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Post by nyuboi on Jul 22, 2013 19:52:01 GMT -5
Really? Roslin doesn't know a single gastroenterologist who can do an endoscopy who is covered by your insurance? That seems very odd. He dictated the below for me, which I am submitting to insurance with other records with a prior auth. request: "This letter is in reference to the above-named patient. He is a patient who had LAP-BAND surgery and presented with a severe esophageal motility disorder. As a result we removed the band. He returns with significant weight gain, but still having esophageal symptomatology and an upper GI that is consistent with an achalasia type appearance.
For these reasons, before going further with bariatric surgery, it is imperative that he is worked up by an esophageal manometric expert. The person we are most familiar with and one of the most highly-respected people in the city is Dr. Arnon Lambroza. Unfortunately Arnon is not in the patients network. I feel it is imperative that he is worked up not by a general gastroenterologist but by somebody who is an expert with esophageal motility disorders so we can get the right guidance for the proper bariatric procedure. The patient requires an endoscopy by such a person as well as esophageal motility studies and probable pH testing. In addition, these tests have to be interpreted based on his unusual history of having a band and determine whether this is a primary of secondary achalasia. I really feel that very few people in the city have the expertise to do this, which is why I suggested Dr. Lambroza. Hopefully his insurance company can make appropriate arrangements if a suitable contract can be reached with Dr. Lambroza."Well after a motility test (much fun where straws get put down your nose all the way to your esophagus), an endoscopy, a "bravo" implant that monitored pH acidity levels for two days, and a gastric empting study, the good news is I do NOT have achalasia as originally suspected. Apparently my vomiting is coming from severe acid reflux disease. (I never heard of extreme nightly vomiting for such, just regurgitation, I hope the surgeon that tested me is right is diagnosing it as extreme GERD). A normal DeMeester score is apparently below a 15 and Im a 95. My acid reflux is up there. They have me on Nexium and Prilosec together, trying to get insurance approval for Dexilant. Assuming it is GERD causing my nightly vomiting, Dr. Roslin gave me THE BAD NEWS: That DS is not going to be a good match for me or as safe as the RNY. He is suggesting a RNY gastric bypass. And we all know he loves his DS, so if he is saying RNY it must be true. He says the sleeve from the DS is a high-pressure system that could potentially be a nightmare with my acid reflux, whereas the RNY is a low-pressure system that should virtually cure my GERD. So it looks like I don't have a choice in the manner. RNY-bound I am. Did the nutrition consult, the psych evaluation, got the tests, and beginning the process of getting insurance approval now. After over a year of following you guys on the DS board, I am very upset to report this, and hope I will still be welcome here as part of the DS family even if I'm a DS want-to-be. I guess I am going to have to work extremely hard to avoid weight regain with the RNY and fight the statistics. My best friend is getting the DS in August by Dr. Roslin. He weighs 325 pounds and is going to get thinner than me, lol. Good for him though. I'll be happy for him, jealous of the DS though. So, now, with my BMI and co-morbidities of asthma, acid reflux, and sleep apnea, hopefully I will attain the approval and have my surgery this summer. I should note I did NOT end up using the expert gastro Dr. Roslin wanted me to see. Insurance denied it on the grounds I could get the same tests performed in-network. So I did such with a different surgeon at Cornell. He is the one that is saying its all GERD and has ruled out achalasia. Again, he better be right as im basing my surgery decision on this being severe GERD. Sorry to report this news, Paul
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PeteA
Full Member
Posts: 221
Surgery Date: 4/15/13
Surgeon: Dr. Phillip Schauer
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Post by PeteA on Jul 22, 2013 20:08:21 GMT -5
Don't be sorry. Take what you have and use it to the fullest. In the end we are all WLS patients. I've been in several post op group sessions where I was the only DS person and I still learned a lot from the other people. I hope the GERD can get resolved. Must be hell to live with.
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Post by nyuboi on Jul 22, 2013 20:15:44 GMT -5
Send your medical records to Keshishian and/or Rabkin and ask for a second opinion. I believe the DS can be done with a larger sleeve, which should make it a lower pressure system. I'd rather take PPIs for the rest of my life (which I am, twice a day) than have an RNY. I also would rather live on PPIs and have the DS. But keep in mind my GERD is highly severe, I throw up in my sleep at least a quart every night. This is a tough one. Dr. Roslin didn't sound like he was even offering a choice in the matter, he said "RNY is safest" option. Are the second opinion doctors you mentioned on the vetted list? I don't know -- Dr. Roslin always pushes the DS so the fact he wasn't I figured was a good indication it should be ruled out.
