Monday, January 11, 2021

Sew Chaotically! ~ The best dude and the quilt frame he built!!!

I casually mentioned I'd like to make a quilt.  I made it clear I didn't know HOW to make a quilt!  That I really had no idea how to proceed with such a thing.  No matter.  Within minutes B was busy!!!  He did a little research, ordered a pattern, and was off to the races!


Cutting out side supports.



Getting all those rails and gears set.

Sanding it carefully!

And there she is!!!!  Isn't she pretty?  Three rails with gears, locks and a support beam!!!

I researched various 'leaders' on both hand quilting frames and long arm machines.  I used canvas duck to create these.  B helped me mark their centers and other points I needed to help line up the quilt layers properly.  He used a staple gun to attach them to the rails.  No more excuses.  I had to quilt something!

I wasn't ready to risk all the work I've put into my sashiko squares in my first attempt!  So...

...as mentioned in my prior post, I put this 60X60 throw together using the Carolina Chain Quilt pattern from bits and pieces I'd been collecting for some time to serve as my quilting rattie!

Trying to make sure I test all aspects, I decided to go ahead and use my Hera Marker to make 'dents' for my stitching lines in the border as a test for duration of said dents through the quilting process.  My super cool new cutting mat was the perfect surface!

As B built it, I tried to figure out how to use it!!!  With so many folks using regular sewing machines, long arm quilting machines and hand quilters using hoop type frames or none at all to make their quilts, it  was a bit of a challenge to find information on these Amish style quilting frames.  While the internet can be used for ill, it also connects folks and allows us to share information of all kinds.  I owe a great deal of thanks to Shawnae Somsen for an excellent video she created after finding it difficult to load her own - Loading an Amish Quilting Frame.  I loaded mine much as she did.  AND ~ I think it'll work!

And because B is super awesome, he made a work table to go alongside - replete with shelves and inset magnetized work bowls!!!

I am pleased to embrace this new adventure.  I am incredibly fortunate and privileged to have the means, space, and access to such extravagant entertainment - the opportunity to develop new hobbies.  I am more than blessed to have a partner who will indulge my whims and play my silly games.  Thanks, B.  I love you.

May you all find peace and comfort in things large and small during this crazy time.  ~ love, les

Sunday, January 3, 2021

Sew Chaotically! ~ I made a quilt!!!!

 Well - a quilt top anyway!


This quilt has been in the works for a very long time!  I have been cutting bits and remnants from all my makes into 2 inch wide strips and squares for the longest - inspired by this post of Julie Lou's Bonnie Hunter's Carolina Chain Quilt.  

I have stitched many "quilts" together in the past.  Lots of little patchwork throws for the kids when they were growing up.  I even made a full sized bed cover for Roo when she moved into her house -


They were pieced with random shaped scraps, their layers tied together with embroidery thread.  Still, having finished all my sashiko blocks - you can peep that prep here:  November's Nesting and Making - I figured I'd better learn some actual quilting skills and practice them on something a little less precious!  With all those pre-cut pieces sitting in a box, I figured they would be a good starting place.  So, last week I got busy.  I decided upon a throw measuring 60" X 60", as a gift for a dear one who just completed and moved into his first house.  I selected greys, browns, blues, and greens from my box as they match his interior.  

Before I began, I read several quilting books.  I watched dozens of quilting videos.  Things can get confusing pretty quickly as quilters are passionate about how they do things ~  Use only size 9 or smaller quilting needles.  No, use embroidery needles!  Use quilting thread.  Wax it.  No, buy pre-waxed.  Use DMC pearl cotton #5.  Press seam allowances to the 'dark' side in one direction.  Press seams open.  Cut this way.  Pin pieces this way.  And so much more!  While all those seemingly disparate techniques can be a bit over whelming to a new quilter - I am ever so grateful to all the quilters who went to the trouble to post their advice, techniques and create tutorials.  I am particularly indebted to these generous quilters for the inspiration and information they provide:

Carolyn Gibbs Quilts      Suzy Quilts      The above mentioned Just Julie Lou

Farm and Folk      Karen's Quilting      Vacilando Quilting Company  

Elizabeth of Mend Learn      Bonnie K Hunter's - Quiltville

Though slow going at first, I began to get the hang of what I was doing and managed to piece the top in about 5 days.  MANY lessons were learned!!!!

