Update : Rizq dr Melaka

Pada bulan July yg lepas, saya menerima email dari seorang bapa dr Melaka yang ingin tahu mengenai clubfoot dan rawatan kaedah ponseti. Tanpa buang masa, saya syorkan beliau menemui Dr Burhan. Kami berjumpa di HUKM, di sana kami ditemukan adik Rizq dan keluarganya dengan kakak Dania.. (maaf takde gambar sebab leka bercerita..:)

Saya telah mendapat izin dari Hazrik untuk berkongsi gambar Rizq sebelum dan sesudah simen cara Ponseti. Gambar dibawah adalah gambar sebelum adik Rizq mendapatkan rawatan Ponseti.

Sebelum ini, adik Rizq mendapatkan rawatan di Hospital kerajaan di Melaka. Sama seperti Dania, rawatan pertama kurang memuaskan tambahan lagi kedua belah kaki adik Rizq masih lagi bengkok. Gambar dibawah adalah selepas berjumpa Dr Burhan & Dr Sharaf di HUKM. Kaki adik Rizq perlu disimen semula, tenotomy, simen sehingga 3 minggu, dan inilah hasilnya.

Dlm tempoh hampir 3 bulan, kaki adik Rizq sudah kelihatan seperti normal. Gebunye kaki adik Rizq mcm ala ala tayar Michelin..:)

Hanya satu nasihat untuk Hazrik & Linda sekeluarga, jangan lupa urut kaki anak setiap kali pagi dan malam, dan jangan lupa kasut istimewa anak kita perlu dipakai sepenuh masa dlm 3 bulan pertama dan disusuli diskaun 2 jam pada bulan2 berikutnya, dan seterusnya selama 12 jam pada waktu malam. Kasut ini perlu diapakai sekurang2nya 3 tahun.Walaupon kita pegi travel jauh sekalipun, kasut itu perlu dibawa bersama. Biarpon adik Rizq tidak selesa dgn kasut ini tapi sebagai ibubapa kita kene disiplin untuk mengelakkan dari bengkok kembali.

Gembirakan hati anak anda semasa memakaikan kasut 'braces' ini, ceritakan kenapa dia perlu memakai kasut ini. Mudah2an anak2 kita faham. Sekiranya dia menangis, tabahkan hati dan teruskan pujuk anak tanpa mengalah.

Terima kasih Hazrik kerana sudi membenarkan author berkongsi gambar adik Rizq.

Thank You, Doctor, we will miss you..

Dr. Ignacio Ponseti, father of the Ponseti Method, a revolutionary nonsurgical means of treating clubfoot in babies, died Sunday, University of Iowa spokesman Tom Moore said. He was 95. Ponseti treated thousands of babies and children with his method at University of Iowa Hospitals and Clinics and trained doctors around the globe to use it.

Dr Ignacio Ponseti, pencipta Ponseti Method, kaedah revolusi merawat clubfoot tanpa pembedahan di kalangan bayi, hari ini meninggal dunia pada usia 95 tahun. Beliau telah merawat ribuan bayi dan kanak2 dengan kaedah Ponseti di Klinik Hospital Iowa University dan telah melatih ramai doktor untuk mengaplikasikan kaedah tersebut.

Semoga Tuhan mencucuri rahmat beliau.

Dr Ponseti dikhabarkan sakit kuat

Salam semua,

Mungkin anda tidak pernah kenal atau tidak pernah ada peluang untuk berkomunikasi dengan lelaki ini. Tetapi lelaki inilah mencipta kaedah ponseti yang digunakan untuk membaik kaki anak anda tanpa perlu pembedahan besar.

Lelaki inilah yang memujuk saya untuk tidak putus asa dan menyarankan saya berjumpa dengan Dr Amnuay di Bangkok untuk menerima rawatan. Kami sekeluarga amat berhutang budi pada beliau. Walau kami hanya berkomunikasi melalui email, kesan dan budinya sangat besar pada kami.

Dikhabarkan Dr Ponseti kini sedang sakit kuat dan terlantar di hospital Iowa, Amerika Syarikat. Moga beliau kembali sembuh atau sekiranya Allah ingin menjemputnye pulang, moga beliau dirahmati walaupon beliau bukan seagama dengan kita.

Kawan2, doakan lah kesejahteraan untuk kesihatan beliau...amin!!

