Ask the Pharmacist Chat Archive 3/6/08 - American Diabetes Association (via Mowser)

Ask the Pharmacist Live Archive, Thursday, March 6, 2008

The American Diabetes Association is pleased to present ADA Live! - a series of live Q&A sessions on topics related to diabetes and healthy living.

Stephanie Harriman, PharmD, is a graduate of the University of Pittsburgh School of Pharmacy and is currently one of the Community Pharmacy Practice Residents at the University of Pittsburgh. Her primary practice sites are Rite Careâ„¢ Centers within Rite Aid pharmacies in the Pittsburgh area where she has the opportunity to be a part of building a patient care practice. She has received training in diabetes education and management through the DM Educate online learning program.

Aaron DiFilippo, PharmD, graduated from Duquesne University and has been practicing community pharmacy with Rite Aid in Pittsburgh, Pennsylvania. As a medication therapy management pharmacist, he makes appointments with patients to provide education and resolve problems with their medications. Aaron routinely works with patients with diabetes to help them achieve glucose control and a healthier lifestyle.

Linda Higgins, R.Ph. is a drug information specialist at the Rite Aid Drug Information Center. She received specialized training in diabetes care through the National Institute for Pharmacist Care Outcomes (NIPCO) Diabetes Care Certificate Program.

The "Ask the Pharmacist " series is brought to you by an unrestricted educational grant from Rite Aid Pharmacy

ADA_Moderator: Welcome to ADA Live. Today our guests are Aaron DiFilippo, R.Ph. a Rite Aid pharmacist in Pittsburgh, PA and Linda Higgins, R.Ph. a drug information specialist at the Rite Aid Drug Information Center. Both Aaron and Linda received specialized training in diabetes care through the National Institute for Pharmacist Care Outcomes (NIPCO) Diabetes Care Certificate Program. It's a pleasure to have you here today Aaron, Stephanie and Linda.

Aaron_and_Stephanie: Thanks, it great to be here. Lots of questions coming in already. .

DeAnna: Hi, I was told a couple years ago that I was prone to have pre diabetes. I bought a test kit last night and I'm not sure what the correct levels should be. Last night it read 240 and this morning is was 160. Are these good levels?

Aaron_and_Stephanie: The American Diabetes Association recommends that fasting blood sugar levels (first thing in the morning, before eating) be between 90-130 mmol/L and 2 hour post-prandial levels (or 2 hours after eating) to be less than 180 mmol/L. These levels can be taken at home, as long as the meter that you are using is accurate. Most meters come with control solution that you can use to ensure that your meter is still working properly. Before testing or using the control solution, check the expiration date on your test strips. When using control solution, follow the instructions that came with the meter. Regardless, you should see a doctor who can either rule out diabetes or make a formal diagnosis. You need to address it as soon as possible in order to prevent long term complications of having high blood sugar.

anil: I am taking diabitic medicines for last 10 years and the bloodsugar levels are generally under control. Now i am facing errectile dysfunction for last 5-6 months. Though I a having the desire ro ahev sexual intercourse but unable to have errection. Pls guide.

Aaron_and_Stephanie: Men with diabetes tend to develop erectile dysfunction 10 to 15 years earlier than men without diabetes. As men with diabetes age, erectile dysfunction becomes even more common.

Aaron_and_Stephanie: To get an erection, men need healthy blood vessels, nerves, male hormones, and a desire to be sexually stimulated. Diabetes can damage the blood vessels and nerves that control erection. Therefore, even if you have normal amounts of male hormones and you have the desire to have sex, you still may not be able to achieve an erection. Ask your physician about treatment alternatives that would be best for your specific situation. If your physician is not able to help you, consider seeing a urologist who specializes in these areas.

Tom: I was diagnosed a year ago with type II diabetes. My last A1C test result was 4.9% Is that too low?

Linda: An A1C test is an average of your blood glucose levels over a 3 month span. The test gives you an overview of your diabetes for the last few months, in which every part of every single day makes up the result. It is a measure of the percent of hemoglobin, which is part of a red blood cell, that has linked up with glucose floating in the blood stream. A person without diabetes would have an A1C of 5% or lower. A person with diabetes should strive to have an A1C of less than 7%.

sweetpea: Are there medications that I shouldn't take while taking Metformin?