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Barb
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Post by Barb on Jul 22, 2013 21:11:11 GMT -5
I agree with Diana! Yes Dr. Rabkin and Dr. Keshishian are on the vetted list and probably the absolute best of the best! I am sure other people will chime in on this subject. I wish you all the best! Barb
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Post by larra on Jul 22, 2013 21:23:05 GMT -5
A second opinion couldn't hurt...but I've never heard of Dr. Roslin recommending RNY over DS, so he must feel pretty strongly about this. While I can't and won't second guess your doctors, I do know that RNY is known to be excellent for GERD. Even people with GERD severe enough to have a Nissen wrap for it can have the wrap taken down and have RNY and do great on the GERD front. There is more to bariatric surgery than weight loss. Your overall health also plays a role in these decisions. While I feel very strongly about the superiority of DS, there are some patients who do very well with RNY, and I hope you will commit to it and become one of the successful ones.
Larra
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Deleted
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Post by Deleted on Jul 22, 2013 21:28:17 GMT -5
There is another option: Do not get another WLS. Give it some time. You might even live just fine as a heavy guy.
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Post by smokinstella on Jul 22, 2013 22:35:43 GMT -5
I know there was a gal I had meet at a class I needed to attend the week before my surgery she was having an RNY. She did not qualify for WLS , the reason she was getting an RNY was that she had reflux so sever that it had gotten into her lungs and damaged them. She was going to be in need of new lungs and they couldn't put her on the transplant list until the reflux issue was fixed. I dont know how things turned out for her but I do know that if reflux is bad enough it needs to be fixed by any means possible because it can cause some serious damage.
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Post by nyuboi on Jul 22, 2013 22:55:52 GMT -5
A second opinion couldn't hurt...but I've never heard of Dr. Roslin recommending RNY over DS, so he must feel pretty strongly about this. While I can't and won't second guess your doctors, I do know that RNY is known to be excellent for GERD. Even people with GERD severe enough to have a Nissen wrap for it can have the wrap taken down and have RNY and do great on the GERD front. There is more to bariatric surgery than weight loss. Your overall health also plays a role in these decisions. While I feel very strongly about the superiority of DS, there are some patients who do very well with RNY, and I hope you will commit to it and become one of the successful ones. Larra Larra, regarding the Nissen wrap: This was an option if I wasn't getting WLS. The surgeon that tested me for the motility disorder and did the pH acid testing said I need to either have Nissen surgery to treat the GERD, or an RNY. (He wasn't a bariatric surgeon though...) He could have done the Nissen wrap personally but said there was no guarantee it would cure the GERD because of my high weight. He said to get an RNY. So basically it looks like an RNY is recommended for someone with severe acid reflux.
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Deleted
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Post by Deleted on Jul 23, 2013 0:33:54 GMT -5
Send your medical records to Keshishian and/or Rabkin and ask for a second opinion. I believe the DS can be done with a larger sleeve, which should make it a lower pressure system. I'd rather take PPIs for the rest of my life (which I am, twice a day) than have an RNY. This. Marshall already tried to talk me into the RNY and I told him no way...that was over 6 months ago and I know he will try again at my pre-op appointment. There is Dexilant that is more potent PPI than the standard Prilosec or Nexium (basically the same drug). If he fights me I will ask for a large sleeve or tapered sleeve at top if geometry is a concern. I know a lot of my GERD issues are from eating too much, late at night, and some bad food choices (lots of acidic sauces and such). I will not do an RNY because I love my pylorous to much to give it up, and I have seen no data proving that the DS is bad for GERD patients.....after all most of the acid producing section of the stomach is cut out. Nyuobi please don't give up without a fight.