  • Quilting is most certainly a 'pay me now or pay me later' sort of thing!  I had cut my stash of pieces rather hurriedly at the end of garment making and had to trim up most of them more carefully if there was to be any hope of them going together with sharp lines and points as they should.  Once the quilt top was finished I created a cardboard template for my sashiko squares, so I could press the edges under and stitch round them to create finished edges and consistent sizes.  Again, I had not put tremendous effort in cutting the rectangles perfectly knowing they were to be hemmed!!!  Given that, a good bit of fiddling and measuring to make certain the stitched designs were centered was required.  Both instances necessitated a stern conversation with my past devil-may-care self!
  • Making a quilt from garment scraps is - sensible, nostalgic, earth friendly, sustainable, useful.
  • Making a quilt from garment scraps is - CHALLENGING!  For this quilt I bought nothing other than a poly/cotton batting and grey linen-esq cotton to use as backing and finish out the top's border.  Finding colors that work together wasn't too difficult as my wardrobe of makes is pretty cohesive.  However, having enough contrast in the fabric I had on hand was a real challenge.  I was very worried that the 'light' and 'dark' lines would not come through as they should.  If I had selected fabric FOR this quilt, that would have been much easier.  Still, I'm pretty happy with how it turned out.  (Despite the block that is turned the wrong way!!!  We'll just call that a design element and leave it at that!!!)  Having to use fabric in a variety of textures and types created another issue.  This quilt top contains linen, tencel, various cottons, including bits of quilting cotton.  Clearly some of those fabrics have far more give than the fabric they were paired with, so it was easy for the squares to go a bit wonky!  I'm pleased enough with how I managed to keep the lines straight, though a few blocks won't tolerate close inspection!!  I just hope they will all hold together with use.  Shockingly, quilting cotton is steady as a rock and stitches together perfectly!  Who knew??? (All quilters - that's who!)
  • Through trial and error, I settled on pressing seams to one side, but alternated the direction at intersections.  I found this method created a lot less bulk and I was able to match seams much more easily.  After the top was completed, further reading led me to a quilter who recommended that practice as well.
Overall, I am quite tickled with how it turned out.  I've made and installed canvas leaders onto the three rail quilting frame B made me.  It is AMAZING!!!  Blog post coming on that adventure soon! Today, I hope to get the top, batting (learning about THAT was a whole other thing!!!), and bottom loaded on it!  

New Year = New Lessons and Adventures!!  Happy New Year and Happy Making to you and yours! - love les

Tuesday, December 29, 2020

Quarantine-while! A Few Good Reads - December

 Whew!!!  Got caught up just in time!!!  Here's what's been filling my reading hours this month:

  • Simple Geometric Quilting - Laura Preston.  Over the past few months I have looked at dozens of quilting blogs and videos.  Having finished all my sashiko blocks at the same time B built me a beautiful quilting frame, I figured I'd best learn something about that which I have proposed to do!!  When I discovered the Vacilando Quilting Company I finally found an aesthetic similar to what I had in mind.  I'll be writing more on all that later, but learning more about this incredible maker, her designs, methods and adventures has been just lovely.  She is an amazing artist and I know I will be returning to these pages for inspiration.  
  • Better Homes and Gardens Complete Guide to Quilting - Beverly Rivers and Michael Maine.  This book wins every prize for being the most complete and best step-by-step guide to quilting out there according to those who actually know how to quilt.  I read it all, but will have to delve into it many more times to really absorb all its information.  B is the best friend a girl could ever have!  Always jumping on board, no questions asked, no matter my fancies - Quilting?  Sure!  A trip from Chicago to Seattle by train?  Why not? (I think we both have a few regrets about that one!) - sweetly purchased both of these for me.  I am sure they will be well used as I traverse my quilting adventure.
  • A Visit From the Goon Squad - Jennifer Egan.  I wanted to like this book.  The characters do stay with you.  Their stories spin like venn diagrams from a group of loosely associated characters.  However, I could never really like or admire any of them, despite having sympathy for their plight. 
  • Quilt with Confidence - Nancy Zimmerman.  If you like conventional, old school quilting patterns this book is for you.  There are lots of details on how to create these designs.  I did learn some things about color and contrast.  However, the main information I am really seeking in all this research - how to hand quilt - is sorely lacking.  It seems I've managed to choose to quilt when most who do so either send out their quilt tops for other individuals and companies to quilt them on fancy machines or either machine quilt themselves via regular or long arm sewing machines.  The search for intel continues.
  • The Dutch House - Ann Patchett.  Very well written.  Vivid.  Characters are real and believable.  Ultimately about relationships and family bonds - their incredible strength and simultaneous frailty.  A story of how to manage when those you trust are weak, those who 'should' have your back do not, while others support you - no matter what.  Good read.
  • Where the Crawdads Sing - Delia Owens.  I identified a great deal with the main character, Kya.  As a child of the swamps, dead lakes, creeks and rivers of south Alabama, with a penchant for active study of the creatures, and furtive examination of the people, that surrounded me, I could feel her discoveries and pain.  Smell the fecund marshy ooze in the summer heat, recognize the natural beauty Owens describes so well.  Abandoned by all she knows and loves Kya makes her way in the world - finding a path to love and family, even with part of her soul in the dark. 
2020 has been a challenging year to say the least!!!  However, I was blessed to be able to download some excellent reads through my local library.  Looking forward to the worlds I will explore through more pages in 2021!!  May many great reads come your way!!! - les