Stephanie: To ensure that you are not taking medications that interact, give your doctor(s) and pharmacist a complete list of prescription medications, over-the-counter medications and herbal supplements or vitamins that you are taking. Update that list at each visit and discuss new medications with your doctor and pharmacist. There are several medications and herbal supplements that should be taken with caution when taking metformin. You should monitor your blood glucose closely when taking any medication or herbal supplement which either increases your blood sugar (steroids like prednisone) or decreases your blood sugar (diabetes medication like glipizide). You should avoid alcohol when taking metformin, as this can affect your blood sugar. If you are having any type of x-ray or CT scan in which requires an injection of dye, you may need to stop taking metformin 48 hours before the procedure. It is very important that you discuss any change in medication (prescription or non-prescription) with your doctor and pharmacist.

ames: I know that diabetes is a genetic disease but what else is it considered to be since it is not always inherited?

Aaron_and_Stephanie: The exact cause of diabetes continues to be a mystery. Although there seems to be a strong genetic link in developing the disease, there also appears to be environmental and lifestyle factors that play a role. Other risk factors include: 1) being overweight 2) being of african american, american indian, asian american, pacific islander or hispanic/latino heritage 3) prior history of gestational diabetes 4) blood pressure of 140/90 mmHg or higher 5) abnormal cholesterol levels 6) physical inactiviy-exercising fewer than 3 times per week. The more risk factors you have along with having a family history increases your chances for developing diabetes. The best way to look at this is to take care of the risk factors that you have control over.

Cookie: What is brittle diabetes?

Aaron_and_Stephanie: "Brittle" diabetes is a term used to refer to a patient who's blood sugar fluctuates from high to low and vice versa in a very short period of time. These patients may have a harder time controlling their blood sugar.

RAN: LATLY I HAVE BEEN DRINKING A LOT OF WATER EVERY NIGHT. STARTING AT ABOUT 6 AND IT GOES ON EVERY HOUR ON THE HOUR UNTIL MORNIG. I HAVE NOT BEEN TOLD THAT I HAVE DIABETES BUT I AM CONCERNED. AND HELP????

Aaron_and_Stephanie: It is generally recommended to drink eight 8 oz glasses of water every day. Increased thirst and increased urination may be symptoms of diabetes, but this is not enough for a diagnosis. The symptoms may be something else or nothing at all. You need to see a doctor to have a physical exam and blood work done to know for sure.

inthedark: Hello, my SO was recently diagnosed with type 2. We look at different lab values..some say normal is between 70-100 and some say 80-120, and some say 80-115. What is the actual normal value

Aaron_and_Stephanie: A normal fasting blood glucose in a patient without diabetes is less than 100 mg/dL. The term "fasting" applies to having nothing to eat for at least 8 hours. One of the most common times to test this is upon awakening in the morning. For a person with diabetes the ADA recommends a goal fasting blood glucose in the range of 90-130 mg/dl.

texasg8tr: i I have locking shoulder and am in pain all of the time as of late. will the pain cause a rise in my blood sugar?

Aaron_and_Stephanie: Some studies have been done to see if there is a link between chronic pain and poor diabetes self management. While the studies do not show pain directly raising blood glucose levels, they do show the majority of patients with chronic pain have more difficulty with diabetes self management. This includes pain causing problems with following a recommended exercise program,eating plan,and taking medications. If this pain continues it would be recommended to see your physician.

tay: Can a young person with t1 diabetes go high after exercise?

Aaron_and_Stephanie: Exercise can be an important part of your diabetes care regimen but should be planned for carefully. For instance if you have type I diabetes and do not have enough insulin on board, exercise can make your blood glucose levels rise. During moderate to vigorous exercise, nerves signal the liver to produce and release more glucose. If you do not have enough insulin to cover the extra glucose in your blood, high levels can result. Conversely if you do have enough insulin on board then you may see your levels decrease during exercise. That is why you should check your blood glucose levels both before and after you exercise. It is also recommended that your diabetes caregiver be aware of your exercise regimen.

