Newly diagnosed - insulin necessary?

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Janice & Johnny

Janice & Johnny

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** I'll definitaly be looking around the site tonight. The vet is calling in the a.m. and I want to represent Johnny's needs as best I can. I think they are looking for $$) If insulin is needed, it's absolutely what we will do!

Our 8.5 year old cat was diagnosed with diabetes this past weekend. His whole life he's been eating dry food (Cat Chow) with a little (~2tsp) of Fancy Feast in the a.m.

We've been doing a ton of online research and decided to switch his diet while we look at other options. We've seen a great turnaround in him just by switching to high protein/low carb wet food, but still need to get a new glucose reading later this week. Last Friday (5/7), he was 12.4 pounds (down from 14 last May; typical weight for him) and his glucose was 491. By switching the diet, he was up to 13 pounds on Sunday night and he's active again, happy and playing in ways he hasn't in months. He was 12.5 lbs again tonight, but still happy and seemingly "reborn." We were hoping that we could try this change in diet for a while while monitoring his glucose. The vet is pushing for the insulin. I just want to be sure it's not $$$ driven. We will do whatever is best for him, but want to be sure he needs insulin before going that route. Also, any experience similar to ours is greatly appreciated. If he goes on insulin, will the vet push it to be permanent?

Thanks for any advice you can offer. :) So happy to find this board!
 
Hi, and welcome! You are definitely in the right place.

It's my understanding that some cats can become regulated by food alone, but 491 is a fairly high number. Take into consideration that cats who are treated early and well have a better chance at remission. Starting insulin sooner than later could help you get your kitty to the point where the diabetes is food-regulated.

You could ask your vet whether she supports home testing, which all of us here do. It is the best way to know how to be sure that your kitty is getting the right amount of insulin and food. Find out what kind of insulin your vet recommends.

Post tomorrow and let us know how your conversation went!
 
Thank you for responding, Kathy!

The insulin she was proposing was Glargine Lantus. Any experience? I typically love our vet, but she has been kind of cold through this process. :(

I'm mostly worried about starting him on insulin and then it's forever (needed or not). I've done a lot of research, but still learning. It seemed reasonable to think that switching from the carbs that he can't digest would make a difference. (please don't laugh, I'm new to this!) I said I'd like one more glucose reading this week to know where he is now. She agreed, because we are moving on Saturday (same area), and said stress can increase the numbers. If they are still high, she'd like to keep him for a day to monitor glucose throughout the day. My worry is that she bases it on a certain food that is vet-sell only, and then we are locked into paying extra. I know it's bad that I feel this way about them, but they really are one of the most recognized practices in Chicago. But, Johnny's MY boy. I want to make sure we aren't all getting used.
 
It is NOT wrong to feel that way! It is super that you are ready to take responsibility for your Johnny's wellbeing. That's our job.

I do have experience with Lantus; it's a great insulin, and the Lantus support board (Lantus Land :smile: ) is full of wonderful, knowledgeable people who can help guide you through every step of the process. My own kitty just went into remission -- no more shots! -- after 15 months. (our case was kind of tough.)

About food: In Lantus Land, we feed low-carb wet food, NO dry food, and no expensive prescription foods. So don't worry about that.

Lantus users follow a specific protocol that begins with starting at a low dose, maybe 1 unit TWICE DAILY, and then gradually increasing. It's the best way to find the right dose for your kitty, and know when you may have a chance to start decreasing.

We also hometest -- it's a must. We test before each shot, to be sure the BG is in the right range, and then at least also about 6 hours in, when the BG is likely to be lowest, the nadir. That's how the effectiveness of the dose is judged.

Your vet may not be used to patients taking charge. You can refer her to this site; there's a "Convert a Vet" section with academic articles she may be interested in. either way, though, YOU can manage Johnny's diabetes, and maybe even achieve remission eventually. I hope you can enlist her support.

Visit the Lantus board, and look at the stickies. There's a ton of education there. There's a lot to learn at first, but it becomes second nature.

You're already making a great start!
 
starfishj said:
I'm mostly worried about starting him on insulin and then it's forever (needed or not).
Click to expand...

