Lost and confused

 

Happy Danny

Happy Danny

Danny in ZombieLand

Danny in ZombieLand

He was even worse yesterday. The confusion has increased. They tell me it’s the toxins building up in his liver which is full of cancer, along with his pancreas, intestines, and lungs. He is not breathing to full capacity in the left lobe. There are glass nodules in his lungs which must have grown to bigger size. He insists he had a haircut, he didn’t. He said he had to leave to go to work because there was ” an odor” , that means a gas leak somewhere. He worked for an utility company. Sometimes he got a little irritated with me when I gently told him it wasn’t true. Sometimes I just agreed with him so he could be calm. And then the cloud of confusion passed and he was back to his normal playful self. Pinching my ass as I walked by, flashing me his beautiful devilish smile, teasing his visitors. He is getting a lot of visitors now. A parade of people who are afraid they might not get a chance to see him again. Danny wanted to have an Irish Wake at the end of the month. He called it a dead or alive party. He wanted people to celebrate him while he was alive and could enjoy it. Now he is to sick. Most of the time he is sleeping or doesn’t know who is here. Then a switch flips and he is totally aware of what is going on. Then in the next millisecond, his eyes half close , roll up so just the whites show and it’s back to zombie land. There is a lot of crying. Not Danny. He is happy and content. He still whispers and sometimes yells, ” I love you” I sit directly across from him so when he opens his eyes he can see me and smile. I make him feel safe in this scary world. He’s not scared at all. I am.

 4. Mental confusion or disorientation

Organs begin to fail, including the brain. Higher-order consciousness tends to change. “Few conditions leave people hyperaware when they’re dying,” says palliative-care physician Ira Byock, author of Dying Well.

The person may not be aware of where he or she is or who else is in the room, may speak or reply less often, may respond to people who can’t be seen in the room by others (see Passing Away: What to Expect When Witnessing a Loved One’s Death), may seem to say nonsensical things, may be confused about time, or may act restless and pick at bed linens.

How to respond: Remain calm and reassuring. Speak to the person softly, and identify yourself when you approach.

Bad News. Cancer has returned.

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How do you write about something so devastating. The CAT scan showed the cancer has returned with a vengeance. We certainly did NOT expect it to be so fast. The whole family gathered around. Even Dori ,way  out in Colorado, tried to fly home but a huge storm is coming today so we urged her to stay put. I feel like the storm has already come. Before this scan life was kind of settling in to a sort of normalcy. We almost could forget about cancer. Even though the commercials reminded us several times a day.

The squirrelly, little, blond doctor came in and immediately said, ” I told you so.” as she handed us the CAT scan report. That’s cold.
You have Stage 4 , uncure-able cancer now. Nothing else can be done. You can get chemo but it would only prolong your life a little bit. Danny shook his head no. No more chemo. It’s not worth living a little longer to just feel like shit the whole time.

Danny is running a low grade fever, we think due to the flu that Ana and Sonnet had. The doctor wanted to admit him to the hospital today. Danny declined. “It’s just a flu. I don’t want to go to any more hospitals.” he was very calm.

“The doctor replied, “Okay, whatever you wish, but if the fever goes up or you are in a lot of pain, go to the emergency room right away.”
“I think you should find a doctor close to your home At this point, it doesn’t matter who you see. You will need hospice.” She said, blinked once and left. As she left she tossed over her shoulder the remark that we could stay in the room as long as we wanted because she knew we had a lot to discuss.

Danny turned to me and said,” Let’s get out of here.”

Soon as we got to the car I couldn’t hold back the flood of tears any longer. And then my nose started to bleed. I only had one tissue. It bled and bled. Danny reached in the back seat where I had a bag of clothes to go to Goodwill and pulled out a purple dress. I bled all over that damn purple! We both cried all the way home. Then I began the painful job of letting the family know what happened. That was harder then getting the news itself.

Little ten-year-old Ry screamed over and over, “I don’t want Gramps to die! I don’t want Gramps to die! ” “I hate cancer!” Everyone was crying. Sean left work to come over even though he wasn’t allowed to do so. Lerin came over, her boyfriend had to drive her over because she was too upset to drive. Dori tried to fly home. Danny’s brother and his wife came over.

