A New York City ENT doctor deals with a variety of different conditions from performing sinus surgeries to diagnosing ear, nose & throat problems.
Posts tagged Sinusitis
Chronic Cough? Sinusitis May Be to Blame
04 months ago
Of all the things we experience in life, there are few more frustrating than a cough. At first, we hope it will last for just a couple of days before then disappearing. After several weeks, this is the time you should go to see a doctor because your body is telling you something. With coughs caused by viral infections or an upper respiratory infection should disappear within a week. Any cough that lasts longer than a week, a chronic cough, suggests an underlying health condition. Of course, this could be asthma, which is a common issue, but there’s another health problem we’re starting to learn more about as time goes on: sinusitis.
The Link Between Chronic Cough and Sinusitis
According to various ongoing studies and research, we now know that sinusitis is a bigger problem than we first thought. In fact, back in a 2005 Mayo Clinic study, at least 33% of all chronic cough sufferers were suffering from sinusitis (some form of inflammation of the sinuses). In the twelve years since then, this number has increased, but there are now solutions available.
If you’re wondering why this inflammation causes a cough, it comes from what we call ‘postnasal drip.’ Here, your sinuses will produce too much mucus to be of any use so some will drip backward into the throat and this triggers the cough reflex. In the medical world, this has a name of its own; upper airway cough syndrome (UACS). As a side effect of having sinusitis, this creates the link with your chronic cough, meaning you need to treat the sinusitis before anything else. If left untreated, the cough will keep returning time after time.
Allergic Rhinitis
While on the topic, we should also discuss allergic rhinitis (inflammation concentrated in the nose). It’s caused by allergens such as mold, pollen, and dust mites. With millions of people suffering from allergies in the US, this is now a huge issue and it just so happens that postnasal drip is a symptom of the problem. As we know, this will soon lead to a chronic cough which persists until you receive treatment.
Generally speaking, patients with sinusitis and rhinitis-related coughs experience a worsening of the symptoms when the sun goes down. Since we go to bed and lie down to get some rest, this horizontal position can cause a disruption in the throat which makes sleeping somewhat difficult. Furthermore, we normally have something else to focus on throughout the day. When we’re trying to go to bed, we tend to concentrate on the things that are preventing us from resting, and this places all the emphasis on the cough.
Seek professional treatment for a chronic cough as soon as you can, as these symptoms often point to more serious health concerns, such as asthma and sinusitis.
Treatment
As mentioned before, treating the cough alone in these situations is a little pointless because it won’t be long before postnasal drip brings it back again. Therefore, you need to consider tackling the cause of the issue which is the sinusitis.
If you’ve been experiencing the symptoms for more than 12 weeks, you’re now past the ‘acute’ phase and are progressing into the ‘chronic’ phase. At this stage, antibiotics aren’t likely to act fast enough, which is why some form of therapy may be required. Treatment options include including anti-inflammatory nasal sprays and the like. If the problem persists and starts to affect your life dramatically, you should see your doctor for a consultation for balloon sinuplasty.
How balloon sinuplasty works: after inserting a small camera into the nasal passage, a balloon is then sent up before being inflated. This inflation procedure works similarly to opening blocked arteries during heart surgery. Compared to more traditional options, this is less invasive and will only see you out-of-action for a couple of days.
From here, you can then treat the chronic cough (if it still exists) as you would a normal cough. Safe in the knowledge the postnasal drip has stopped, you can treat the cough without worrying about it returning anytime soon.
Ultimately, you know your body better than anybody else. Only you know when the cough is unusual in duration and severity. If you pay attention to the length of a cough, by marking it on the calendar, you’ll soon learn the right time to see a medical professional and find the underlying issue.
Reducing Indoor Allergens
05 months ago
For the most part, there’s not much we can do to control the allergens and wider environment outside. However, we can control what’s inside our home and today we have some simple yet effective tips for reducing indoor allergens both now and long into the future.
Common Indoor Allergens
First and foremost, we should note that the most common allergens you might experience in your home include pet dander, food, cockroaches, mold, dust, and dust mite droppings. For the people inside your home, this can lead to allergic reactions, eczema flare-ups, and asthma spells. Therefore, prevention will always be better than the cure and you should be looking to remove these indoor allergens before doing anything else.