Friday, December 25, 2020

If you know - you KNOW!!! Or - Melanoma Metaphor!!!

There was a time in my melanoma world when crappy news, followed SH*%%Y news, followed only by more crappy news!  I wanted so much to shield those I cared about from it.  I tried.  Once.  However, my dear ones made it clear that such subterfuge would not do!  After that - I fessed up.  Poor Freddo always met such news with the laconic, "Well, that sucks balls!"  Ruthie likened melanoma to the stinky green underbelly of wizards.  Ten years down the road from those days, I have acknowledged the shock, dismay, and horror at what melanoma can do with an amalgamation of their two sentiments.  My dear MPIP-ers are only too familiar with my "metaphor" ~ "Damn!  Melanoma sucks great big green hairy stinky wizard balls!!!!"

There has been of late, some discussion that this old saw may need a bit of an adjustment.  I am more than fine with moving on up!  Especially now.  Because of this....


My dear John sent word that something special was on the way!  It arrived a few days ago.  You can see the clear directives noted in the lower left corner.  Those who know me, are well aware that I am impatient, spoiled rotten, and tend to ignore directions.  But, for John, I did as I was told.  And IT. WAS. WORTH IT!!!!!!!!!!!!!!!!!!!!!!!!!!!!


I laughed and laughed!!!  What a wonderful way to celebrate 10 years NED.  Ten years of my melanoma metaphor.  Ten years of meeting dear ones with the best hearts, greatest sense of humor, and the hard earned ability to find joy.  The fact that melanoma brought us together is irrelevant.  The bonds of friendship, respect and love have kept us together.  My sincere thanks, to you John - for many things.  But today, much love and gratitude for helping me (and all the MPIP peeps) ride out this crazy ass year in great green hairy wizard ball style.  You da best!!!!

Love always ~ les

Friday, December 18, 2020

Quarantine-while! A Few Good Reads - November

November reading was a bit - well - heavy!