And yet I think Danny almost seems calmer. The extreme stress of knowing that at some time the monster cancer would return was over because its here now. Danny kept saying, “It’s easy for me, I’ll be dead. It’s harder for all of you then it is for me.” Yes, it is hard. So fucking hard. This morning I cried so hard, my nose started bleeding again- both barrels! It bled so much that I vomited blood. The first time I heard Danny’s death sentence my hair fell out, now my blood is falling out. My body is in shock.

Here are some of the results of the scan that blew away the last shred of hope we had.

CA 19-9- ………1921 ( that means the tumors are active)  is a tumor marker that is used primarily in the management of pancreatic cancer.Anything higher than 37 U/ml is considered abnormal. The higher the number, the more advanced the disease may be.

Liver– Multiple new lesions- the cancer has spread to his liver
# 1   lesion: 1.2 x 1.1 cm (the size of a pea)
#2 lesion: 1.7 x 1.2 cm
#3 lesion: 1 x .6 cm
#4 lesion: 1.7 x 1.5 cm

Pancreas– #5  tumor: 1.4 x .9 cm

Peritoneum: # 6 tumor: 0.7 x 0.7 cm in lower left quadrant

Lungs: Multiple Ground glass nodules- nodules described as having a “ground glass” appearance are more likely to be malignant.

Reglan, can’t live with it, can’t live without it!

iCant

Danny is going through a new kind of hell now. Just when you think how can there be anything worse than what he has gone through already, something new drags itself up from the dregs of slimy hell.

REGLAN, the black box drug, Danny had to take to make his lazy stomach wake up after surgery has turned out to be an angel and a devil. He had to have it because nothing else would’ve made his stomach start working again. But the side effects have been horrendous.

It started in the hospital, shortly after his first dose. He became anxious and restless. Okay, we thought, who wouldn’t after spending so much time in the hospital and going through what he did. Walking as many as 7 times up and done the hallway trailing his IV pole behind him. Each time from 10-15 minutes each. But he still felt restless. He began jiggling his foot-a lot.

Then he came home and the crying started. Anything could trigger a crying jag, which is very embarrassing to a man who hadn’t cried since he was a small boy. This should be the happiest time in his life, but it has turned into the saddest.  It seemed odd, but sometimes people react this way after major surgery. The visiting nurse said it was probably the effects of being under for 8.5 hours.

Three nights ago Danny really had a lot of trouble sleeping.  He had to take Reglan at 3 in the morning , so I would wake up and then have to wake him up . So we decided to stop giving him the three o’clock dose of his Reglan.

The next day ( Monday) , he was  very depressed. He had a hard time sitting still. He had very negative thoughts. We went to visit a friend who just got surgery, we noticed right away that Danny wasn’t himself. Things were getting worse.  That night Sonnet and I tried doing some detective work to try to figure out what was causing all of Danny’s extreme emotions.

What had changed?

We finially pinpointed it down to the Reglan.  The FDA had already made it a black box drug. It was banned in many countries. We started reading story after story of people going through the same emotional problems. Some people had it even worse, they developed  horrible ticks, muscle jerks and strange facial movements. Thank God, Danny hasn’t got to that point.

He is scheduled to stop taking Reglan tomorrow. No one warned us that this could happen. As we researched more about Reglan, we found out that when you stop taking it the side effects get worse! Poor Danny, how much more can he take? We weren’t about to let him just stop cold turkey. So we developed a slow wean off. Each day taking less and less.

Yesterday was so bad for him. He felt helpless against the chemical warfare going on inside his body. Dopamine is very important. That along with seratonin is what makes us feel happy. But this drug blocks the dopamine from doing its job. Danny flipped back and forth between  anxious to sadness. He didn’t feel like eating, sleeping or doing anything. I feel so helpless watching him suffer so much.  I don’t know what to do to “FIX” it.

Last night he took 2 sleeping pills to try to fall asleep. He slept 4 hours and woke up unable to fall back asleep.

“I can’t do this anymore!” he quietly screamed. He wanted to scream out loud but didn’t want to wake the kids.
I rubbed his back.
I ran and got my iPhone, found a white noise app and downloaded it.
I played ocean sounds to try to sooth him.
I gave him a Benadryl, hoping it wasn’t too much.
Finally he fell asleep.