shortstop: what are the numbers for a good blood sugar and a bad blood sugar

Aaron_and_Stephanie: Blood glucose level recommendations for nonpregnant patients with diabetes vary depending on the source of the recommendation. General blood glucose level guidelines according to the American Diabetes Association (ADA) are: A1C - Less than 7% (The A1C goal for an individual patient is an A1C as close to normal (<6%) as possible without significant hypoglycemia); Before meals - 90 - 130 mg/dl (5.0-7.2 mmol/l) (plasma/serum blood glucose reading); and Peak after a meal (1-2 hours after the start of a meal) - Less than 180 mg/dl (less than 10 mmol/l)(plasma/serum blood glucose reading). The new general blood glucose level guidelines according to the American College of Endocrinology (ACE) are stricter than the ADA guidelines and include: A1C - Less than or equal to 6.5%; Before breakfast in the morning - Less than 110 mg/dl (less than 6.1 mmol/l)(plasma/serum blood glucose reading); and Two hours after eating a meal - Less than 140 mg/dl (less than 7.8 mmol/l)(plasma/serum blood glucose reading). You should talk to your physician to determine what specific goals are appropriate for you.

Corny: can you tell me what kinds of medications affect my sugar levels ?

Stephanie: You should monitor your blood glucose closely when taking any medication or herbal supplement which either increases your blood sugar (steroids like prednisone) or decreases your blood sugar (diabetes medication like glipizide or glyburide). You should avoid alcohol as it will initially increase your blood sugar, but when used over time, may cause an unsafe drop in blood sugar. When taking any new medication it is critical that you talk to your doctor or pharmacist.

Bren: i am constantly cold....could it be a result from my diabetic condition?

Aaron_and_Stephanie: Feeling cold all the time could be the result of decreased circulation caused by complications of diabetes. However there may be other causes such as low thyroid hormone. It would be best to see your physician for a full work up concerning this issue.

slyxcarnie: how bad is it for sugar to be 300-400 for 3 days?

Aaron_and_Stephanie: Blood glucose readings that are high can be very dangerous even if it is only for a short period. More serious complications include diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic nonketotic syndrome (HHNKS).

Aaron_and_Stephanie: Diabetic ketoacidosis (DKA), also known as diabetic coma, occurs when the body lacks insulin and breaks down fats for energy. When this occurs the body produces ketones which can be found in the urine. Ketoacidosis occurs when the body does not get rid of all the ketones in the urine and they build up in the blood. This is a life-threatening situation and needs immediate treatment. DKA is associated with blood glucose levels from 200-2,000mg/dL. Symptoms of DKA include unexplained blood glucose greater than 250mg/dL, fruity smelling breath, dry mouth, nausea, vomiting, fever, abdominal pain, low blood pressure, shortness of breath, dehydration, increased heart rate, shock, and coma. Medical assistance is needed from hospital staff. Treatment includes insulin infusions, fluid replacement, and potassium replacement.

Aaron_and_Stephanie: Hyperosmolar hyperglycemic non-ketotic syndrome (HHNKS) can be life-threatening and is associated with blood glucose levels greater than 600mg/dL. Symptoms of HHNKS include dehydration, excessive thirst, low blood pressure, glucose in the urine but no ketones, hallucinations, sensory deficits, rapid eye movements, paralysis on one side of the body, loss of vision in half of the visual field, seizures, and a partial or total loss of the ability to comprehend spoken or written language and express ideas. Medical assistance is needed from hospital staff. Treatment also includes fluid replacement, potassium replacement, and insulin infusions.

Aaron_and_Stephanie: If your getting blood glucose readings that high it would be best to call your physician.

lee: what determines an a1c level of less than 7 percent? your fasting blood sugar levels, or your post-prandial levels

Aaron_and_Stephanie: This is a very good question. Think of an A1C test as an average of your blood glucose levels over a 3 month span. The test gives you an overview of your diabetes for the last few months, in which every part of every single day makes up the result. It is a measure of the percent of hemoglobin, which is part of a red blood cell, that has linked up with glucose floating in the blood stream. A person without diabetes would have an A1C of 5% or lower. A person with diabetes should strive to have an A1C of less than 7%.

Anne: My biggest problem as a diabetic is what to eat for snacks - I just can't figure out what is the best snack, rather than chips, cookies and the rest of the bad stuff.