  • The Immortal Evening - Stanley Plumly.  As one of the characters in The Guernsey Literary and Potato Peel Pie Society noted, "That's what I love about reading: one tiny thing will interest you in a book, and that tiny thing will lead you to another book, and another bit there will lead you to a third book.  It's geometrically progressive - all with no end in sight, and for no other reason than sheer enjoyment."  And so it was.  A Society member had a great fondness for the writings of Charles Lamb and his enthusiasm induced me to pull this volume off my shelves for a re-read!  Plumly tells the story of his main characters' lives through their writings, relationships and in particular an "immortal dinner" Benjamin Robert Haydon held; documented in letters and journals written by the attendees.  What characters, you may ask?  Given that they are known historical figures, these deets should do your read no harm!!!
    • Haydon (1786 - 1846) - Large living, opinionated painter of majestic historical/biblical scenes on a grand (read - physically enormous) scale.  He unwillingly made needed cash via occasional portraiture, at which he was skilled, including some unflatteringly realistic ones of patrons that didn't go down so well. Had little commercial success. Frequent flyer in debtors prison.  But, for whom we owe great thanks!!!  His love of the Elgin Marbles played a huge role in their being rescued from Lord Elgin's garden and run down barn along with the creation of one of my favorite places on the planet - The British Museum. Check out his work - Christ's Entry into Jerusalem - for portraits of all his dinner guests mixed among the spectators.  Though longer lived than many of his compatriots, his death, like his life, was an exercise in frustration.  When shooting himself in the head when broke (again) at the age of 60 was unsuccessful, he cut his own throat - TWICE!!! - before his suicide was complete.  YIKES.  (You can't make this shit up!!!)
    • John Keats (1795-1821) - His father died from a horse wreck when he was 8.  His mother passed from TB (though likely not before sharing the mycobacterium) when he was 14.  Keats apprenticed with a surgeon in 1815, gaining his license and working in a hospital as a junior surgeon in 1816.  Man!  That on-the-job training must certainly have been based on the premise of - See one, do one, teach one! However, depression reigned due in part to fear he would never become a poet and two failed romances.  Even so, his last lady love went into mourning for 6 years after his death.  He battled TB with frequent hemorrhages from same for some years.  His treatment of the disease included a move to Rome for the more temperate climate, being bled regularly (shockingly - THAT DIDN'T HELP!!!!) and a bread and anchovy diet to "ease his stomach".  He died 5 months after his move at the age of 26.  Thanks to Haydon sharing his fascination for the Greek Marbles with his young friend, Keats gave us, Ode to a Grecian Urn.
    • William Wordsworth (1770-1850) - Based on interactions with his friends, Old Willie seems a rather puritanical prick!  But, behind that rather sanctified exterior there was an excursion to France in 1791 at the age of 21 that garnered a lover and a daughter.  Two years later he left both behind and returned to England.  In later years he [finally] sent some financial support to the woman and her child.  Back in England, he married a childhood friend with whom he had 5 children, two of whom died.  Was employed as a government 'distributor of stamps' and a conservative Tory.  His wife suffered a mental breakdown.  His brother drowned.  Reports note he died from pleurisy at 80.  Don't think pleurisy actually kills you, so his death was more likely due to pneumonia.  Whew!  Makes you wonder about his "I wandered lonely as a cloud..." doesn't it?
    • Charles Lamb (1775-1834) - Charles was a writer and essayist.  When young, he attended Christ's Hospital Boarding School known for the violence and brutality suffered by its students.  It is thought young Charles fared better than his peers because he was not a boarder.  Living in town, he was able to go home each day.  HOWEVER!  His home life may have made school look like a cake walk.  He and his sister were in and out of mental institutions throughout their lives.  When he was 21 he entered the kitchen to discover a bloody scene in which his sister, still wielding a kitchen knife, had stabbed their mother to death.  Charles managed to have her placed in a mental institution rather than jail and on her release attained custody of her and cared for her for the rest of her life.  Interestingly, Lamb collaborated with his sister in the writing of several successful children's books.  She earned money doing some sewing and needle work, writing an 'op ed' in a popular British lady's magazine of the time arguing that sewing should be recognized as a valid profession rather than just a domestic task women did at home.  Charles worked as an accountant for 25 years until his retirement.  At the age of 44 he fell in love with an actress who refused him.   He died a generally quiet, funny, bachelor drunkard at the age of 59.  I am planning to read his essays.  One is titled ~ "Lawyers, I suppose, were children once."
    • Joseph Ritchie (1788-1819) - A medical physician (whatever THAT means given the times!!!) turned adventurer who sought the source of the River Niger and location of Timbuktu with George Francis Lyon.  Despite crossing the Sahara, something no European had previously accomplished, Ritchie never neared the destination of his dreams due to incompetence and poor planning.  He died without funds or supplies, dependent on the locals for charitable care, of fever, aged 31, in Murzuk, Fezzan.  Hilariously and horribly, Lamb (deep in his cups as was his wont) on hearing that a guest at the Immortal Dinner was planning this excursion, raised a glass saying, "...who is the Gentlemen we are going to lose?"
So!  Not the lightest read.  Gracious!!  Some seriously interesting peeps with some seriously messed up lives.  Truth may well be stranger than fiction.  Will be seeking out some Charles Lamb essays soon!