I dread today, how will he get through another day of withdrawal from the clutches of the horrible, yet necessary drug?
Reglan-Metoclopramide-Tardive-Dyskinesia

Generic Name: METOCLOPRAMIDE – ORAL
Metoclopramide is also used in patients who have poor emptying of their stomachs (gastroparesis). Treating gastroparesis can decrease symptoms of nausea, vomiting, and stomach/abdominal fullness. Metoclopramide works by blocking a natural substance (dopamine). It speeds up stomach emptying and movement of the upper intestine.
It can also disrupt the uptake of dopamine signaling in the brain. In the brain, dopamine functions as a chemical signal to promote feelings of happiness. Therefore, it can contribute to side effects such as depression.
Reglan is a dopamine antagonist, which explains its other possible side effects, including severe depression, anxiety, agitation, pacing, inability to sit still, jitteriness.

Common side effects of Reglan include:

  • feeling restless, sleepy, tired, dizzy, or exhausted
  • headache
  • confusion
  • trouble sleeping

What is a “Black Box” warning?
The Food and Drug Administration (FDA) oversees the safety of all medications used in the United States. Sometimes the FDA issues a warning to doctors and consumers to warn of specific side effects or drug interactions that may make a particular medication less effective or harmful. A Black Box warning is the most serious warning issued by the FDA indicating that particular care needs to be taken when deciding to use the medication.

Why did the FDA place new warnings on Reglan?
There is new concern that long term use (more than 3 months) of high doses of Reglan may lead to short term or permanent Tardive Dyskinesia symptoms. The FDA believes the greatest risk for side effects is in the elderly and elderly women in particular.

Keep in mind that the warning does not say Reglan should not be used at all. It is clarifying that it should be used with great care at the lowest possible dose and for short term use only.

The part of the warnings that concern us are:

  • Depression, thoughts about suicide, and suicide. Some people who take REGLAN become depressed. You may have thoughts about hurting or killing yourself. Some people who take Reglan have ended their own lives (suicide). YIKES!

Making progress, Mr. whipple

imageI got the train at the Queen Lane Station and rode in to the Market East station. Nice.
Danny greeted me with a big smile and was empty-nosed! Hurray! The nose tube was pulled out last night right after I left! His voice is still all crackly and squeaky like he’s going through puberty.
He is coughing up dark red blobs of goo, but the nurse says that’s okay. It was just stuff from the tube being in( and jammed repeatedly against the back of his throat!)
Danny still can’t have any liquids. He is getting cold sweats and soaking his sheets.
Around 1:00 they decided he could have little sips of clear liquids like orange jello, soup broth, tea, and Kool-aid. His stomach hurts a little bit but so far so good.
Come on Lazy Stomach-WAKE UP!

Poke it with a stick!

Poke it with a stick!

Elephant boy

image
Monday- Day 6 post Op
Weight: 165.1pounds ( he has lost 51 pounds since July 13)
I start out early again to day, I don’t wait for it to get light, so maybe I’ll beat the traffic.
Danny still has the tube in his nose, he looks like an elephant. He still can’t have any liquids, not even ice chips- nada. He seems a little better today. I guess he’s getting used to the tube.
They have added a huge IV bag of ” Nutrition ” sounds like it’s something like Ensure, but probably Boost because the nutritionist love to push Boost. They must get free pens from them.

Danny was taken done to get a cat scan to see what his stomach was up to. If all looks good he might get his nose tube pulled out.
Gerald and Ashley came to visit. Ashley gave me the keys to her kingdom, which is just a short train ride away. I love train rides.
image

Fever!

F7D9FFC4-73FA-4292-8B14-B2B66115A93B.pngDanny started out the day with a fever of 102.
Dr.Lavu said that when they took out his gall bladder, along with his pancreas head, section of intestine and bile duct, the gall bladder had been full of pus.
So maybe that where the fever was coming from. Or maybe a urinary infection from the catheter. Or maybe just from not breathing deep enough. So they took lots of blood for tests. Urine samples. They gave him an antibiotic.
His fever came down.
Dr.Lavu said,” We can take out your nose tube if it’s too uncomfortable .”

“No, leave it in , if you think it will be better.
It’s not too bad.” Said Danny.

The fever went down, but Danny only got in 2 walks today.

I drove into Philly today by myself this morning leaving At 5:00am, I can’t expect anyone else to get up this early on Sunday. I pack my suitcase and expect to stay with a woman I met on the airplane back from Japan last year. She offered her home to me which is very kind.

