha 1 Antitrypsin assay tomorrow which may add a piece to the jigsaw puzzle, concerning my lungs.

I’ll wait to hear from the GP as to what the endocrinologist suggests. It could be more tests, or not.

On the GP front we are probably good until September now…fingers crossed…

The working notion is that whatever it is that may be going on, it is just not manifesting in a sufficiently serious way, yet…

It could just go away or it could develop.

I am a bit of an anomaly, so it is no surprise that my blood results are a tad skewed from the normal.

Girlfriend in a Coma, Punctured Bicycle and Caligula

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Reviewing my most recent blood tests in preparation I can’t help questioning. Is it serious? Probably not. But like Spike Milligan quipped “I told you I was sick!” Is the whole shebang massively overly dramatic?

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“I know you’re antiseptic, your deodorant smells nice
I’d like to get to know you, you’re deep frozen like the ice”

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I don’t think I am obsessing simply going along with it all but it being my nature, I do look things up. It gives me something to do and stops me playing outside in the traffic.

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“I’m knobbled on the cobbles
Cos I hobble when I wobble
Swim!

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Hello to you out there in Normal Land,

you may not comprehend my tale or understand”

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I did not come by this notion of surgery all by myself. I have not been the one pushing this agenda. It has taken up a lot of time and money so far, both for me and the French health system.

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But I’m a creep, I’m a weirdo
What the hell am I doing here?
I don’t belong here

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Perhaps I am missing the point entirely.

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We are stardust
Billion year old carbon
We are golden
Caught in the devil’s bargain
And we’ve got to get ourselves
Back to the garden

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It all seems so very far away, so unimportant.

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Where be it Blackbird to?
I know where he be
He be up your wurzel tree
And I be after he
Now I sees he, and he sees I
Bugger’d if I don’t get him
With a girt big stick, I’ll knock him down
Blackbird, I’ll have thee

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I remember aged just shy of thirteen walking along a beach in Pwllheli North Wales, that sentiment is more timely now.

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People try to put us d-down (talkin’ ’bout my generation)
Just because we get around (talkin’ ’bout my generation)
Things they do look awful c-cold (talkin’ ’bout my generation)
I hope I die before I get old (talkin’ ’bout my generation)

This is my generation
This is my generation, baby

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Shit Happens…

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This afternoon whilst watching Al Jazeera News I had a feeling of warmth towards Donald Trump. He said “Fuck” live and direct to camera. It brought a smile to my face and has slightly changed my opinion of him. He should do this more often; it will be good for his ratings.

I never thought I would say that.

On June 21st I quoted Robbie Burns “The best laid plans of mice and men often go awry…”

Which is a more poetic way of saying shit happens.

The ethos for the year has been to investigate the possibility of getting replacement hips done here in France before we sell up and downsize. I had an orthopaedic appointment on Monday. That investigation seems to have hit a road block which I cannot see a way around. I am due a non-urgent nuclear medicine appointment for a 90mTc Bone scan. Later this week I get my gene tests back and may discuss the “osteoporosis” blood results with the GP. After that the next appointment will be early autumn, assuming nothing acute crops up. I may explore if there are other avenues for the hips. It being both a small world and the back of beyond there may be none.

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This means that I will have to factor in many more months with the severely osteo arthritic hips. I can probably hack it.

It does raise the question of if to put the house on the market or not, with a mind to a UK based plan B.

It is just one of those things which cannot be helped, shit happens. I will just have to adjust to what is / may be possible. It is perhaps a kind of accepting stoicism that things are out of my hands.

Did you know there is a shopping channel “JML direct”? It was on this morning when I got out of bed. It look likes I will be getting up early ongoing as a pain management strategy.

Word wanted to write that “piano management” perhaps suggesting an alternate career.

It look like a re-adjustment in orientation and thinking is now in progress…

What is the next tune, Pete?