AV Ganesh Kumar, Author at Complete Wellbeing

Heart health: The news is not so heartening

AV Ganesh Kumar — Thu, 12 May 2016 11:12:51 +0000

How common is the incidence of heart disease in young Indians?

We don’t have concrete data, but over the past two decades it has certainly been growing. 15 years ago, when I was in King Edward Memorial hospital, we saw only one or two under-40 patients per year with a cardiac problem. From there, we have come to a stage where I see at least 10 cases of cardiac-related events, and almost 3 – 5 angioplasties a month, in individuals under 45—most of them being men. That’s a huge shift.

What’s the reason for such a big shift?

There are a few hypotheses. First is the type of food we eat in India and the subcontinent at large, which is carb-rich. 30 years ago there were hardly any fast food restaurants and so we consumed fewer calories in those days. Kids too didn’t consume as much milk and sugar syrup-based foods. There’s a notable difference between the kind of food we ate growing up, and the food that our children eat today. Their dietary habits are unhealthy. Add to this poor lifestyles—they are less involved in sports and outdoor activities—and kids and teenagers around are overweight or obese. So the seeds of heart disease are sown in their early teens.

The obesity that we see in India is worse as most of the fat accumulated is around the tummy [abdominal obesity], which is directly responsible for heart disease. Even women, who generally tend to put on weight around the hips and thighs, are now acquiring apple-shaped obesity and further complications start developing once they hit menopause.

And then there is sugar. The amount of pure refined sugar we eat is simply shocking. People have 6 – 7 cups of tea a day in this part of the world, and the tea is like sugar syrup. So you end up having more than 5 – 10 teaspoons of sugar a day. A recent study by the American College of Cardiology [ACC] has shown that consuming excess sugar is directly linked to heart disease. So the FDA [Food and Drug Administration] in America is planning to soon start warning people about the foods that are safe to consume and those that are not.

What lifestyle and dietary changes do you recommend?

As far as possible, we must cut down on our sugar intake.

Secondly, we must change the way we cook our food. Our cooking is so elaborate that most of the nutrients are lost. We also heat our food a lot, which destroys vital nutrients like B12, pyridoxine and folic acid. If you look at a typical spread in Indian weddings or any buffet in a hotel, you will see a layer of oil floating over the food. Compared to us, Caucasians and Europeans eat more salads and they don’t fry their food as much as we do. We need to cook in a way that preserves nutrients and requires less oil. I mean, don’t burn the food.

The third thing we can do is change our overall attitude towards life. In this day and age, everybody is working harder and for undefined hours. They also have to face the stress of travel, have EMIs to pay etc. Now, I agree that the previous generations had to face stress too, but the amount and type of stress has surely increased manifold. So try and take things a bit easy.

The last thing is that we must pay closer attention to how our vegetables are being grown. Nowadays many of us take pride in declaring ourselves as vegetarians. But do we think about the fertilisers and sprays used in growing these vegetables? Yes, they are linked to cancer but did you know that they can also be a cause of heart disease? I can already see how the concept of ‘contaminated vegetarianism’ will come into the spotlight in the coming years.

Smoking too has an impact but I don’t think it is responsible for the spurt in cardiac cases we are seeing now, as people smoked even 30 years ago. Changes in diet and increase in stress levels are to blame.

At what age should a person start getting routine cardiac checkups done?

If your family has a history of heart trouble, for example either of the parents have had a cardiac event before the age of 55 or you are a smoker, obese, hypertensive or diabetic, you should start going for cardiac checkups from your mid-20s. If there are no risk factors at all, for example, you are a non-smoker or there are no cardiac ailments in the family, then you can start going for annual checkups after the age of 30.

And what should a cardiac check-up involve?

Typically, if there is a family history of cardiac events, we check the cholesterol values. In addition to the routine lipid profile, HDL, LDL, VLDL, triglycerides, blood sugar levels, ECG, etc, it is important to get some other tests done too. They are Lipoprotein[a], hs C-reactive protein and homocysteine levels. Lipoprotein[a] is a type of cholesterol that is extremely atherogenic, which means it is responsible for causing fatty deposits in the arteries, leading to blockages and heart diseases. It is also responsible for causing diseases in the family… so people with high Lipoprotein[a] levels will require early drug intervention, like statins, which reduce cholesterol levels.