Jesse,Dotty and her new husband Robert came to visit.
Sean and Lara came to visit too and Lerin. Sean brought a huge green turtle that walks upside down across the ceiling. That’ll make some interesting hallucinations!

I left before dark so I could find my friends house before dark. I found her house, only 10 min away. But there was no place to park! I drove and drove and then I started getting scared. It was like I was on Mars! Rows and rows of houses all connected. Strange loud cars with stuff sticking out of them. I tried to call my friend, she didn’t answer her phone. So I headed back home. A bus almost hit me, a large horned buck was on the Schullkill,I can barely see at night- but finally I made it home. Exhausted I went straight to bed.

Scan Troubles

6:30am only 27 degrees, I go out and start. The car to warm it up for Danny. Headed to Philadelphia to review. The Cat scan. He is scheduled for chemo but he is not doing it today. He wants to be strong for surgery.
image

8:30am- Darryl , the best blood taker in the world  finds a vein and draws blood from Danny As we wait to talk to the doctor. When I called earlier in the week to find out the results of the scan, I was told they won’t give results over the phone because the doctor likes to put up the new scan and old scan and compare them and show you everything while explaining and talking about where to go from here.

Wrong

Wasted time.

Wasted time.

Doctors love Sugar water!

Doctors love Sugar water!

When the doctor finally came in she didn’t have any scans to show us. I believe she hadn’t even looked at the scan at all before walking into the room. She turned to Danny and commented on his weight loss of 50 pounds.
She berated him with, ” Why don’t you just eat?”
What a stupid question, especially from a cancer doctor. It seemed she had no understanding of how pancreatic cancer works. It affects digestion and makes it nearly impossible to eat. Danny tries really hard to eat, but he just can’t.

 

She began with saying things about the initial scan that was totally wrong. This set my alarms off right away. Who was she talking about? She wasn’t talking about Danny. I certainly know every minute detail of his initial scans. I argued with her and she started back peddling. I guess she thought she was dealing with some backwater yokel. I’ve been reading volumes and volumes of information about pancreatic cancer and I at least know when someone is bullshitting us. Once, she realized she couldn’t lie her way through the visit, she began bullying Danny into getting more chemo treatments even though Dr. Lavu only ordered 6!
Danny said “no”.
She said his cancer would grow while he waited for surgery which could be a long time. We said we wanted to talk to Dr. Lavu first before making a decision. She said, we had to make a decision now! ( the old car salesman trick)
I said, “We don’t have to make a decision now.”
She said,”If we didn’t we would never be able to get an appointment again because it would fill up.”
Danny said ” No!”
And we left. Danny fired her and will look for a new oncology doctor.

image

We walked the cold, blustery streets of Philly over to Dr. lavu’s office to see if we could pick up the prescription for the PET scan. And maybe even catch a glimpse of Dr. Lavu and just touch the hem of his white lab coat for good luck.

Nadine, the office girl, told up the Pet scan was denied by the insurance company! We have learned that much of what goes on with modern medicine is powered by “the insurance”. But she assured us that they were reapplying and will get back to us tomorrow. She said, that if we can’t get a PET scan Dr. Lavu still wants to see Danny on Thursday.
Aghhhhhhhh… It makes your chemo head spin! Needless to say Danny is feeling discouraged, but only for a short blimp , tomorrow he will be back to his chipper and hopeful self.

Emergency! Emergency!

P1000775

Decorations are up, ice cream cake made,presents wrapped and waffle iron heated. We were getting ready for Jocie’s big birthday bash- 12 years old! How did she grow so fast? She’s as tall as me already.But when Sonnet walked in from work, Danny asked her to get his thermometer. His temperature was 101.3! Now that doesn’t sound like much for a normal person, but for a chemo patient that is bad. I have orders that is it goes over 100.3 we have to call the Doc. Jocie requested waffles and ice cream with roasted seasoned potato wedges  for her special birthday dinner, I dropped the lid on the waffle iron and ran to the phone. The on call doctor ( Dr. Sandrio) told us to immediately report to the Emergency room at Jefferson Hospital in Philadelphia. Thank goodness Sean agreed to drive us. I mean, I can do it, but I HATE driving in the city- at night! So I was extremely grateful he was there to drive us. And drive us he did, at one point I looked at the huge round speed dial in the middle of the dash on my mini at it hovered at 100.  I couldn’t tell if my car was thrilled or as scared as I was. But I was proud of my little yellow car, it didn’t shake or shimmy at those high speeds.