At first, this might seem like mission impossible because your home is a large place to cover all in one sitting. For this reason, today we’re concentrating on the most common hiding places for indoor allergens. By targeting the allergens at their source, you can keep issues to a minimum and breathe freely in your own home.
Clean Air
As a starting point, you should be aiming for the cleanest possible air and this comes from some form of indoor air cleaner such as a High Efficiency Particulate Arresting (HEPA) air purifier. By recycling the air and capturing allergen particles, your home can be free from dust mite debris and pet dander for some time to come.
While on the note of clean air, we also recommend moving your spring cleaning. If you leave the cleaning until later in the season, allergens will make their way into the home as soon as you open the windows to let your house breathe. For example, pollen is a big one in spring and an issue that will cause havoc for many.
Purchasing a HEPA air purifier and changing the filter frequently can help reduce airborne indoor allergens and help you breathe easier.
Bedding
With the air as clean as possible, the next area to target should be your bedroom because this should be your haven from the world. As well as cleaning your bedsheets regularly, you should also keep pets away from your bedroom and invest in dust-proof pillows and mattress. Since dust mites feed on the dead skin cells found within the bed sheets, cleaning them in hot water is important to kill them off and ensure your sheets are free from dust mites at all times.
Carpets
If you have a high pile or shaggy carpet, this is the perfect breeding ground for dust mites so a weekly vacuum is essential. If you have pets, make this more frequent and this will keep your carpet as clean as possible. Every 12 to 18 months, we also recommend a professional steam as this will pull all deep-rooted stains and dust. Since the flooring covers the whole house, this is important for removing allergens and staying healthy in your home.
Clutter
Often, we tend to build piles of what can only be described as ‘stuff’ around the home. Whether it’s magazines, paper, or clothing, they end up being forgotten and it creates a safe home for cockroaches. Over time, they’ll shed body parts, leave feces, and drop saliva all over the place and this will be awful for those with allergies and asthma.
Kitchen
While on the topic of cockroaches, you’ll need to keep an eye on your appliances to ensure all food debris is cleaned every so often. In your oven, microwave, toaster, and other appliances, the best way to remove the threat of cockroaches is to keep their food source to a minimum.
Storage
Sure, you wash all bedding once it gets pulled from your bed but how long does it stay in the linen closet after being washed? If you have three or four sets of linen on rotation, dust mites will build by the time you come to use the set and this can be dangerous. If you have sets that don’t even make their way out of the closet, they’ll be a hive of activity for dust mites which immediately taints everything else nearby. To prevent this, we highly recommend cleaning all linen with hot water even if (or especially if) it hasn’t been used for a while.
Humidity
Finally, we recommend investing in a small humidity monitor because mold and mildew thrive in humid areas. If you can keep an eye on the most humid areas within the home, you should be able to prevent the growth of mold thus also preventing issues for those with allergies and asthma. Let’s not forget, mold can affect the respiratory system of even healthy people so it’s always best to keep your home free from the problem!
Home Remedies for a Sinus Infection
01 year ago
by ADMIN
in Sinus Infection
Which home remedies can help you with a sinus infection?
Is it a cold, the flu, or a sinus infection? Sometimes it can be hard to tell. Situations, where you end up sick, can occur at any time. And sometimes you can’t get to a doctor right away. So, what do you do in the meantime? Well, until you can see your physician, we suggest using these home remedies to help you ease your symptoms.
Saline Sprays and Washes
Designed to wash out your sinus cavities and nose, saline sprays and washes are your first defense against sinusitis. They provide quick relief and eliminate the nasty bacteria and other materials that cause infection. And if you are experiencing dryness, they are especially useful. They provide moisture within the nasal passageways, which prevents headaches, bleeding, and inflammation.
Stay Hydrated
You should always stay hydrated. It is especially important when you are dealing with a sickness. Like we said before, the sinuses must remain moist. A lot of water or healthy fluids will keep your body adequately hydrated and your sinus healthy.
Keeping the Air Moist
If you have noticed by now, these home remedies are all following a theme. Moisture in the sinuses means relief from pain and congestion. Another way to keep the sinus moist is to either take a steam shower or buy a humidifier. Breathing in the moist air will help you breathe easy and reduce the swelling of the sinuses.