Starting insulin does not mean he'll be on it forever. many, many cats have managed to become diet controlled and stop their insulin shots. If you want to try diet alone and hold off on the insulin, make sure you are testing daily for ketones in his urine.
 
In fact, cats that start on the Lantus protocol within four months of diagnosis stand a better chance of remission.

So yes, I agree with Deanie!
 
I think you are all saying that the insulin is probably necessary right now, right? Increased activity and happiness does not equal happy BG levels? If so, that makes me feel so much better.

We're definitely going to do hometesting? What kind of meters do you have and love/hate? Also, we need a lancet, right? Recommendations welcome. We have a pretty cooperative kitty, but the less stress, the better.

I will definitely check out the Lantus board. It's on here?

THANK YOU to all who responded tonight. I will sleep so much better hearing from you and about your experiences. It sounds like we are all interested in doing the best we can for our kitties.
 
You don't need to worry about your vet prescribing Lantus to make $$, because Lantus is a Rx-only insulin for humans that you have to buy at a pharmacy, so your vet won't make any money off your purchases. It's a great one to start with, because like others have said, Johnny will stand a greater chance of going into remission if you treat him with Lantus early. The fact that he's always eaten dry food probably gives greater hope that his diabetes may be diet-driven, so hopefully with the new low-carb diet and some time to let his pancreas heal, he can go OTJ.
 
Ask your vet to write the prescription for the Lantus cartridges. Shop around (you might do that now),
Walmart, Costco (you do not need to be a Costco member to use their pharmacy).

You get 5 cartridges at a time. Each cartridge contains 3ml of insulin (300 units).

The cost of 5 cartridges is more than the cost of one 10ml vial of Lantus, but since Lantus
has a short shelf life after opening, you will actually save money in the long run by buying the
cartridges.

The manufacture states that the useful life after opening is 28 days, but most here
get 2-3 months of life from each Lantus Cartridge before it 'goes bad'.
The manufacture expects it to be used by people who carry it around with them un-refrigerated.
If you handle it properly, you should get longer useful life.

If you get the 10ml via, you will be tossing away most of it before you can use it up.
A 10ml vial holds 1,000 units of insulin. Since you will likely start at 1-2 units of insulin 2x per day,
you will only use 60-120 units in a month, so a lot of a 10ml vial will go to waste.

Yes, you will need some testing supplies. You want a meter that uses a very small drop of blood
(1 micro liter up to 3 micro liters). And you want one that uses 'sipping' strips. (Most sold today
use sipping strips).

The cost of the strips is what you need to consider rather than the cost of the meter. Strips are
your biggest expense, and you will use a lot at first---several per day.
Try to get about 100 test strips if you can afford it. Most meters come with a starter supply of
about 10 strips...not nearly enough.

After you get over the hump learning to home-test, you will likely use two strips per day most days,
and 4-6 on the days you run a BG curve (once every week or two).

You can get a Reli-On meter at WalMart (their brand). And the strips that go with it are among the less
expensive. Also you will need a lancet device and some lancets . Again Reli-On brand lancet device and
their 'fine (not 'ultra-fine' ) lancets to go with it. Some here use the lancet device, and others here
poke 'freehand' using the lancet not mounted in the device.

Lantus is a U-100 insulin (100units of insulin per ml of liquid), so you will need insulin syringes for U-100
insulin. These are available at human pharmacies (Most states do not require a prescription for the syringes).
While your calling around for Lantus prices, ask one of the places if a prescription for insulin syringes is
required in your state).

You will want the smallest capacity syringes (3/10ml liquid capacity), Preferably 30 or 31 gauge (the smallest).
I liked the 'short' needles...5/16-inch length.

You might want to ask if they have syringes with 1/2-unit marks. Some pharmacists will claim such does not
exist, and will try to sell you 1/2 cc capacity syringes instead. Insist on seeing the words "1/2-unit markings' on
the box. This is not a big deal at this time, but will make it easier to make small dosage adjustments.
You can eye-ball it between full-unit marks if you don't have the 1/2-unit marks.

Do not let the vet give or sell you anything except a small starter supply of insulin syringes. Be sure they
are insulin syringes and not TB syringes or other general-purpose syringes. It should say right on
the syringe itself...something like "for U-100 insulin".