We got to the ER in record time and they made Danny wear a yellow mask because of his fever. Not sure if that was to protect him or others. And then we waited and waited and waited. Finally they called us back to a room where they took his vitals. His temperature had come down to 99.8 already. Must have been the cool breezes down the highway. They took vial after vial of blood, put in an IV and took a chest X-ray. The doctor looked just like our nephew Jack. He told us that Danny would be admitted to the hospital tonight. The funny little Jamaican guy came in with a computer to fill out all the paperwork for admittance.

Soon as Danny got back from the bathroom they asked his to pee in a cup. He was pissed (funny choice of words) because he waited as long as could knowing that they would eventually need some urine. He knew it would happen this way and it did. He told them there was no way he could pee again. They said he wasn’t going home till he did. A STAND OFF.

Sean ran out to find a big bottle of liquid for Danny to drink so he could pee. Danny drank a whole bottle of FUZE ice tea and could fill that little urine cup in no time.  That did the trick. The sweet doctor came back and said they found  nothing yet that showed where the fever was coming from. He thought maybe it was some type of unknown flu virus. He told us we could go home but had to return in the morning because the hospital is too, dangerous a place for chemo patients! Well that made us feel better! I think?

We got home around 1:30 in the morning and tumbled into our wonderful germ-free bed.

P1000755

Happy 12th birthday Jocie

Chemo Nausea

kiss

Today was not so good for my man. He got unconnected from his chemo man bag. He hates that bag and doesn’t like to go out in public with it because it looks like a girl’s purse. This is a guy who wont even order a “girly” drink for me because… ? I don’t know? I guess its written in the big book of man laws.

After he got disconnected, we went down to the ghost mall to take a walk since it was raining. He started having little bouts of nausea. We went home and he took his nausea meds. And slept most of the evening. He sleeps a lot after chemo. Its probably a good thing to just dream away all this crap.

I painted the steps turquoise , cleaned the kitchen, swam in the pool while a torrent of rain poured on my head, sculpted a cute little dog for an Etsy shop commission and researched cancer. I have read mountains of information on cancer now. Remember when I couldn’t read any? I just read “The China Study” in 2 days – a 419 page book. Very interesting stuff. the king  of China or whatever they called him  got cancer and commanded 650,000 researchers to find a cure for cancer. It’s good to be king! They analyzed the entire country- took blood samples, urine, watched them eat. they did the most extensive study ever done!  Poor king/ big guy died before the study was complete but all that information will help everyone else with cancer. The most important thing they learned is to eat “whole foods, plant based.” I’ve seen this in many of the clinical trials of read also.

Danny woke up around 3am feeling nauseous, he went to bed feeling nauseous. Today at 8:00 am, we have to be at Jefferson hospital, he gets the dreaded Neulasta shot (a med used to reduce the risk of infection ) that will make him feel even worse. Or not? He took a Clartin yesterday and will take another this morning which is suppose to help. Nobody knows why. Maybe this time his body will accept it better. We stay hopeful till we can’t.

china study

 

and now for the arguments against the China Study! Oh dear! Who’s a girl to believe?

“Yet the China Study data speaks for itself: Animal protein doesn’t correspond with more disease, even in the highest animal food-eating counties—such as Tuoli, whose citizens chow down on 134 grams of animal protein per day.” – DENISE MINGER

Fever

Danny eating

Go here to see him in action!
Danny woke up feeling great this morning. Only slight pain. He is ready to venture out of the house, but not good enough to go to the beach yet. We left 7:00 in the morning to go to one of our favorite breakfast spots in Terre Hill. Danny uncovered his car ( we have to keep it covered because the damn cat insists on sleeping on the roof and getting it full of cat hair and paw prints). Danny puts down the top, throws the cooler in the back seat and away we go! We play a dangerous pretend game of chicken as we fly through the gorgeous Amish farmland.