Though there is no proven treatment for reducing Lipoprotein[a], taking cholesterol-lowering drugs from a younger age can work well as primary prevention to prevent a cardiac event from occurring in the future. Secondary prevention is when you are already a heart patient and we prevent the occurrence of another cardiac event. These measures can postpone an event by one or two decades, or even completely prevent it.

When are exercise and dietary changes enough? And when are cholesterol-lowering medications needed?

Well, this can only be decided by your physician, but there are few new guidelines issued about five months ago by American Heart Association and ACC regarding who should be
put on cholesterol-lowering drugs. They were recommended for the following groups:

All diabetics between the ages of 40 and 75.
Anybody with LDL Cholesterol of more than 190 mg per deciliter of blood.
Established heart patients who have undergone an angioplasty or a bypass or who have had any other event, even with normal cholesterol levels.
People who have a cardiovascular risk score of 7.5% or more. This is calculated by the cardiologist with the help of overall parameters like cholesterol, blood pressure values, age, smoking status etc This predicts the individual’s chances of having a cardio-vascular event in the next 10 years.

The thing is, these guidelines are meant for the Caucasian population in America. There are no such guidelines for India. And the disease burden we see in young Indians is not the same as native Americans or Europeans. Even the younger cardiac patients in those countries are mostly Asians. So the occurrence of cardiac events may have something to do with our ethnicity and lifestyle. Chicago-based Professor Enaz, who has done extensive research in lipidology over the last two decades, suggests that we should double the risk score for native Indians and start early drug intervention to reduce cholesterol values.

What about edible oils? How safe are they?

Reusing oil is a strict no for cooking. And transfats are the worst—these are found in vanaspati, dalda and oil that has been used for frying but is reused. Most bakery items and processed foods contain transfats too.

Is it possible to prevent heart disease? What is the role of the doctor in the same?

I will say that coronary heart disease, among all serious diseases, is the most predictable and preventable disease. When a person comes in crashing with a heart attack to the emergency room, I rush and do an angioplasty on him. I save his life and society makes me a hero. But our family physicians who prevent heart disease in many more patients with the advice they give, go unrecognised. The patient doesn’t even realise that his physician may have prevented a coronary artery disease from occurring. I too prevent heart disease in about half the patients I see, if they heed my advice—but they don’t acknowledge it. We as a society do not give importance to prevention. I’ve seen patients who, if prescribed a pill, will go and crosscheck with their family, neighbours, friends or colleagues if they should actually be taking the pill. Sometimes they come back and ask for the dose to be reduced. Today everybody thinks they are cardiologists and dieticians and I am not blaming them—with the incidence of heart diseases going up, everybody has some knowledge of it. But the prevention regime provided by the physician needs to be followed and the mindset of questioning medical advice needs to change.

Are there people who opt for cardiac health check-ups even if they don’t have any symptoms or risk factors?

That is seen only among the elite and affluent class. And yes, if there are promotional packages offered, people grab the chance to get themselves checked. The middle and lower-income class feel that spending money on health is a burden. So even if they go for checkups, they opt for small centres, which are ill-equipped and so don’t give them accurate results.

Do you think the media is creating more panic about heart diseases in the young?

The media memory is short–lived. What is read in the newspaper is forgotten in a day or two. More than the media, a person panics when a colleague of the same age suddenly has a cardiac episode. That’s the time there is a panic in that office, and I would say that it is not a bad thing. If a person has chest pains they should always get themselves checked by a cardiologist or a physician. If it’s a panic episode, it will be addressed accordingly, but some cases of chest pains will inevitably turn out to be actual cases.

What is absurd is that when younger people have cardiac pain, they assume it to be gas or acidity and sit on it until it’s too late. People think, “I am young, how can it happen to me?”—and this kind of denial is deep-rooted.

To a certain extent it has to do with our economy. I have tried asking people why they didn’t come in the night, they don’t answer. But I sense that if they are insured or if their company takes care of expenses, they are more likely to come forward. A patient who was operated upon for an angioplasty kept cribbing about his health even two years after the surgery. He was consulting the family physician in the same hospital as mine, who noticed that the man was very unhappy about having to go through the angioplasty. So the doctor asked him if this life-saving surgery had been performed on him free of cost, would he still be cribbing today? The man didn’t answer then, but he came back next day saying that what was really pinching him is that the surgery had wiped off his savings, and he had hardly considered that it had saved his life. And he never cribbed after that. But I’m sure he’s not the only one who thinks that way.