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Deleted
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Post by Deleted on Jul 23, 2013 0:36:42 GMT -5
Send your medical records to Keshishian and/or Rabkin and ask for a second opinion. I believe the DS can be done with a larger sleeve, which should make it a lower pressure system. I'd rather take PPIs for the rest of my life (which I am, twice a day) than have an RNY. I also would rather live on PPIs and have the DS. But keep in mind my GERD is highly severe, I throw up in my sleep at least a quart every night. This is a tough one. Dr. Roslin didn't sound like he was even offering a choice in the matter, he said "RNY is safest" option. Are the second opinion doctors you mentioned on the vetted list? I don't know -- Dr. Roslin always pushes the DS so the fact he wasn't I figured was a good indication it should be ruled out. If you are throwing up you should have been on Dexilant now...no reason insurance shouldn't approve it. Additionally there is a procedure now where they are suturing the upper GI sphincter internally so it keeps from leaking. I have read it is having good results (Anecdotal, no data sorry)
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Deleted
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Post by Deleted on Jul 23, 2013 0:40:56 GMT -5
Walter A (http://weightlosssurgery.proboards.com/index.cgi?action=viewprofile&user=waltera) (https://www.facebook.com/walter.albert1) has both a Nissen and a DS - Dr. Anthone gave him a "pork chop" shaped stomach. Interesting...my oldest son had a Nissen in January. He has also lost about 30 pounds since then too....working well for him, outside of having to be stretched a few times. Again, Dr Marshall told me it was all about geometry so the pork chop shape makes sense to me...
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Post by Leonie on Jul 23, 2013 1:05:40 GMT -5
I am sorry to hear this, and hear your despair, tinged with hope.
Dr Keshishian is also referred to as Dr K. You will see him mentioned all over this board. He takes on the toughest cases, he is the most compassionate. He has done over 2000 DS'es. He says the RnY sucks with capital letters, even more than the band. He passionately believes in the DS. He is not afraid of any complicated revision. He has saved the lives of many people on this board.
Only if HE says you should not have the DS, would I believe it.
Go with your conviction and do not settle until you have sent him your file and he has said no.
Please.
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Post by kirmy on Jul 23, 2013 1:28:43 GMT -5
I had the most horrific GERD after my DS for about 8 months. I can honestly say it was terrible. It was never terrible enogh that I regretted my decision. It resolved to the point that I haven't taken any omprazole or over the counter antacids in about a year or more.
I time your VSG will strech enough for this not to be an issue. Having said that the amount of eroision caused by the reflux may be an issue here. That really should underpin any surgical decision making. Get a second opinion about this off Rabkin. He is the grand master of tricky surgery.
So now you know you're not going to be the easy patient. Best get tolled up with the best of the best then. Seen all delays as benificial pit stops in gathering the experts you need to support your future lifestyle.
Good luck.
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Deleted
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Post by Deleted on Jul 23, 2013 8:14:35 GMT -5
If you get an RNY, Ask for it to be a DISTAL RNY, and not a Proximal. That way you get more Mal-absorption to help keep the weight off longer term.
You could be a candidate for a Hybrid procedure that could give you the best chance of maximum weight loss and cure the GERD.
Just sayin' maybe a second opinion would be a good thing. Rabkin, or Dr.K. The Revision MASTERS, may have something they could do for you..
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Post by bradleyp on Jul 23, 2013 9:29:29 GMT -5
If you don't call Dr. K, I will personally show him this thread today.
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Post by newyorkbitch on Jul 23, 2013 9:32:37 GMT -5
I had GERD before my DS, and I still do, and it's over 13 years post-op. It's controlled by 20mg of prilosec ever day. Everybody is different.
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Post by angelcake on Jul 23, 2013 12:39:28 GMT -5
Nissen fundoplication + DS intestines sounds like a better option than ERNY. You preserve the pyloric valve so no dumping, you can eat and drink together and take NSAIDs. If you get an RNY, Ask for it to be a DISTAL RNY, and not a Proximal. That way you get more Mal-absorption to help keep the weight off longer term. You could be a candidate for a Hybrid procedure that could give you the best chance of maximum weight loss and cure the GERD. Just sayin' maybe a second opinion would be a good thing. Rabkin, or Dr.K. The Revision MASTERS, may have something they could do for you..
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Post by Undoing on Jul 23, 2013 12:43:06 GMT -5
Dr K did my Nissen Wrap 360, and VSG. I love him ... I love him ... I love him. I have a new life I love him
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Deleted
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Post by Deleted on Jul 23, 2013 13:11:02 GMT -5
Nissen fundoplication + DS intestines sounds like a better option than ERNY. You preserve the pyloric valve so no dumping, you can eat and drink together and take NSAIDs. If you get an RNY, Ask for it to be a DISTAL RNY, and not a Proximal. That way you get more Mal-absorption to help keep the weight off longer term. You could be a candidate for a Hybrid procedure that could give you the best chance of maximum weight loss and cure the GERD. Just sayin' maybe a second opinion would be a good thing. Rabkin, or Dr.K. The Revision MASTERS, may have something they could do for you.. I doubt that enough stomach would be left after a Sleeve to perform a Nissen (a nissen is simply wrapping the stomach around the esophagus to strengthen the lower sphincter). The other part with a Nissen is you can never vomit again so your dry heave ...this been very unpleasant for my son, and for many you will not be able to belch (thankfully my son can)....so it is something to consider if it can be done.