Terre Hill Grill is a cute little country restaurant, that has extremely fat waitresses, an all farmer men clientele , cheap prices and yummy delicious food. There’s a sign on the wall that says ” Eat till you fill out the wrinkles”

There are only two old men there when we arrive. One at the counter and one reading a paper. We sit at the booth next to him. That was a mistake, because everything he read he wanted to get into a politician debate about with me. ( the curse of a friendly face, no one does that stuff to Danny). I hate political debates, I only like pleasant conversation.

The 350 pound waitress shuffles up to take our order. She has a “Dutchie” accent.

” Eggs over hard, dry rye and ham, Danny orders. ( this only costs $3.00)

” One pancake, scrambled eggs with onions on top, rye with butter and coffee, I say. See why I,m fatter than Danny. Simple math- I eat more.

A tiny bent-over man walks in holding a newspaper clipping. He laughs as he makes his way to the counter.

“Good morning,  Roger, “sings out the hefty waitress.  Roger laughs a beautiful infectious laugh. Danny and I smile at each other. Roger sits next to the guy sitting at the counter and sticks his face real close to the man who seems engrossed in his coffee cup contents.

“Hey, did you read what I wrote in the paper?”, yells  Roger only half an inch from the guy’s ear. Roger laughs out loud again. I can’t help it. I laugh too. The coffee cup reader man ignors Roger. Roger doesn’t seem to notice or care. He shoves the article into the man’s hand. The man never turns away from his fascinating cup of Joe.

” I wright something everyday for the paper.” Says Roger.

No response.

I wish I could read his article.

” I want to get old and laugh all day.” says Danny. This makes me sad.

Next we go to our Amish butcher on Tobacca road. Farmers bring livestock and shot things like deer( bad wives) and stuff like that here to get butchered. The surplus is sold to heathens like us. Their meat tastes better than meat from the supermarket. Tastier, cheaper. Notice a theme here? We like cheap and good. We buy 10 pounds of ground beef, t bone steaks, eggs, cheese.,ham and frozen seasoned patties. A quick stop over at Shady Maple for some Shoofly pie Danny has been craving and then a long stop over at B&B’s a discount( here it is again- cheap and good food that’s dented or discontinued). Finially we head home, but first Danny pulls into Sonic ( by now it’s lunchtime) he suddenly has another craving. He wants a hot dog. Strange! In case you don,t know us, we have eaten ” healthy” for about 30 years. We never eat hot dogs or go to fast food places.

After eating Danny says, ” I guess I just wanted to relive a part of my childhood.”

” Was your family the ones who cut hotdogs length- wise and laid them flat to grill them?” I ask.

” No , we cut slashes and then broiled them. They would puff all up.” He replies.

“Well, why didn’t you say you wanted hot dogs, I could’ve bought some Amish ones.”

” I only wanted one.”

Last night he wanted meatloaf. His mother always told me that meatloaf was Danny’s favorite meal.

Mickey Mouse cloak

Mickey Mouse clock

Oh, talking about his mother! A very strange thing happened yesterday. Danny’s mother had given me a Mickey Mouse clock about 20 years ago. It played Disney songs on the hour. It had stopped working years ago so I put it high up on a shelf and forgot it.

I was making Danny’s lunch, when I heard ” It’s a small world” playing on the radio. I didn’t think anything of it until it kept playing over and over. I went to my studio to see what was wrong with the radio. Here it was the old clock, playing one of Gran’s favorite songs. I climbed up on a stool and pulled it out of the dust. Goosebumps rippled down my arms! I couldn’t shut it off. The clock arms still weren’t moving but the music kept playing. I pulled out one of the batteries and it still kept playing. It finially stopped when I pulled out the rest of the batteries. weird? Has Gran come to look after her baby boy? The Grandkids have been saying there is a ghost walking up and down the hallway at night and opening their doors. Ana ( the 15 year old) even recorded it one night. Well now we know who the ghost is-Gran!

Around 2:00, my best friend Sandy came over to paint with me. She hugged and kissed Danny .

“You feel warm, she said.

I ran and got the the actor right away.

100.3 DEGEES!!!!!!

Oh no! The doctor said if his temp went up to 100.5 , I would have to rush him to the emergency room! Something about the low white blood cell count and also the common problem of stents becoming infected. I told him to jump in the pool and that brought it down to 100. It kept going up and down the rest of the evening. We had thought about going to t he beach tomorrow but not if that temp stays up! Oh, dear. Just when things are going so well.
Dan red

Weight: 200