  • Primary Care:  2019 Current Concepts Pediatric Updates - PNCB. 167 pages addressing - chronic/recurrent abdominal pain, community acquired bacterial pneumonia, plagiocephaly, 'back to sleep'/SIDS, supporting grieving children and families, NP precepting, transgender children, enteroviral infections, meningococcal disease,  hepatitis A, B and C, Marfan syndrome, congenital heart disease.
  • Primary Care:  2020 Current Concepts Pediatric Updates - PNCB.  130 pages addressing - Newborn and maternal readiness for discharge, bronchiolitis, complicated pneumonia, newborn jaundice, PCOS, fungal infections and infestations, concussion, separation anxiety, fetal alcohol syndrome, electronic cigarettes, lead poisoning.
BOOM!!  That's what I DO!  Bahahaha!  I have a love/hate relationship with the continuing education study and testing that my RN and Advanced Practice/NP certifications and licenses require. I think they are incredibly important, but if not well done they can be a supremely useless time suck.  When they are medically sound and cover topics I feel are important to my practice, I enjoy them.  Gotta say, these were pretty good.

So there you go.  Not necessarily reading that would tempt everyone.  But if you like art, poetry and tragic lives - give Plumly's book a go!  - les

Monday, December 14, 2020

Quarantine-while! A Few Good Reads - October

Pages (and pics) I've enjoyed.... 

OCTOBER  ~
  • Eleanor Oliphant is Completely Fine - Gail Honeyman.  I was blessed to read TWO INCREDIBLE books this month!!!  This was one.  Eleanor, as awkward and diffident, yet outspoken as she was, was such a relatable character.  Guess that says a lot about me!  HA!!!  So many of the things she thought - and actually said - have certainly buzzed through my brain.  The writing was smart.  The vocabulary amazing.  Her mother certainly had resonating characteristics! Where else might I read a passing reference to Paros fishermen tenderizing octopus by beating them against rocks?  An experience I have actually witnessed!!!!  I don't want to give too much away.  But, please!!!  Give this one a read.  Through her struggle there is redemption and a great deal of humor.  I will never ever forget Eleanor!!!
  • Lunch at the Picadilly - Clyde Edgerton.  Meh.  I've read and enjoyed some of Edgerton's other books.  I was probably drawn to this one because of the many lunches I shared with my Granny at Morrison's.  I don't know.  The characters all seemed a bit tired.  Perhaps that was the point?  Maybe I just wasn't in the mood.  But, I couldn't find a real value in the tale.
  • The Guernsey Literary and Potato Peel Pie Society - Annie Barrows and Mary Ann Schaffer.  YES!!!  Lightening can strike twice in the same month!  A truly incredible work!  A warning - it is written completely in the form of letters.  After the first few pages, I was thinking, "What the heck?  I can't keep up with who sent what to whom!!!"   Please persevere!!!  After a couple more pages it all fell into place.  My brain got in the groove and IT. WAS. WONDERFUL!!!!  Matter of fact, when I got to the end of the first section, I turned back to the beginning and read the entire book OUT LOUD to B!!  He didn't fall asleep or leave!!  And I read it to him ALL DAY!  Not daring to risk spoiling any of your discovery and enjoyment, I'll share that it is a work of historical fiction surrounding the German occupation of Guernsey; an island in the English Channel off the coast of Normandy that I didn't even know existed, much less had the history it has.  Now, I very much want to visit!!!  My only critique is that the rambling end could have been edited a bit, but the sum is so good it doesn't matter.  There is also this:  I wondered at the two authors.  How is a book of this sort written by two people?  Well... Mary Ann Schaffer spent her life working in bookshops, libraries and as an editor.  Rather late in life she began work on this story.  Her manuscript was accepted for publication in 2006, but a good deal of work remained. Unfortunately, about that time Ms. Schaffer began to have significant health problems.  She asked her niece, Annie Barrows, a children's book author, to assist with the editing and rewrite, which she did.  Sadly, Ms. Schaffer passed before publication in 2008.  A story of partnership and love behind and on its pages.  The characters of this book touched my soul.  Their letters demonstrate the best and worst of human nature, the power of love, and the incredible ability of the written word to inspire and sustain us. 
  • The Help - Kathryn Stockett - the film.  Films rarely do justice to a book and almost NEVER make it better.  However, this one and "A River Runs Through It" are exceptions.  I'd seen this before.  But, these characters brought to life as they are by Viola Davis, Octavia Spencer, Emma Stone, Jessica Chastain, and the entire cast is something else again.  It is heartbreaking to SEE what white privilege once looked like and get real about its continued presence today.  I broke down in sobs right in the middle of it.  Given what we see in the streets of our nation TODAY - it is clear to me that we have a long way to go.  I pray to whatever gods may be that we do the work.  That we make our society a place of support, respect, and safety for all.  No matter the color of your skin. 
Written words have made me think, feel, learn.  Books like these give me hope.  Happy reading ~ les