Eid Mubarak

Salam AidilFitri, Maaf Zahir & Batin..kepada yang terlibat dengan perjalanan Clubfoot ini..:)

-Ina, Imran & Dania

Perjalanan Clubfoot Dania

telah diedit pada 130909...

Selain daripada terjemahan bahasa inggeris ker bahasa melayu berkenaan dengan Kaedah Ponseti pada posting bertarikh 19hb March, saya menyimpan keinginan untuk menceritakan perjalanan saya sekeluarga untuk mengubati Clubfoot anak saya, Dania untuk dikongsi bersama dengan pembaca khusus dari Malaysia.

Untuk pengetahuan pembaca semua, saya anak kedua dari 5 adik beradik dan saya seorang yang 'vocal' (lantang bersuara), saya tidak malu bertanya sekiranya saya kurang pasti dan oleh kerana saya sudah 8 tahun kerja dengan syarikat Jepun, saya diasah untuk mencari 'root cause' atau punca sebenar secara bertubi2 bagi sesuatu masalah dan mesti di akhiri dengan penyelesaian atau jalan-jalan yang boleh menyelesaikan masalah berkenaan.

Saya berjaya melahirkan seorang anak perempuan pada 1hb April, 2009 setelah 4 tahun berkawin dan setelah 3 kali keguguran akibat masalah pintu rahim yang mudah terbuka pada trimester kedua. Seperti saya katakan tadi, saya tidak mengenal erti putus asa dan saya tidak takut untuk mencuba mengandung lagi.

Semasa Dania lahir, jururawat yang menyambut kelahiran anak saya, memberitahu yang kaki anak saya ada bengkok sedikit. Saya ada menanyakan kenapa tetapi jururawat berkenaan menyuruh saya bertanya sendiri kepada doctor. Saya juga sempat melihat kedua belah jari kaki anak saya hitam lebam, begitu juga jari2 tangan.Anak saya ditempatkan didalam NICU kerana pramatang 33 minggu dan juga saya adalah GBS-carrier.

Saya khabarkan kepada suami dan ibu tentang keadaan kaki anak saya. Maklumlah Dania dilahirkan di Hospital kerajaan, oleh itu keadaan di NICU tidak mesra penjaga membantutkan hasrat kami untuk mengetahui lebih lanjut. Kalau ada apa pon, jawapan diberikan acuh tak acuh sahaja. Kawan2 semua bertanya kenapa saya memilih untuk bersalin di hospital kerajaan sedangkann saya mampu bersalin di hospital swasta yang serba canggih. Jawapannye senang saje. Ibu saya adalah pekerja hospital tersebut dan saya adalah pesakit yang diawasi dengan sepenuhnya oleh Pakar Kanan Perbidanan yang terbaik di hospital berkenaan. Insya allah kalau ada rezeki, sekiranya saya megandung lagi, saya pasti akan memilih hospital swasta.

Pada hari kedua kelahiran Dania, kami dibawa ke Unit Carakerja yang kononnye boleh membantu memperbaiki kaki Dania. Kaki Dania dia urut, dan mungkin keadaan urat yang ketat, Dania menangis dengan sangat kuat. Inilah hasil lawatan kami ke Unit Carakerja.

Splint ini tidah dibenarkan dibuka walau pon hanya seketika. Tapi kami buka jugak splint tuh, tak nampak perubahan pon.

Kami tidak puas hati, dan kami mengambil keputusan pegi ker hospital swasta berdekatan untuk pendapat kedua. Doctor kenalan ibu mencadangkan agar kaki Dania disimen untuk hasil lebih baik. Beliau mengarahkan kami ke Unit Orthopedic di hospital kerajaan tersebut untuk mendapatkan rawatan.Sejak dari itu kaki Dania disimen yang dilakukan oleh pembantu hospital sahaja. Disini naluri ibu saya dicabar kerana Dania menangis dan melalak tanpa henti.

Setelah 2 bulan bersimen, masih tidak banyak berubahan. Kakak ipar saya mencadangkan kami ke HKL untuk rawatan selanjutnya dan kakak memberitahu ramai pesakit yang mempunyai masalah clubfoot mendapatkan rawatan di HKL. Kami pon memindahkan kes Dania ke HKL. Pada masa yang sama kami juga melayari internet untuk mencari jawapan.