What is the effect of alcohol consumption on heart health? And what do you recommend to those who like to drink?

There is some confusion in patients about alcohol because you frequently see reports that state that alcohol is good for the heart. However I would like to clarify here that there are a lot of studies conducted in India, including the All India Institute of Medical Sciences that show that alcohol consumption is not good for Indians. In India, most people drink whiskey, and the pattern of drinking is such that they drink a lot on a particular day and then don’t drink any alcohol for the next 5 – 6 days. This is binge drinking. The person may say he is a social drinker, but they don’t realise that they are actually consuming a lot of calories in the form of alcohol and also eating fatty food with it. And this is seen across classes.

If you have to choose an alcoholic drink, you could have a glass of wine [150ml]. But that does not mean that wine should be had everyday simply because it has health benefits. Or people who don’t drink alcohol should now start having wine. That is never recommended.

What are your views on marathon running?

If you are very well-trained and athletic, you can do marathons but don’t get out of your chair 15 days before the date of the marathon and decide that you will run because your colleague is running. I am a critic of marathons and I think it has become a fad now. To me, marathon running is not meant for two-legged animals. We have evolved in a way that our bodies are no longer suited to running. Every Mumbai Marathon has at least one person dying and for that family, it’s a permanent loss.

Just this past January, a guy training for the marathon went to the neurologist with jaw pain. He was brought to me and we found a critical 90% blockage in his arteries. Had he run the marathon five days later, it could have been fatal. Marathon running is not everybody’s cup of tea, and especially not of young, unfit Indians. There is an article in The New England Journal of Medicine that says that the incidence of deaths is low in the more than million marathon runners they have accounted for. But those deaths are due to abnormal congenital heart diseases [like hypertrophic cardiomyopathy etc] and not the kind that occur due to blocked coronary arteries that we see in here India every year. The issues people face after the marathons are not reported either. My advice: get in shape first before running marathons.

This was first published in the April 2014 issue of Complete Wellbeing.

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World Heart Day Special: Heart disease explained

AV Ganesh Kumar — Tue, 29 Sep 2015 08:49:02 +0000

~World Heart Day Special~

What causes cardiovascular diseases?

There are many risk factors that contribute to the development of cardiovascular disease. Some people are born with conditions that predispose them to heart disease and stroke. Most people, however, develop cardiovascular disease because of a combination of factors such as poor diet, lack of physical activity and smoking, to name just three. The more risk factors you expose yourself to, the higher the chance of developing cardiovascular disease. An estimated 17.3 million people die of cardiovascular diseases every year globally. 80 per cent of the deaths occur in low and middle-income countries.

I have no signs of heart disease. How would I know if I am at risk?

The signs of heart disease are not always obvious, and a heart attack can often be the first indicator. There is no single cause of heart disease but there are risk factors that increase your chance of developing it. Risk factors include lifestyle choices, such as smoking or being overweight, as well as high blood pressure, high cholesterol, diabetes and a family history of heart disease.

These risk factors often don’t have symptoms. So, how can you find out if you are at risk of heart disease? Visit your doctor to get a heart health check, which involves discussing your heart disease risks with your GP and getting your blood pressure and cholesterol levels checked periodically.

How is coronary heart disease diagnosed?

There different ways to diagnose coronary heart disease.

Electrocardiogram or ECG: This test records the electrical activity of your heart. It measures the rate and regularity of heartbeats, the size and position of the heart chambers, the presence of any damage to the heart, and the effects of drugs or devices used to regulate the heart. It is a non-invasive procedure.
Echocardiography: This test helps visualise the heart’s valves, its size, and its pumping capacity.
Non-invasive stress tests: There are a number of non-invasive stress tests which help doctors to know if the blood circulation to the muscles of the heart is compromised or not.
Coronary angiogram: In this test, a dye is injected into your arteries and then an X-ray is taken to see how the blood flows through your heart. The image, or angiogram, will show any atherosclerotic blocks. This is the most definitive and gold standard test.

How do symptoms of heart attack differ in men and women?

The symptoms of heart attack in a man are intense chest pain, discomfort in the left arm or jaw and difficulty in breathing.