Clean Your Home
Your symptoms can also be a result of allergies. Allergy symptoms usually don’t go away until the all the allergens in your home are gone. There are a few steps you can take to remedy this. For example, having someone clean your home for you will avoid upsetting your allergy symptoms. You can also use dust covers and run the air conditioner to prevent allergens from affecting you.
Confirm if You Have a Sinus Infection
While these home remedies will provide temporary relief, your condition can persist. It is important to know exactly what you’re dealing with. An otolaryngologist can confirm if you do indeed have a common cold or a sinus infection. Reach out to one for help.
Heart Failure and PAP Treatments
02 years ago
Did you know approximately 5.7 million Americans suffer from heart failure every year? This is a staggering number. If you are a patient dealing with this condition, you might want to also monitor your sleep. Sleep apnea can harshly affect your heart. However, there is positive news. A new study suggests that treatment of sleep apnea may help improve progress in patients with heart failure.
Treating Both Sleep Apnea and Heart Failure
Heart failure is a condition in which the heart grows weaker. When this happens, the heart cannot pump enough blood that the body needs in order to function properly. This may cause fatigue, shortness of breath and fluid build-up in several parts of the body.
Most patients with heart failure are constantly in and out of hospitals. According to research recently published in the American Journal of Cardiology, treatment of sleep apnea may help patients with the condition.
Researchers tested 70 patients with both sleep apnea and heart failure. Of those 70 patients, 37 actively used a treatment that helps breathing, called Positive Airway Pressure (PAP) Therapy. The other 34 patients where non-compliant—and did not use the PAP ventilation machine.
A common problem with patients who undergo PAP therapy is that they don’t commit. Many find the mask required for the treatment to be uncomfortable, leading them to discontinue further treatment. However, those who did continue using PAP therapy experienced positive results.
“Our research showed that early recognition and treatment of patients hospitalized with decompensated congestive heart failure is associated with a reduction in readmissions, for patients who use their positive airway pressure (PAP) therapy on a regular basis,” said first author Sunil Sharma, M.D., FAASM, Associate Professor of Pulmonary Medicine in the Sidney Kimmel Medical College at Thomas Jefferson University.
These results heavily indicate that sleep apnea and heart failure may be connected. “Physicians should be on the lookout for sleep apnea in patients with heart failure with the goal of diagnosing and treating early, which might help prevent readmissions and emergency room visits,” Dr. Sharma said. While more research needs to be done to validate these findings, this research puts patients and doctors on alert.
Azithromycin and Chronic Sinusitis
02 years ago
A new study shows treatment with long-term low-dose azithromycin in combination with the conventional therapy can reduce the recurrence rate of chronic sinusitis symptoms after functional endoscopic sinus surgery, but there was no sufficient evidence to support clinical significance of azithromycin at the investigated dose.
The aim of clinical trial was to evaluate the efficacy of long–term consumption of low–dose azithromycin after a successful endoscopic sinus surgery.
Chronic sinusitis is recognized as a common disease that imposes a huge burden on the healthcare system worldwide. About 37 million Americans suffer from at least one episode of sinusitis each year. Besides the burden on the healthcare system, there is a huge burden on the individual due to missed workdays and reduced productivity that the condition causes. This study is needed because when it comes to conventional therapies, other less invasive surgeries should be considered such as balloon sinuplasty.
Method of Research
Sixty-six patients were randomly divided into intervention and control groups. The subjects received the standard conventional treatment (fluticasone nasal spray plus normal saline solution irrigation) or the conventional treatment plus 250 mg of azithromycin on a daily basis for 3 months. Evaluation was made based on the 22-item Sino-Nasal Outcome Test (SNOT-22) immediately before surgery and 3 months after surgery.
Results
The intervention group showed a significant improvement in SNOT-22 scores after the treatment and a higher percentage change after 3 months of therapy compared to the control group. Also the researchers found a significant correlation between the percentage change of SNOT-22 scores and smoking in the placebo group.
Conclusion in relation to chronic sinusitis
Treatment with long-term low-dose azithromycin in combination with the conventional therapy could statistically reduce the recurrence rate of chronic sinusitis symptoms after functional endoscopic sinus surgery. However, more evidence is needed to support clinically significant conclusion of azithromycin at the investigated dose. Thus a larger scale trial and a longer follow-up period are warranted to evaluate the effectiveness of the therapy.