Friday, December 11, 2020

Surgical removal of melanoma lesions -


With promising studies regarding "neoadjuvant" responses, deciding whether or not to opt for surgery before or after treatment is a bit more complicated.  Here's a link to Neoadjuvant Reports  
Here is a prior report on metastasectomy -  Surgical Removal of Melanoma   
Now, there's this:

Survival Outcomes After Metastasectomy in Melanoma Patients Categorized by Response to Checkpoint Blockade.  Bello, Panageas, Hollmann, et al.  Ann Surg Oncol.  2020 April 27.  
Introduction: Checkpoint inhibitors have improved outcomes in metastatic melanoma, with 4-year overall survival (OS) of 46% for anti-PD-1 alone or 53% in combination with anti-CTLA-4. However, the median progression free survival is 6.9 and 11.5 months, respectively. Many who progress have gone on to alternative treatments, including surgery, yet the outcome of patients selected for surgery after checkpoint blockade remains unclear.   Methods: Patients who were treated with checkpoint blockade from 2003 to 2017, followed by metastasectomy, were identified from a prospectively maintained institutional melanoma database. Response to immunotherapy was assessed at the time of surgery. Patients were categorized as having responding, isolated progressing, or multiple progressing lesions.   Results: Of the 237 total patients identified, 208 (88%) had stage IV disease, and 29 (12%) had unresectable stage III disease at the start of immunotherapy. Median OS following first resection was 21 months. Median follow-up among survivors was 23 months. Complete resection at the first operation (n = 87, 37%) was associated with improved survival compared with patients with incomplete resection (n = 150, 63%) [median OS not reached (NR) vs. 10.8 months, respectively]. Patients resected for an isolated progressing or responding tumor had a longer median survival compared with those with multiple progressing lesions (NR vs. 7.8 months).   Conclusions: Patients selected for surgical resection following checkpoint blockade have a relatively favorable survival, especially if they had a response to immunotherapy and undergo complete resection of isolated progressing or responding disease.  
And this -   
Metastasectomy for Melanoma Is Associated With Improved Overall Survival in Responders to Targeted Molecular or Immunotherapy.  Medina, Choi, Rodogiannis, et al.  J Surg Oncol.  2020 May 22.  
Background and objectives: Metastasectomy for melanoma provides durable disease control in carefully selected patients. Similarly, BRAF-targeted and immune checkpoint inhibition has improved median overall survival (OS) in metastatic patients. We hypothesized that there is an increasing role for metastasectomy in melanoma patients responding to these therapies.  Methods: Retrospective analysis of a prospectively maintained database identified 128 patients with stage IV melanoma who received targeted molecular and/or checkpoint inhibitors at an academic institution from 2006 to 2017. Records were reviewed to characterize clinicopathologic characteristics, response to treatment, and intent of surgery for those who underwent metastasectomy. OS was analyzed by the Kaplan-Meier method.   Results: Median OS from stage IV diagnosis was 31.3 months. A total of 81 patients received checkpoint inhibitors, 11 received targeted inhibitors, and 36 received both. A total of 73 patients underwent metastasectomy. Indications for surgery included the intent to render disease-free (54%), palliation (34%), and diagnostic confirmation (11%). Responders to systemic therapy who underwent metastasectomy had improved OS compared to responders who did not (84.3 vs. 42.9 months).   Conclusions: Metastasectomy for melanoma is associated with improved OS in patients that respond to targeted molecular or immunotherapy. Resection should be strongly considered in this cohort as multimodality treatment results in excellent OS.
Melanoma never makes things easy.  If I found myself in this position now, I would probably opt to start systemic therapy.  Follow-up fairly quickly with scans to see what is happening.  If the tumor is growing, surgically remove it, and complete systemic therapy.  If it is shrinking, watch while continuing therapy and remove the lesion surgically if systemic therapy cannot take care of it on its on. 

For what it's worth.  Hang tough, peeps.  - c