A woman may have some of the same symptoms, but her pain may be more diffused, spreading to the shoulders, neck, arms, abdomen and even her back. A woman may experience discomfort like indigestion as well. In her case, the pain of a heart attack may not be consistent. Alternatively, she may not experience pain, but, instead, suffer from unexplained anxiety, nausea, dizziness, palpitations and cold sweat. Heart attack in women may also be preceded by unexplained fatigue. Women who are diabetics [especially long-standing ones] may experience breathlessness, rather than chest pain, as a symptom of heart attack.

Compared to men, women tend to have more serious first heart attacks, often leading to death.

How is heart disease treated?

Treatment for coronary heart disease [CHD] usually is the same for both women and men. Treatment may include lifestyle changes, medicines, medical and surgical procedures, and cardiac rehabilitation. The goals of treatment are to:

relieve symptoms
reduce risk factors in an effort to slow, stop, or reverse the build-up of plaque
lower the risk of blood clots [Blood clots can cause heart attack.]
widen or bypass plaque-clogged coronary [heart] arteries
prevent CHD complications.

Is heart disease hereditary?

Heart disease can be hereditary. But even if you inherit the risks factors that predispose you to heart disease, such as high blood cholesterol, high blood pressure, diabetes, or being overweight, there are measures you can take that will help you avoid developing cardiovascular disease.

What can I do to prevent heart disease?

Heart disease is largely preventable. You can reduce your risks of heart disease by living a healthier lifestyle. Try to:

be smoke-free
enjoy healthy eating
stay physically active
manage your blood pressure
manage your cholesterol levels
achieve and maintain healthy body weight
maintain your mental health and wellbeing
take any medicines as prescribed.

What are the innovations and advancements in treating heart disease?

There is always research going on that focusses on developing new ways of treating heart disease. However, here are some of the latest and most trusted techniques.

Bioresorbable Vascular Scaffold [BVS]: It is a non-metallic mesh tube designed to treat coronary artery disease. The prospect of a temporary vascular stent has always been the goal of the interventional surgery community. Such a device would provide support by opening the narrowed artery to restore blood flow to the heart. BVS gradually dissolves once the artery gains the ability and strength to stay open on its own. This is similar to the way a cast supports a broken arm and is then removed.
Heart transplant: This is a modern and relatively recent advancement in treating end-stage heart disease. A heart transplant is needed when a person’s heart can no longer work effectively on its own. It is considered a viable option if other treatments fail, or if the person’s heart muscles are weak, potentially putting his/her life at risk. Due to the advances in treatment, the risks associated with having a heart transplant have been reduced, but not eliminated. Unfortunately, the poor response of organ donors [lack of awareness] has led to heart transplantation being not yet picked up well in India, though some centres have initiated the practice of transplantations.
LVAD [Left Ventricular Assist Device]: This is a sort of an artificial heart that can help a weakened heart. Earlier, the LVADs were used as a bridge to cardiac transplantation—as a temporary support device till the patient gets an organ donor. However, the newer generation LVADs can now be used as long-term, permanent treatment for heart disease. This is termed as ‘destination therapy’ for heart failure. The biggest challenge for LVAD at this stage is the prohibitive cost, but I am sure the costs will come down with more usage and time.

This was first published in the September 2015 issue of Complete Wellbeing.

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Preparing for a Bypass Surgery

AV Ganesh Kumar — Thu, 09 Oct 2008 00:00:00 +0000

Instances of ischemic heart disease and heart disorders are growing at an alarming rate in India. The number of people requiring cardiac surgeries is on the rise. These surgeries put immense financial, emotional and psychological burden not only on the patient but on the family as well. However, a few guidelines and preparations could go a long way in easing the surgical process.

In our September issue, we had discussed various procedures that could help a patient before undergoing stenting, the process that involves widening the narrow artery by temporarily inflating a tiny balloon in the blood vessel. In this issue, we focus on getting ready for a bypass surgery.

Preparation for bypass surgery

Unlike angioplasty/stenting, bypass is a major surgery. Following are some of the concerns, thoughts, beliefs, and burdens that a patient goes through while preparing for or awaiting bypass surgery.

Can I get through it?