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Deleted
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Post by Deleted on Jul 23, 2013 13:14:19 GMT -5
Dr K did my Nissen Wrap 360, and VSG. I love him ... I love him ... I love him. I have a new life I love him Did you have a Nissen and a VSG at the same time? This is interesting because that might be something I need to look in if it can be done. The surgeon who did Cameron's (my oldest son) Nissen is a partner of Dr Marshall's (my DS surgeon) so the could tag team it...they both use the Da Vinci robot as well for these procedures so that would be cool. I am very interested in knowing because I might need this ammunition to if he pushed for RNY.....I DO NOT WANT RNY!.
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Deleted
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Post by Deleted on Jul 23, 2013 13:36:59 GMT -5
Dr. Marshal only uses the robot for the Duodenal-illieal Anastomosis at the Pylorus, and the Illieal - Illieal anastomosis at the beginning of the common channel. He does the VSG Sleeve by hand (LAP) . He says it saves time, and doing the anastomosis's by robot is safer. I believe him, and his record of over 100 Ds's and NO LEAKS (confirmed by the nurses). Technically, he has had NO leaks EVER from his DS patients.
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Deleted
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Post by Deleted on Jul 23, 2013 13:41:41 GMT -5
Dr. Marshal only uses the robot for the Duodenal-illieal Anastomosis at the Pylorus, and the Illieal - Illieal anastomosis at the beginning of the common channel. He does the VSG Sleeve by hand (LAP) . He says it saves time, and doing the anastomosis's by robot is safer. I believe him, and his record of over 100 Ds's and NO LEAKS (confirmed by the nurses). Technically, he has had NO leaks EVER from his DS patients. According to Melinda he does it all Da Vinci now.
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Post by Girlrocker on Jul 23, 2013 15:05:41 GMT -5
If you don't call Dr. K, I will personally show him this thread today. HILARIOUS and you are posting ONE DAY post-op! nybuboi-I'm sorry your situation is so complicated, but I have to say, I am blown away by the information on this thread and have bookmarked it. Not in the realm of my knowledge, but as a Dr. Keshishian revision patient, I too would recommend a 2nd, even 3rd opinion. I would say this to anyone - and do - you should have all the information you can so you can make the best decision for yourself. I know Drs K and Rabkin are here in California, no idea if this is doable/feasible for you should they think there are revision options for you. There are plenty of Dr. Rabkin patients here who can speak about him, particularly Gail. I know that Dr. K will want to see ALL your tests, paperwork, videos, whatever you have for him to be able to offer a real consult/second opinion. And it's possible he might want to see you to run his own tests, he's very cautious, very thorough. I was revised from an RNY; I do know plentry of successful RNY patients as well. I opted for it because it was the only viable solution for me at the time, the DS was not an option with my insurance and neither was self-pay. And as others pointed out, this isn't just about weight loss but your overall health, so you want to really see what your options are, not settle, and also be pragmatic.
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Post by nyuboi on Jul 23, 2013 16:22:20 GMT -5
There is another option: Do not get another WLS. Give it some time. You might even live just fine as a heavy guy. I am 31 with severe sleep apnea, asthma, acid reflux, and a back killing me. It will only get worse. Plus, I have gained 50 pounds (and counting) since last October when the lap-band came out. If I do nothing I will likely see 300. The lap-band in 2007 was a mistake. I should have done a different WLS procedure in the first place, live and learn I guess. :/ Dr. Roslin said if I had come to him the first place back then, he would have done a DS and talked me out of the band. (I was a low BMI so every local surgeon was telling me the band only...) I appreciate the suggestion, I do. But I'm reluctant to do nothing.