Take the Taste Test: To Aid in Sinusitis Surgery Treatment Selection
02 years ago
A new study proves that your taste buds may predict post-surgery results for sinusitis surgery patients, according to a Penn study.
Taste buds pickup what is called biomarkers, that is, the existence of a certain biological state or condition, such as bitter or salt. The researchers from Penn Medicine and the Monell Chemical Senses Center reported their findings in International Forum of Allergy & Rhinology.
It might sound strange but the team discovered that a genetic biomarker—the receptor for bitter taste—could better predict post-surgery results for patients who underwent surgery for chronic sinusitis. Remember that this seasonal-related condition afflicts around 37 million Americans each year. The condition reduces daily productivity in lost worktime, and is associated with a lower quality of life. In the US, sinus infections cost more than $13 billion in lost productivity each year.
The study found people sensitive to a certain bitter compound reported breathing more easily through their nose, having fewer subsequent infections, and sleeping with ease six months after surgery than those less sensitive to the bitter compound.
Bitter taste receptors are proteins that are found in taste cells of the tongue, where they protect against the ingestion of toxic plant and bacterial products. The collaborative Penn Medicine/Monell team had earlier identified these cells lining the passages of the nose and sinuses and contributing to the natural defenses against certain bacteria.
For the study, patients were asked to taste a specific bitter chemical and report their sensations. Those more sensitive to the bitter chemical than those who were not proved to better fight off certain types of respiratory infections. This specific genetic difference correlates to how much one group is able to combat infection following surgery. Thus, the study suggests those more sensitive to certain bitter tastes fight off upper respiratory infections better, and if they do get sick enough to require surgery, they improve more than people with less sensitive systems.
The researchers warn that there is still much research to do because of the diverse functions of taste receptors, but for now, once an easy test kit is produced, ENT specialists will be better able inform and chose a treatment for their patients.
This is welcome news for otolaryngologists who can correlate surgical outcomes to bitter taste tests in order to forecast postoperative complications and results, and thus choose the best sinusitis surgery options.
Citations
Other Penn authors are Douglas Farquhar; James N. Palmer, MD; David W. Kennedy, MD; Laurel Doghramji, RN; Shane A. Morris; David Owens; and Robert J. Lee, PhD.
Other authors are Corrine Mansfield, Anna Lysenko; Beverly J. Cowart PhD; and Danielle R. Reed, PhD, all from the Monell Chemical Senses Center in Philadelphia.
Some Over-the-Counter Drugs May Be As Effective as Surgery for Chronic Sinusitis Treatment
02 years ago
A new study offers some surprising answers to offering chronic sinusitis treatment. According to the study, those with this condition may find great relief in quality of life with nasal sprays and other nonsurgical treatments. For those with chronic sinusitis, this is great news because surgery may not be the best way to treat this infection. The general rule is: the less invasive treatment is the best response to most conditions.
Chronic sinusitis treatments can include nasal sprays and antihistamines may be as effective as surgery in helping some patients achieve a better quality of life, the small study found.
The study was funded by the U.S. National Institutes of Health and published online Oct. 29 in the journal JAMA Otolaryngology-Head & Neck Surgery. Dr. Jordan Josephson, a sinus specialist at Lenox Hill Hospital in New York City, said, “Chronic sinusitis is the number one cause for chronic fatigue and is closely associated with snoring and sleep apnea.
Thirty-eight patients with chronic sinus infections were given medical therapy rather than having surgery. “Patients who have relatively minimally reduced productivity at work and minimally reduced quality of life from their underlying chronic sinusitis can avoid getting worse by continuing with medical
therapy,” said lead researcher Dr. Luke Rudmik, a clinical associate professor of endoscopic sinus and skull base surgery at the University of Calgary in Canada.
The decision to choose medical therapy versus surgery for chronic sinusitis should be based on patient preference, and the decision for each treatment should involve an honest conversation between the doctor and patient so that the patient understands the expected outcomes and potential risks.
Surgery, however, can be a good option too for people with severe sinus infections. Surgery is just an aide to the necessary long-term medical plan that is required to improve the quality of these patients’ lives. Surgery can be minimally invasive, performed with local anesthesia. During surgery, the doctor uses probes and a laser to remove tissue and bone and polyps that have developed during the infection and are narrowing the nasal passages.