Pada masa ini, saya sudah mengalami sakit kepala yang teramat sangat. Saya tidak berjaya menyusu badan anak saya lebih dari 3 bulan kerana saya perlu mengampil pil anti sakit untuk masalah sakit kepala.

Di HKL, pakar Orthopedic yang membuat simen/'casting'. Nampak perubahan sedikit tetapi masih belum meyakinkan lagik. Dania masih menangis, melalak. Airmata mmg nak gugur dah setiap kali Dania disimen.Dania dijadualkan menjalani satu pembedahan 'tenotomy' iaitu memotong tendon yang degil. Tidak ada satu doktor pon menerangkan kepada kami kenapa pembedahan ini perlu dilakukan, berapa lama, apa yang mereka akan buat, dan berapa lama tempoh penyembuhan.

Dania kes yang pertama dan pada pukul 1o pagi doctor membuat lawatan. Pakar Kanan yang hadir ada mengatakan yang sebenarnye kaki Dania belum sedia untuk pembedahan. Tapi mereka masih melakukannya. Saya simpan perasan marah sebab saya sakit kepala. Pakar tersebut ada mengatakan mereka akan bantu apa yang boleh untuk Dania. Kaki dania disimen selama 2 bulan. Pakar yang membuat pembedahan ini adalah lelaki. Kami ingat muka doktor ini sebab muka dia pucat semasa Dania datang untuk pemeriksaan susulan.

3 bulan kemudian, Dania di jadualkan untuk pembedahan kali ke-2. Oh ye kedua2 pembedahan ini dilakukan di dalam Bilik Pembedahan Paedetric. Pembedahan yang ke-2 mengambil masa yang agak lama dari pembedahan yang pertama. Kali ini saya diberitahu Pakar perempuan yang akan menjalankan pembedahan tersebut. Kami juga diberitahu bahawa Pakar yang membuat pembedahan pertama Dania tempoh hari sakit teruk. Kaki Dania disimen sehingga 2 bulan.

Hari Raya pertama Dania, kakinya bersimen. Tapi Dania masih kecil untuk memahami semua yang dialami olehnya. Saya masih lagi sakit kepala, berdenyut dan tapi saya masih gagah untuk pegi bekerja.

Suami saya ditugaskan berkerja di Canada pada Nov 2007 selama sebulan dan saya ditinggalkan sendirian bersama Dania. Walaupon kepala saya berdenyut dan sakit sangat teruk, saya berjaya memandu dari Subang Jaya ke HKL. Saya pernah pengsan dirumah ketika bersama Dania. Suami saya sempat menelefon ibu saya untuk datang menjenguk.

Kepulangan suami saya diraikan di Hotel Legends tetapi saya pengsan lagi ketika berada di hotel tersebut. Pakar di SJMC mengatakan jangkitan telinga semakin pulih dan Pakar disebuah hospital kerajaan menjadualkan saya membuat CT Brain scan setelah saya mengadu penglihatan kabur dan saya tidak boleh berjalan lurus. Pada masa ini Dania masih bersimen.

Nak lihat cara simen HKL?


Oleh kerana saya dianugerah oleh Allah swt dengan semangat yang kental, saya diberi peluang untuk hidup untuk kali kedua setelah selesai menjalani pembedahan 10 jam untuk membuang ketumbuhan di dalam otak (Brain tumor) pada 18 January 2008.

Saya dan ibu saya pergi ke Umrah pada April 2008, untuk sujud syukur atas Nikmat Allah berikan saya dan saya juga tidak putus2 doa untuk melihat kaki Dania sembuh seperti kanak2 biasa.

Doa saya dimakbulkan. Alhamdullilah. Setelah saya pulang, Saya sepatutnye membawa Daia ke HKL untuk pembedahan kali-3. Entah apa pulak yang hendak dibuat pakar2 ini. tetapi hati saya sangat berat dan saya menulis email kepada Dr Ponseti dan Dr Matthews Dobb utk mendapatkan pendapat mereka.

Dalam tempoh 24 jam, saya mendapat jawapan dr mereka dan mereka setuju dengan tindakan saya yang tidak membenarkan apa2 lagi pembedahan dilakukan kepada kaki Dania. Dr Ponseti juga mengkritik cara simen yang dilakukan oleh pakar HKL dan juga dia juga mengatakan kaki Dania belum pulih sepenuhnya walaupon setelah ada 2 pembedahan dilakukan.