Aaron_and_Stephanie: Learning how to read food labels is a critical part of managing diabetes. Look for snacks lower in calories and carbohydrates, such as apples, carrot sticks, or low-fat cheese to replace cookies and chips. You will greatly benefit from meeting with a dietician who can work with you and the foods you like to eat to devise a diet regimen that allows you to control your blood sugar. Your doctor should be able to refer you to a dietician.

idajean: I have been feeling hungry, tired, I haven't been able to see right, my heart has been racing, I can barely stand up without holding on to something, sweating for no apparant reason, chills to where it disrupts my life, and I am only 26. My family has a history of diabetes. So I was just wondering if what I have been going through is diabetes?

Aaron_and_Stephanie: Some of the symptoms of diabetes include: excessive thirst, extreme hunger, frequent urination, blurred vision,irritability,and tiredness. Based on the symptoms you are experiencing, we recommend contacting your physician. She/he can do blood work to determine if you have diabetes.

bj: where can i get some good info on neuropathy?

Stephanie: The American Diabetes Association has wonderful patient-friendly information on a broad range of topics relating to diabetes. You can go to www.diabetes.org and specifically http://diabetes.org/type-2-diabetes/diabetic-neuropathy.jsp for information on diabetic neuropathy. Please keep in mind that while this is a great source of information, it does not replace talking to your doctor if you think that you may be experiencing diabetic neuropathy.

nagla: Why we should not start insulin very early in type 2 diabetes?

Aaron_and_Stephanie: Often times it is very appropriate to start insulin early when managing type 2 diabetes. Sometimes physicians will even initiate insulin when the patient is diagnosed. Depending on a patient's individual circumstances insulin therapy is frequently the most effective way to control their glucose levels, so why wait to use it.

cindy: my mother in law has diabetes she checked her sugar in the morning around 9:00am and it was 102 now it is 302 should we be worried

Aaron_and_Stephanie: The reading of 102 mg/dl is very good and probably a fasting reading if she is taking it before eating breakfast. The reading of 302 mg/dl seems too high, but without knowing how long it had been since she had eaten or how many carbohydrates she had consumed, it is hard to quantify it. The American Diabetes Association recommends that 2 hours after eating the blood glucose reading should be less than 180 mg/dl. It would be best to bring any high readings like this to the attention of her diabetes caregiver, but with future readings try to have her write down what she ate and how long since her last meal so her caregiver has a better understanding of the reading.

Corny: Can medications with prednisone affect my sugar levels or steroids ?

Aaron_and_Stephanie: Steroid medications like prednisone can increase your blood sugar levels significantly. It is important to monitor your blood sugar levels closely while taking a steroid medication.

al: my father is typr 1 diabeties and inject 30 unit NPH in the morning usually at 3pm his BS is anywhere between300- 400 and also he inject 12 unit in the aftrenon but his fbs is low <60 how should i manage this?

Stephanie: There are several issues here, and in general, require a consultation with the health care professional that is monitoring this patient's diabetes (ie. Primary care doctor or specialist). A fasting blood sugar reading of less than 70 mg/dL must be treated by having the patient consume about 15 grams of carbohydrates in order to raise their blood sugar to a safe level. This can be accomplished by eating 3-4 glucose tablets, or 4-5 pieces of hard (but not sugar free!) candy, or drinking half a glass of orange juice. Wait 15 minutes and then check their blood sugar again. If it is still below 70 mg/dL, you may repeat the 15 grams of carbohydrate intake or consider getting the patient to a hospital, depending on how low it is. It is critical that patients with diabetes, particularly those that are experiencing low blood sugars, are closely monitored and managed by their physician.

Manda: is it possible if i lose weight will my diabetes go away?

Aaron_and_Stephanie: Patients with type II diabetes struggle to control their blood sugar for two reasons- 1) their bodies do not produce as much insulin as they need, and 2) their liver, muscle and fat cells do not use insulin properly. This second reason is referred to as insulin resistance. Being overweight or obese and having excess fat cells prevents the insulin in your body from working as it should, leading to higher levels of sugar in your blood. Maintaining a healthy weight and getting regular exercise are very important to controlling blood sugar. Many people are able to control their blood sugar by diet and exercise alone, but this does not make their diabetes "go away." A healthy diet and lifestyle are lifelong commitments, but are very possible by taking a few small steps at a time. Working with a health care professional, discuss ways that you can cut calories out of your diet and begin an exercise program that is right for you.

chica: I had an MI in 1999, followed by angioplasty with stent but was still left with moderate to severe LV dysfunction. I have recently been diagnosed as pre-diabetic and prescribed metformin. i am very confused about whether I should be taking this with heart failure, some say yes, some say definately not. What is the truth. Ingrid