Is there anyone who goes to surgery without a worry? It’s normal for people to be afraid or to wonder if they are going to make it. Fears and doubts are common, and the patient should not feel odd if they have them. They should not feel odd talking about them either. It helps to share your feeling about heart surgery with someone who cares about you. Even if talking about it makes you a little anxious, it can bring out good feelings. It can make you and your family or friends feel closer. You may want to read what others have written about heart surgery or talk with others who have already had it. All you need to remember is that each person’s experience is different.

About heart surgery

One part of getting ready for heart surgery is to know about the surgery itself. All hospitals where bypass surgeries or other surgeries like valve operations are routinely performed, the hospital cardiac departments give brochures/booklets/pamphlets explaining the basic technical details of the surgery in simple language. All patients/family members should read this and can jot down queries if any and ask the concerned doctor or the attending nurse. Do not feel foolish for asking questions or saying what you feel. The more you know about what to expect, the easier your recovery will be.

Be kind to your body

If you have several days or weeks to get ready for heart surgery, this is the time to take very good care of yourself. Plan to:

Eat well – Try to eat a variety of foods each day even if you aren’t hungry. It’s important that your body gets enough vitamins and proteins. Eating well speeds healing and you will be less tired after surgery.

Rest – Don’t let yourself get too tired before surgery. The more rested you are the stronger your body will be. If frequent phone calls from visitors tire you, just tell your friends that you need more rest at this time. They will understand.

Exercise – Walk or do whatever exercise your doctor has allowed. This helps relax your body and tone the muscles. It is less tiring to walk on flat surfaces at an easy pace. Stop any exercise if you feel the pressure is being put on your heart.

Smoking – Smoking is tough on the heart and lungs. It raises blood pressure, makes the heart beat faster, narrows the coronary arteries and smaller blood vessels and makes more mucus in the lungs. So, not smoking is one of the best things you can do for your body before any kind of major surgery. Stopping for even a short time helps. You will breathe better, and your heart won-t have to work as hard.

It is really hard to quit smoking when you are anxious or under stress… like before your surgery. You can follow some of the suggestions as below:

Take it one day at a time. Ask family and friends not to smoke when they are with you. When wanting to smoke, do something else with your hands. Go for a walk, get busy, or pursue a hobby.
Learn to relax. Plan time to be alone. Just sit and listen to the sound of your breathing. Read a book or simply listen to your favourite music.
Cut down on coffee, alcohol and other drinks that you are used to having with a smoke.
Get up from the table as soon as you are through with your meal. This helps if you are used to smoking right after a meal.

The hospital

If you have been a patient before, you know some things about hospitals. If not, it may be very strange at first. It is not easy being a “patient”, but knowing these things can help you relax.

Things to ask – Get your nurse or another staff person to explain:

Times for meals and medications
Use of call light by your bed
How your bed works
Location of showers or bathrooms
Visiting hours.

Things to tell – If you let your nurses know these things, they can take better care of you:

How to contact your family
Foods you don’t like or food allergies
Eye or hearing problems
Who will be at home after surgery
Anything about family, home or work that you would like to share.

Before surgery

There are a lot of little things done to your body to get you ready for surgery. These are routine for any surgical practice like cleaning and shaving the skin, preparation of bowels, preoperative medications, and orders regarding oral intake of food and liquids and fasting requirements. All these will be well informed by the attending nurses,

Things for the family to ask before surgery

Be sure your family asks your nurse about these before you go to the operation room:

The time of surgery
Where to wait while you are in surgery
How often and from whom they may hear of your progress
Where you will be after surgery
When and how often they can visit you after surgery
What items you can have in the intensive care
What to do with your clothing, glasses, hearing aid or dentures.

Conclusion: It is not easy to prepare oneself for any major procedure or surgery, especially when it is cardiac. Logical thinking, keeping calm and listening to your trusted cardiologist will ease your burden.

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PRIMARY ANGIOPLASTY: A Life-saving procedure

AV Ganesh Kumar — Wed, 30 Apr 2008 00:00:00 +0000

The term coronary angioplasty is used to describe a technique wherein a balloon is used to crush blockages in the blood vessels [coronary arteries] supplying the heart, thereby restoring good flow of blood. These procedures are invariably followed by insertion of a metal scaffolding called a stent which prevents recoil and reduces re-blockage at the ballooned site, which is called a stenting procedure.