With newer surgical techniques, these procedures allow most patients to be free of black-and-blue marks, with most going home the same day. After surgery, patients still need their medical treatment because the procedure doesn’t stop the running nose. The best chronic sinusitis treatment is designed for each patient.
The best news here is that traditional treatments, alternative treatments, and surgical techniques that have failed patients in the past have been renewed and improved so that for them new medical and surgical treatments may offer significant improvements for their quality of life.
DIY Diagnosis of a Sinus Infection
02 years ago
Anyone who’s had a sinus infections will attest to the misery they suffer during allergy season. So it should come as no surprise that those who are hardest hit want—even need—relief now and thus they call their doctor complaining of the pain. Yet the nation’s ear, nose and throat doctors say that is not a good idea for most cases.
Most people who get sinusitis feel better within a week–your doctor will assure you of this–because many of those infections are caused by viruses. So even if you did get antibiotics, they are not going to help. Truth be told, this is how it is. You can only blow to your heart’s content and resist antibiotics for a typical sinus infection.
But should you be more sure about whether you’ve got a viral or bacterial sinus infection? Today, ENTs (Ear, Nose and Throat specialist) are becoming more and more involved with patients on figuring out what’s causing the infection, partly because patients should learn how antibiotics don’t work and can even harm the patient. And part of getting the patients to understand this is by their self-diagnosing the infection.
“For the first time we’ve really made it crystal clear how to self-diagnose your own bacterial sinus infections without going to the doctor, with a high degree of accuracy,” says Dr. Richard Rosenfeld, lead author of the practice guidelines published Wednesday by the American Academy of Otolaryngology-Head and Neck Surgery Foundation.
How can you tell if it’s bacterial or viral?
It’s rather simple: If you’ve been ill for fewer than 10 days and your symptoms remain the same, it’s most likely viral. If your symptom become worse within 10 days or if they get worse in that 10 days after having improved a bit, bacteria could be to blame. The premise here for waiting it out in the DIY approach is that it’s OK to wait and see what happens, rather than rushing off for antibiotics.
Even if it is bacterial, antibiotics help very little Rossefeld says, and adds that “most of what’s going on is your body fighting off the infection yourself with maybe a little boost from antibiotics.”
So what can I do for some relief?
ENTs highly approve of nasal saline washes, as well as over-the-counter pain medications. The saline washes out mucus and reduces stuffiness, and refreshes and –re-invigorates the membranes, Rosenfeld says.
Steroid nose sprays may help with inflammation, the guidelines say, especially for people with chronic sinusitis, which lasts more than three months.
Chronic sinusitis shouldn’t be diagnosed just on symptoms, the guidelines say. A doctor needs to document inflammation of the nose and sinuses, which is usually done by inspecting the nose with special scopes.
You can diagnose acute sinusitis from the comfort of your home remember, but not chronic sinusitis. For that you need a doctor.
Sinus Surgery May Also Ease Sleep Apnea
02 years ago
Anyone with chronic sinus trouble will tell you how it causes problems with breathing and sleep. Anyone can also tell you that much research has been done about improving sinus problems. But what about those with both sleep apnea and sinus problems? In a recent study, published in the JAMA Otolaryngology — Head & Neck Surgery, researchers have found that surgery may help those with chronic sinus problems so that they can breathe easier, better, and even improve the lives of those with the sleep-related condition called obstructive sleep apnea.
In the study, researchers found 15% of people with chronic sinus problems also had the sleep disorder obstructive sleep apnea (OSA). And those who had surgery for clearing the sinuses reported a better quality of life and improved sleep, regardless of whether or not they had a sleep disorder. Of course, this is not surprising for sinusitis treatment. Improved quality of life is the purpose of many surgeries for sinusitis. However, what’s important about this new study is that patients with both sinusitis and OSA have a substantially reduced quality of life, but those with both conditions had dramatic improvements in quality of life following surgery.
OSA is a condition that causes people to stop breathing hundreds of times during sleep throughout the night. For those with OSA, the tongue and other structures might relax too much, blocking the airway and preventing breathing. There are several signs of OSA. Here are the most common ones: Snoring, choking and gasping for air, and daytime fatigue.
Dr. Jordan Josephson, an ENT specialist at Lenox Hill Hospital in New York City, says, “Sinus and nasal problems often are part of the problem leading to snoring and sleep apnea, and are often overlooked and left untreated.” Josephson was not involved in the current study, but was a reviewer of it. He added that patients with sinus problems and nasal breathing problems “should all be evaluated for snoring and sleep apnea.”