Dr Ponseti mencadangkan kami ke Bangkok dengan segera untuk rawatan yang lebih bagus. Kami berangkat ke Bangkok setiap minggu bermula May 2008. Dengan sekali simen sahaja, perubahannye sungguh ketara. Kaki anak saya tidak jengket lagik. Ada pakar di HKL mengatakan kaki anak saya pendek sebelah dan kaki anak saya tidak boleh diperbaiki dengan hanya cara bersimen. isk isk isk. Nak lihat cara Dr Amnuay simen kaki Dania?

Dengan hanya 4 kali simen (dalam tempoh sebulan), anak saya sudahpun memakai kasut Ponseti (Mitchel braces) selama 4 bulan penuh. Pada bulan September 2008, Dania genap
1 tahun 5 bulan. Tiada tanda2 yang dia nak berjalan sendiri. Macam2 tawaran saya berikan kepada Dania termasuklah LCD 29" warna pink. Dr Amnuay menyarankan waktu pemakaian kasut Ponseti hanyalah pada waktu malam dan nap time.

Pada 14hb Februari 2009, pada usia Dania 22 bulan, kami suami isteri dikejutkan dengan satu kejutan yang sangat menggembirakan hati kami. Pada hari tersebut, Dania bangun dan terus berjalan tanpa henti. Sebagai meraikan kejayaan Dania, kami bawa Dania ke Tokyo Disneyland pada harijadinya yang ke-2.

Sebenarnye jauh lagi perjalanan kami ni. Tapi kami ingin berkongsikan pengalaman kami ini kepada ibubapa iaitu tiada mustahil dalam hidup ini. Cuma kita kene ikhtiar sikit ajek. Tabahkan hati kerana ini hanya ujian sikit dr yang Esa.

Kaki Dania perlu diawasi sehinggalah umurnya mencecah 4-5 tahun. Kalau umur saya panjang, insya allah saya akan bantu mana yang saya terdaya kepada ibubapa yang senasib dengan saya. Doakan lah saya yang masih bersusah payah melawan ketumbuhan otak yang khabarnya datang balik ni!..iskkk

Sekiranya ada pertanyaan, saya boleh dihubungi dengan email di zarinawatims@yahoo.com
facebook Zarinawati dan juga Yahoo Mesengger.

Semoga hari-hari kita diberkati..insya allah..

Ini gambar kaki Dania yang mungkin sekarang kalau orang tengok, mereka tidak akan percaya Dania ketika dahulu mempunyai kaki clubfoot..:)

Worth Reading..:)

Extracted from nosurgeryforclubfoot forum..

Hi everyone,

We just returned from Iowa for a second opinion for 17 mos old DS (BCF). Met with Dr. M and Maria, who felt like old friends because I've read so much about them!! The hospital is beautiful and the clinic is awesome. Iowa City is a very nice small city full of incredibly friendly people.

DS was treated here in Detroit by a Ponsetti approved doctor. Dr. M said he did a good job, and used our pictures of DS's serial castings to teach his "students of the day". The only difference in our doctor's treatment verses Dr. M's treatment is for DS's tightening heel cord. It's been getting stiffer since taking off the shoes during the day so he can walk. Our doctor was talking about doing another tenotomy. I pushed for PT, which helped. Dr. M said it's common for this to happen once the shoe time decreases. In fact, keeping the heel cord stretched is one of THE most important job of the shoes. He gave us the option of PT for 20 min/day for 3-4 months, then recheck, or recasting for 2 times. We chose the casts because DS doesn't like the PT, plus it's almost a sure fix. So I will return to Iowa in 10 days for a cast change. Then we can remove the 2nd casts at home.

As far as the DOBBS BAR - Dr. M didn't say anything bad about it, BUT he did say there are only 2 papers (studies) on it so far, and the first paper was done using a slightly different model than is sold now. The concern is that the mobility allowed with foot flexion and extension allows the heel cord too much movement and it seems to start tightening up. They have seen 6 cases of tight heel cords possibly form Dobbs bar use already. (We got ours after DS's problem was noticed, so I don't think his tightness is from the Dobbs bar). Dr. M didn't tell us not to use it, but did suggest that if we did continue to use it that we definately should do the heel cord stretches. If it starts to tighten up within 6 weeks time, then he would recommend going back to the Ponsetti bar.