Aaron_and_Stephanie: Patients taking metformin who have heart failure that requires treatment with medication are at an increased risk of developing a serious condition called lactic acidosis. That risk increases with the degree of renal dysfunction and the patient's age. If you fall into the above category, then regular kidney function tests should be done along with using the lowest effective dose. You should discuss this with your physician along with any other concerns.

gautam: Hi, I am 35 years old. I am a diabetic for 8 years. Since last year my sugar is not getting controlled. I have a fasting of 250-300. My glycoselated Hemoglobin was 12.8. I was taking Amaryl 2mg + Pioglitazone 30 mg. I could control sugar for 7 years using this medicine. But now it has stopped giving the desired results. Even increase of dosage did not help.Right now I am taking Dianorm-60 +Mopaday but still sugar is 250+. I have been exercising daily for 1 hour (20 minutes on treadmill covering 2-2.5 km and 3 sets of weight lifting 25-35 Kg.. I have maintained this exercise regime for the last one year. Can my increase in blood sugar be related to this routine. Am I exercising too much. What is the limit for exercising for a diabetic? What prescriptions do you advice in this situation.

Aaron_and_Stephanie: The American Diabetes Association (ADA) recommends that fasting blood sugar levels (first thing in the morning, before eating) be between 90-130 mmol/L, 2 hour post-prandial levels (or 2 hours after eating) to be less than 180 mmol/L and A1C levels be less than 7%. The ADA also recommends that patients with diabetes perform at least 150 min/week of moderate intensity aerobic physical activity and perform resistance training at least 3 times per week. There is no â€œlimitâ€ý to the amount of exercise that patients with diabetes should obtain, as long as you can tolerate it and you do not have episodes of low blood sugar (less than 70 mmol/L) while exercising. If oral medications no longer keep your blood sugar within your goal, you may need to consider insulin therapy. Talk to your doctor about your blood sugar goals and how you can best achieve them.

Tony: I take Lantus insulin by injection each night. I keep the unused cartridges in the refrigerator, but the cartridge in use in the bathroom as I am using it. Should it be refrigerated as well?? What about when I travel??

Stephanie: The unused cartridges may be kept in the refrigerator until their expiration date, unless used before then. The manufacturer of Lantus claims that once a cartridge has been used, it is good for 28 days at room temperature. Your bathroom may not be the best place to keep it, especially if it gets hot during showers. Where else could you keep the cartridge so that it stays at room temperature, but so that you don't forget to take it? How can you keep track so that you donâ€™t use the cartridge longer than 28 days after opening? When you travel, the Lantus does not need to be refrigerated but should not be exposed to very hot or cold temperatures. There are many travel packs to keep insulin cool. If you will be flying and/or traveling abroad with your medication(s), please visit the Transportation Security Administration's website, www.tsa.gov, and the United States Department of State travel website at www.travel.state.gov for more information.

Cat: Why am I getting test results at home that do not indicate diabetes when 2 OGTT tests do indicate it? A1C was 5.49

Aaron_and_Stephanie: You may ask your doctor to perform a fasting blood glucose test to see if your results are above the ADA diagnostic criteria of 126 mg/dl. In any case 2 OGTT tests given on subsequent days above 200 mg/dl would be enough to diagnose diabetes. The use of A1C is not recommended for diagnosis at this time. However with an A1C of 5.49, your diabetes may be in the early stages and now would be the time to get into healthly habits for managing your glucose levels. Talk to your doctor or pharmacist about helping you get started in a nutrition and exercise regimen that works for your lifestyle. Good luck!

zanellyd_yahoo_com: who is the drug company that has been experimenting with gila monster saliva and had the good results here in san antonio

Aaron_and_Stephanie: The medication is called Byetta and it is co-marketed by Amylin and Eli Lilly.

lupita: I have high blood sugar levels. will liquid fasting(maple syrup/lemon) for five days be bad for my health?

Aaron_and_Stephanie: It would not be recommended. A well balanced diet with consistent meals is much healthier. It would be a good idea to sit down with a nutritionist to make a plan for eating a proper diet. If you don't know a nutritionist in your area, ask your doctor or pharmacist to refer you to one.