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Post by larra on Jul 23, 2013 16:53:45 GMT -5
From the above post, it's clear you are not living just fine as a heavy guy, and the more weight you gain the less fine you will be living. However, it's also clear that you are not convinced at this point that RNY is your only option. And that's fine. Anyone having bariatric surgery should be convinced and confident about their decision. Not that anyone should be unaware of the risks, we are very much aware of them, but we are also aware of the risks of not having surgery. So if you are not convinced that RNY is your only option, get a second opinion. This is not an emergency. You don't need to rush into anything. Take as much time as you need and talk with as many of the best surgeons as you need to be confident about whatever decision you make.
Larra
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Post by nyuboi on Jul 23, 2013 17:49:15 GMT -5
I have emailed the following to Dr. Keshishian:
Dr. Keshishian, I am a New York patient of Dr. Mitchell Roslin who was referred to you by the users of the duodenal switch forums, which I am active on. Several people had suggested I contact you for a second opinion. I am 265 pounds with a 39 BMI. I have co-morbidities of sleep apnea, asthma and acid reflux. I have a hiatal hernia. In 2007, I had a lap-band placed. In 2012, my esophagus became highly dilated and the lap-band had to be removed. I am preparing for revisional surgery and was opting towards the DS. Unfortunately, since the lap-band came out I am experiencing nightly vomiting several days a week where I vomit a significant amount – a quart or so, especially if I eat close to bed time. Because of this, before going forward with a surgery, I was referred to gastroenterologists and other doctors. I had a motility test study to rule out achalasia performed by a non-bariatric surgeon. I had a gastric empting study which came back normal. And I had a bravo implant device to monitor pH levels. A normal “DeMeester” score is below 15 and I came back at a 95, showing severe acid reflux disease. For this reason, doctors think it is the severe GERD causing the vomiting. I have heard of regurgitation, but never severe vomiting from GERD. However, it’s the only diagnosis doctors have come to. The doctor who did the motility testing and made the acid reflux diagnosis as the cause suggested either a NISSEN surgery or an RNY gastric bypass, although he is not a bariatric surgeon. In view of the severe acid reflux, Dr. Roslin has suggested an RNY instead of a DS. He is a big fan of the DS so I figured if he is suggesting an RNY he must truly believe a DS is a bad fit. He explained the sleeve from a DS is a “high pressure” system which could make the GERD worse, and that the low-pressure pouch from an RNY would alleviate the GERD. If you had a patient with highly severe acid reflux, would you be reluctant to perform a DS on them, or more likely to consider a gastric bypass? I have all my medical records, test results, and upper GIs in my possession. Any feedback or thoughts would be greatly appreciated. Very truly yours,
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Post by nyuboi on Jul 23, 2013 18:09:23 GMT -5
Dr. Keshishian JUST CALLED ME. VERY NICE OF HIM. HE BASICALLY SAID HE WOULDNT RECCOMEND A RNY TO A FAMILY MEMBER AND THAT ITS "CRAP," AS IS THE BAND.
He did agree an RNY would take away the acid producing section of the stomach and disconnect it from the mouth. But he said this can cause a "silent asthma" in that the acid wont come up to the mouth when it needs to and that food would sit in the esophagus.
He said he would do a loose Nissen wrap with a partial DS. He said he would have my weight loss rely on the malabsorption component and do the intestinal bypass, but potentially NOT do a sleeve to avoid the high pressure. Possibly a very gentle sleeve depending on my medical records. But likely the intestinal portion of the DS and not a sleeve, making the weight loss from the malabsorption and not from any restrictive property.
He said the original DS from DeMeester was actually for acid reflux. Finally, he doesn't do a fixed common channel. (I wanted a 150 conservative cc). He does it as a percentage of total length, which usually results in a common channel of 50-100.
So that's another opinion. But he definitely was against an RNY -- not even for weight loss reasons but for health reasons.
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Post by horsnhound on Jul 23, 2013 18:54:58 GMT -5
nyuboi, Did they do biopsies with your endoscopy? Did the gastro check for Barretts?
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Post by nyuboi on Jul 23, 2013 20:22:29 GMT -5
nyuboi, Did they do biopsies with your endoscopy? Did the gastro check for Barretts? No because they didn't want to irritate the esophagus right before the Bravo implant/pH testing. Having another endoscopy on Thursday by my regular GI who is going to biopsy the polyps in my stomach and all...
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Post by nyuboi on Jul 23, 2013 20:25:32 GMT -5
So, what is the next step? Dr. K's plan sounds pretty reasonable to me, of course. Awaiting Dr. Rabkin's reply...
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