We also talked about the ATTT. Dr. M there's a long time study now that shows that the surgery doesn't cause any later-in-life problems at all (no arthritis, etc.), so if DS does need it later, not to worry at all. (We repeatedly stated we were trying to avoid surgery at all costs). He did caution us not to let anyone do it before the age of 3, because one of the foot bones isn't fully calcified until then. Otherwise, it's not the end of the world or a failure and shouldn't cause us any sleepless nights.

While we were waiting for our casting, Maria went over all the details about coming back to Iowa next week. The Ronald McDonald House takes requests, using severity of illness as their criteria, so we may or may not get a room. They do work with the local hotels if they're full. I just saw the lobby and family room area when I went to get on the list, but the place is very comfortable and inviting. There is a free shuttle to/from the airport and the hospital. We stayed at the Heartland Inn, which is undeer $70/night with the hospital rate. Free breakfast, light supper snacks, and a shuttle to the hospital are included. It was also very nice, and most guests are there for hospital reasons.

Then the best part - I turned around and there was Dr. Ponsetti!! I teared up, and just really couldn't express my gratitude enough. My child and many others will live completely normal lives thanks to the dedication of him and his staff. How can words ever be enough?? He looked at DS's pictures, touched his feet, smiled and nodded. He still goes to clinic regularly to see "his kids" and watch them walk. He is very excited about the upcoming Ponsetti races, so if you're in Iowa for the conference definately participate. He should be at the finish line watching and smiling.

All in all, it was a very wonderful experience. Lessons learned:
*If you're unsure about your child's feet at all - GO if you can. You won't regret it.
*The businesses around the University cater to hospital patients and their families. You will be comfortable no matter where you stay.
*Everyone at the Ponsetti Clinic will do absolutely everything in their power to help you in any way they can.
*Consider doing the heel stretches once your shoe time decreases and your child starts walking. It won't hurt and may help.
*Use your bar and shoes 14 hours/night faithfully.
*The Ponsetti-recommened doctors are very well trained and skilled at the method.
*Meeting Dr. Ponsetti is a humbling and awesome experience.

I hope our experience helps and encourages some of you on your club-foot journey.
Many Belssings,
Diane


Blog Author Note :

We went to see Dr Amnuay in Bangkok on 11th Aug.Dr Amnuay said Dania's feet seems to be normal but he need to know in details. He sent us for X-Ray.After X-ray, it was found that Dania's heel cord is still tight and was not as good as what he expected to be.Dr Amnuay told us that, we need to change the way we strech her feet. We need to do it more frequently. He also said that perhaps Dania need another tenotomy. Tenotomy means her tendon will be cut again and she will be recast for another 3-4 weeks. However, he said it is the last things that he wants to do seems Dania can walk, can run and can squat like any other normal kids.

Still, he wants to see more improvement when he see us for another 6 months..
We need to work harder..I wont let Dania's tendon to be cut again...
I'll make sure this time, the heel cord will cooperate..insya allah!!

Relapse

Frankly, I'm scared of relapse..That's why I'm trying very hard to strictly stick to brace protocol..tried to make it 10-12 hours per day,but sometimes it is almost impossible..Recently Dania was complaining again..her feet is in pain again and at night she was crying..She's pointed at the scar located at the heel..(the most stupid surgery that happened to her)..If it is really that surgery that caused her pains, I hope the doctors that decides to perform the surgery will never find peace in their life...will never..

I've to punish Dania whenever she is not cooperating with the brace protocol..hmm..Pity her but we're giving her our best, right?

Extracted from Ponseti International website..

Relapses are a common occurrence among children with clubfoot up to the age of six years. The following is the rate of relapse for discontinuing brace-wearing at the age designated: 1st year 90 percent, second year 70-80 percent, third year 30-40 percent, 4th year is 10-15 percent, subsequent years are about 6 percent. Bracing is an essential part of the treatment of clubfoot and prevents relapses very effectively. Severity of the deformity at birth is not a reliable indicator of the odds of relapse, therefore almost all clubfoot patients are held to the same bracing protocols in order to provide them with the best protection against regression.