Drew: I'm doing research on possible diabetes drugs. Is there a place where I might find a comprehensive list of drugs that treat diabetes?

Aaron_and_Stephanie: Go to the American Diabetes Association's website (www.diabetes.org). On the left hand side click on Type 2 diabetes, then click on "Conditions and Treatment." There will be a link that reads, "Other medications for Type 2 Diabetes". Click on that link and all the medications excluding insulin are listed.

fred: What about taking chromium picolinate - just recently diagnosed type 2- 57 male

Aaron_and_Stephanie: Unlike prescription medications, "natural" products are not required to undergo the FDA (Food and Drug Administration) approval process to demonstrate their safety and effectiveness. The FDA only regulates the package labeling, prohibiting a product from making claims that it is intended to diagnose, treat, cure, or prevent a disease. There is some evidence that chromium picolinate can lower blood glucose levels, but it is hard to evaluate it since there are not many well controlled clinical studies. We recommend talking to your doctor about how this supplement may fit into your treatment regimen.

Teresa: What does one do to attempt the conquering of constipation along with the diabetes?

Aaron_and_Stephanie: Let's start with some common causes of constipation: A diet low in fiber, not drinking enough water, lack of exercise,

Aaron_and_Stephanie: eating large amounts of milk or cheese, or

Aaron_and_Stephanie: stress. If any of these apply to you, then start by making the appropriate lifestyle change. If you still have constipation even after doing that then talk to your doctor or pharmacist about whether you need a laxative or stool softner.

Barbara: Where can I find places with diabetes education?

Aaron_and_Stephanie: You may obtain information about diabetes from the American Diabetes Association at www.diabetes.org or from www.riteaiddiabetes.com. You should also talk to your health care team- your doctor, nurse, dietician and pharmacist to obtain information on diabetes and how you can best manage it.

Angela: Hi, I had gestational diabetes with my last pregnancy. The baby will be a year old the 27th. I am wondering if there is a chance I still have it. I still have all the symptoms

Aaron_and_Stephanie: Many women who have gestational diabetes do indeed go on to develop type 2 diabetes. If you are more than 20% over your ideal body weight, your blood glucose was very high during your pregnancy (requiring insulin), or your diabetes was diagnosed early in your pregnancy then you are at an even higher risk for developing diabetes after pregnancy. It would be recommended to see your doctor to determine the cause of your symptoms.

frenchtwin: For the last three days my blood sugar has been going up and down I started yeaterday morning at 94 by noon it was at 40. got back up too 84 by bedtime. this morning started at 72 at noon it was 76 and just now it went 30 drink some juice it is nom at 81. I take metformin 1000 mg twice a day and 5 mg of glyburide twice a day. been taking the meds. for two years.

Aaron_and_Stephanie: My first question would be, what are you eating and how do you schedule your meals? It appears you are having frequent hypoglycemic (low blood sugar) episodes. These can be very dangerous so it is important to figure out why this is happening and you should let you physician or caregiver know immediately about it. Make sure you are not skipping any meals. You may also benefit by adding a mid-morning, mid-afternoon, and bedtime snack to your regimen. This may keeping you from going so low between your larger meals. We recommend consulting your physician as soon as possible regarding your blood sugar readings.

gabi: Hi!. I want to know if it is possible to become an diabetic just because you come in contact with a diabetic's blood on your open woond? thank you very much!

Aaron_and_Stephanie: Diabetes is not a "contagious" disease. It is believed to be a disorder with genetic and environment causes where insulin is either non-existent or not effective in utilizing glucose. Although there are other very good reasons why you would not want to contaminate yourself with another persons blood, contracting diabetes should not be a concern.

ADA_Moderator: That's it for today. Thanks so much for taking the time to be here Aaron, Stephanie and Linda. Thanks to all of you who joined us by asking great questions or by just tuning in. If you wish to continue any of today's discussions please feel free to visit the ADA Message Boards.

Keep up to date with all the ADA Live events and reference the archives here. We hope you found this interesting and informative and that you'll join us again next time here at ADA Live. Our guest Marie McCarren, will discuss and answer your questions on her book "Guide to Insulin & Type 2 Diabetes" at 1:00 p.m. EDT Tuesday, March 25, 2008. See you then.

Aaron__Stephanie_and_Linda: Thanks! It was great to be able to answer everyone

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