For the study, researchers studied 400 patients who underwent surgery for chronic sinus problems. They then checked the outcomes of those with both chronic sinus problems and OSA. Of this group, sixty had OSA, and following surgery these patients had improved psychologically and with their sleep problems.
The link between OSA and chronic sinus problems is still inconclusive, but might much evidence suggests how air passages through the nose and airways and how sleep affects the body’s ability to manage infection have a lot to do with both conditions.
Peter Fotinakes, a neurologist and sleep disorders specialist at St. Joseph Hospital in Orange, Calif., has one theory for the two conditions overlapping, “When we’re asleep, we prefer to breathe through our noses.” He further added, “When we can’t, we open our mouth to breathe, and when you open your mouth, it sets your tongue free.” That freed-up tongue, he said, can fall back into the airway, blocking it.
Does this mean anyone with a chronic stuffy nose and fatigue should go straight for sinus surgery? Of course, not. Patients should try noninvasive measures first, such as medication before surgery. But many patients have experienced tremendous benefits in both disease severity and overall quality of life after sinus surgery. Seeing an board-certified ENT specialist is in your best interest if you’re looking for solutions to your chronic sinusitis and you suspect a sleeping disorder.
No one likes the prospects of surgery, but the good news is that newer surgical techniques can be performed on an outpatient basis without general anesthesia with minimal discomfort and most patients can go back to work the next day. This is welcome news for those suffering from both chronic sinus problems and sleep apnea.
Bide Your Time With Acute Sinusitis
02 years ago
Antibiotics have been a wonder drug since their beginning. You can’t overstate penicillin’s impact on medicine and society, especially its role in treating bacterial infections, preventing the spread of disease and minimizing serious complications of disease.
But sometimes too much of a good thing does more harm than good. For example, what happens when antibiotics are overprescribed? They should be used for serious bacterial infections, but now, due to overprescriptions, have become less effective, even ineffective, because certain strains of bacteria have become resistant to newer and stronger antibiotics.
Some main reasons for this trend in antibiotics losing their effectiveness is due to overuse and misuse by doctors and hospitals. Both play a role in ensuring best practices of such drugs. Granted that bacteria develop resistance to any drug is normal and expected. But also the way drugs are used affects how quickly and to what extent drug resistance occurs.
If you didn’t know, a bacterium becomes more resistant to a drug when it has changed in some way that either protects itself from the drug or neutralizes that drug. And any bacterium that survives an antibiotic treatment strengthens itself and can multiply and then pass its resistant properties on. In short, bacteria become stronger and more resistant to treatment.
In general, antibiotics are only for bacterial infections, not viral ones. For example, we use antibiotics for strep throat, caused by the bacterium Streptococcus pyogenes, but it’s not the right treatment for sore throats caused by viruses such as a severe flu, because the flu originates from a virus.
If you take an antibiotic for a viral infection, the antibiotic attacks the good and bad bacteria in your body. The good bacteria can then promote antibiotic-resistant properties in harmless bacteria and that can be shared with other bacteria.
Yet many people with severe sinus ailments—like facial pain, fever and nasal congestion—want immediate relief and often wonder why their doctors don’t prescribe antibiotics right away. As mentioned in the last blog, patients and doctors need to bide their time wisely, and that means even if you’re really sick with a high fever, it’s still okay to wait out the use of antibiotics. Research shows that there’s not any greater benefit with antibiotics.
The American Academy of Otolaryngology—Head and Neck Surgery Foundation recommends “watchful waiting” for people with sinusitis before they resort to antibiotics. This is not a new guideline and has always been part of best practices for ENT specialists.
For those acute sufferers, the guideline applies to acute sinusitis, even when symptoms last 10 days or more. In addition to this time, seven more days for a total of 17 days should pass before antibiotic therapy should begin. We understand that such a wait is dreadfully painful, but in the long run, it’s essential to keeping the good bacteria strong and the bad bacteria weak by your body’s natural immune system when suffering from acute sinusitis. Remember, your body needs to keep a certain balance and part of it is its good and bad bacteria.
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This is a topic that is close to my heart... Best wishes!
Where are your contact details though?
4 years ago