Bracing protocol needs to be tailored to the individual child based on the age, the relapse rate associated with that age, and when the correction was finished. For example, bracing hours will be longer for a new born that was corrected in three weeks as opposed to an older child that is already walking when correction is achieved. Importantly, the underlying cause of clubfoot is a muscle developmental and growth problem, so it is very important that children who are using the brace maintain some degree of mobility.

The foot abduction brace is used only after the clubfoot has been completely corrected by manipulation, serial casting, and possibly a heel cord tenotomy. The foot abduction brace, which is the only successful method of preventing a relapse, when used consistently as described is effective in > 95% of the patients. Use of the brace will not cause developmental delays for the child.

A Foot Abduction Brace (also commonly mis-labeled a Denis Brown Bar or DBB) consists of an adjustable length aluminum bar with adjustable footplates onto which shoes attach. It is recommended that an adjustable bar is used in stead of a fixed length bar because the child will quickly outgrow the fixed length bar. The orientation of the footplates to the bar is set by the orthotist as recommended by your doctor. Typically, the shoes are set at 60-70 degrees of external rotation. The last cast applied by the doctor must also have been rotated to the 60-70 degrees of abduction (external rotation), otherwise the brace will be uncomfortable for the child. There should be a bend in the bar or the mounting of the footplates to obtain 10-15 degrees of dorsiflexion. The shoes are straight last, meaning there is no curvature, so they can go on either foot. If the bar does not have a quick-release mechanism, the shoes are oriented with the buckles on the inside, so that you do not have to turn the baby over to tighten the strap and laces. Importantly, the distance between the inside edges of the heels of the shoes is equivalent to the child’s shoulder width. This distance is the most comfortable for the child and prevents knee or hip problems. If you lay the brace on the floor with the shoes facing upward, the child’s shoulders should fit snugly in between the shoes. Children go through major growth spurts, so if your normally agreeable child is suddenly waking and fussing, it is appropriate to check the length of the brace to see if an adjustment needs to be made prior to their next follow up appointment with the doctor. The FAB holds the foot in the proper abduction (external rotation) and dorsiflexion (forefoot lifting up toward the calf) to keep the foot properly stretched.

Wearing Schedule:

Use the brace once the last set of casts is removed. DO NOT wait to get the brace after the cast is removed since there is a high chance of regression that can lead to discomfort and non-acceptance of the brace. If the brace is not ready, a holding cast should be applied to maintain final correction. It is also important not to end treatment early.

The following schedule is recommended:

a. For young babies with clubfeet corrected in the first few months of life:
i. 23 hours for three months.
ii. Then a gradual weaning schedule as follows: one month 20-22 hours, one month 18-20 hours, one month 16-18 hours and one month 14-16 hours. The time in the brace does not need to be consecutive, but try to have the bulk of the time while the child is sleeping nights and naps to encourage mobility during the waking hours. If your child attends a daycare, consider leaving the brace on in the morning and instructing the daycare as to what time each day that the brace should be removed, or if your daycare providers are confident and willing, instruct them how to remove and reapply the brace for nap times.
iii. As the child grows and is walking full time, maintain night-time wearing of the brace for 12-14 hours per day up to age 4-5 years.

b. If the final correction is achieved after 8-9 months of age and the child is ready for crawling or walking, it is important to allow some mobility to help in the development of the weak muscles.
i. Therefore, it is recommended to start initial bracing with 18-20 hours a day for 2 months, then go to 16 hours a day for 3-4 months, and then to the standard maintenance protocol of 12-14 hours to age 4-5 years.

c. Some children with clubfoot (about 2 or 3 percent) may also have loose joints.
i. In these cases, the abduction (external rotation) of 60 to 70 degrees may lead to flat foot, usually presenting when the patient starts walking at 10-16 months of age and after. These children should set the shoe to 30-40% abduction. Do not stop using the brace as there would be risk of relapse.

d. If the child has atypical/complex clubfoot.
i. After correction the shoe used for the affected foot should be set to 20-30 degrees. There should not be bending on the bar unless there is 10-15 degrees of dorsoflextion with the last cast. As the foot becomes more normal looking the abduction (extended rotation) of the shoe should be changed to 40-50 degrees.

e. For those children who are treated 2 and older at the time of correction please refer to Dr. Morcuende.

Details can be viewed at Ponseti Website. This website is most helpful. If you sceptical with your current doctor, pls feel free to refer to this website or email to Dr Morcuende.