The process

Balloon angioplasties and stenting techniques have become a very routine day-to-day procedure performed in most tertiary care hospital across the country. Primary angioplasty, however, is a term used to describe an angioplasty done as a life-saving emergency procedure in a patient with an on-going heart attack [PAMI – Primary Angioplasty in acute Myocardial Infarction]. Heart attacks occur due to sudden total occlusion of a pre-existing partial block, thereby completely cutting off the blood supply to a portion of a heart muscle.

These 100 per cent blockages need to be removed within 3-6 hours from the onset of heart attack; else the muscle of the heart gets damaged permanently. Doing angioplasty in a critical patient of heart attack is in itself challenging and doing so in the critical window period of this 3-6 hours further adds to the challenge. Recently, we did an audit of our door to balloon time [that is the time at which the patient reaches the hospital with ongoing heart attack to the time actually the balloon opens the block and restores the blood flow to the muscles of the heart] was 42.5 minutes. The international accepted time is within 90 minutes. Therefore our response time was indeed encouraging. Can you imagine the impact of a short door to balloon intervention, on a patient who often comes crashing with a massive acute myocardial Infarction? A few hours later, we are wondering why he is still in the hospital.

The only other option available for the treatment of heart attack other than the primary angioplasty is use of specific intravenous medications called “thrombolytic agents”. These agents are thrombus [clot] busting medications, and when administered in patients, dissolve the clot in 60-65 per cent of cases. The remaining 35-40 per cent of cases either die due to failed thrombolysis [failure of drug to lyse the clot], or even if they survive the attack, go home with a very weak heart due to a large portion of the heart muscle being permanently damaged. These patients who do survive with weak hearts go on to live with either heart failure, valve leaks, ruptures in the portion of the heart or rhythm problems [electrical disturbances] and have a very morbid and unproductive life, with abundant economical, social and psychological burden.

Difficulties faced during the procedure

We have millions of such patients in our country with this morbidity, which ultimately is a large burden to the state. On the other hand, success rate of primary angioplasty is more than 95 per cent when performed by experienced doctors. Mind you, several procedures are not easy during primary angioplasty. Identification of culprit lesion may require a thorough evaluation; vessel access can be challenging; lesion morphology can be tricky; thrombus burden can be truly “burdensome”; hemodynamics critical and worsening by the minute; or no re-flow may be stubborn to usual treatment. Or, simply, a combination of these variables and darned, bad luck! This requires not only specialised training in interventional cardiology, more importantly a dedicated team of nurses, and cath lab technician who can react quickly to an emergency call.

The day-to-day angioplasty and stenting procedures have become routine and boring in some ways. However, this primary angioplasty is a new challenge in life, something which calls for a little personal sacrifice. Anybody can do a short door to balloon intervention! Most skilled interventional cardiologists in Mumbai and across the country can do an exceptionally good job with short procedure times and a door to balloon time of less than 90 minutes, when it is on routine hours. To do it regularly, day-to-day, and during off hours in a community hospital, in a fairly standardised methodology, does call for a lot more dedication and commitment. PAMI is not rocket science. I cannot overemphasise the urgency that exists in achieving the mandatory short door to balloon time guidelines.

PAMI reminds of a relay race in a 400 meters race. Like these relays, I am the final person with the baton and I must make up time for the delays of late presentation to the emergency room [ER], at times patient presents late to the ER, the clock is ticking and time to alarm at 90 minutes. If the ER/transportation doesn’t get its act together, the clock continues to tick; if patient’s/relative’s decision is delayed, it is still ticking, and always, yes always, I am expected to get it right and finish within 90 minutes. My 27/7 commitment means I am immediately available. I have to see the patient and I have to set the process rolling. In most cases, I try to lead from the front. I scrub in along with them, so I am even able to help them prepare a patient. It disseminates a feeling of urgency and team work. It lets the message resonate that each moment is precious. My availability has been an absolute personal decision, and a calling in life, sparked by a fierce determination to get it exactly right. Remember, the procedure is just one part. Some patients need an extremely close follow-up post procedure; especially those with cardiogenic shock [Cardiogenic shock is based upon an inadequate circulation of blood due to primary failure of the ventricles of the heart to function effectively]. Not every patient has a perfect result and often requires additional care. At times, physically it is very exhausting, though mentally it is extremely rewarding.

Hopefully, I will have the good health and the support of the hospital and the staff to continue doing it for many more years to come.

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