Oh yes, as mentioned above, you will want to get some KetoStix from the pharmacy....sold behind the pharmacy
counter, so ask for them. Vial of 50 will last a long time ...less than $10 if I remember right. Bayer makes them,
but chain-store pharmacies may have their own house brand (not sure).
 
The cost of 5 cartridges is more than the cost of one 10ml vial of Lantus, but since Lantus
has a short shelf life after opening, you will actually save money in the long run by buying the
cartridges.
Click to expand...

While that is true that the package of pens costs more (total price) and yes it does save in the end because of less waste, it is not true that the pens cost more than the vial when you consider that a package of pens contains 15ml (1500 units) and a vial only 10ml (1000 units) so the pens are 1.5 times the amount of insulin.

Taking the price from an online pharmacy http://www.bigmountaindrugs.com/Drug/Lantus

a 10ml vial costs $95 thats $9.50 per ml
5x 3ml Solostar pens (15ml) costs $125 thats $8,33 per ml

So actually based on quantity alone the pens are cheaper.
 
Here's the link to Lantus Land (LL), the Lantus users support group: http://felinediabetes.com/FDMB/viewforum.php?f=9.

Regarding lancets, some of us use freehand style, and some use pens. I always like using the lancing pen, because it allows you to 'dial' the force behind the stick, and give a controlled push every time. I use the Accuchek Aviva lancing device, but there are others.

Let us know what Johnny's next test result is, and what your vet says!
 
Monique & Spooky said:
The cost of 5 cartridges is more than the cost of one 10ml vial of Lantus, but since Lantus
has a short shelf life after opening, you will actually save money in the long run by buying the
cartridges.
Click to expand...

While that is true that the package of pens costs more (total price) and yes it does save in the end because of less waste, it is not true that the pens cost more than the vial when you consider that a package of pens contains 15ml (1500 units) and a vial only 10ml (1000 units) so the pens are 1.5 times the amount of insulin.

Taking the price from an online pharmacy http://www.bigmountaindrugs.com/Drug/Lantus

a 10ml vial costs $95 thats $9.50 per ml
5x 3ml Solostar pens (15ml) costs $125 thats $8,33 per ml

So actually based on quantity alone the pens are cheaper.
Click to expand...

True...but some have sticker shock at the start-up cost for the insulin....that was my point.

Thanks for the clarification.
 
to answer one of your concerns about starting insulin along with diet change and do you really need insulin. your cat's pancreas is in overdrive now so altho diet change will help you want to help heal the pancrease so it can have a good chance at getting back to doing it's job. you stand a better chance of remission if you help the pancrease along now rather than later (which you will eventually end up doing i believe)
you got lucky with a lantus recomendation from your vet...it's a great insulin and we have an excellent team with that.
 
Agree with Lori and Tom. The quicker you get your kitty into pancreas healing range (between 60 and 150 BGL generally) the greater the likelihood of remission. Lantus is indeed a very good insulin and comes highly regarded on this board. Good luck.

Edit: Also wanted to mention that it is very wise to be suspicious of any vets and their so-called 'proven' techniques. If I listened to my original 'highly regarded' vet, Blue Cat would still be on high doses of insulin and would have had at least a couple hypo episodes. Read all the material you can on this site. :cool:
 
THANK YOU all so much!!

Everyone was so helpful, I feel like I can't thank you enough. Karen, the detail you supplied was priceless!

We're heading to the vet tomorrow at 6pm to learn the ropes and get Johnny started on the insulin. It's going to be 2-units twice a day of Lantus. We're getting the Relion monitor from Wal-mart and called ahead to make sure they have it. DH will pick it up in the a.m.

Wish us luck! Here we go! :) So grateful to all who commented and for this site! I'll update when I can. We're moving Sat. a.m.so it's crazy around here. But I'm mentally gearing up to give my first shot tomorrow night. Yikes. But it is for the best!
 
You had great information given to you - the few things I"d like to add is this link to the lantus protocol that most of us try to follow: viewtopic.php?f=9&t=1581

You can see this link and the "very important stickies" at the top of the lantus insulin support group (you already had link to this). There is great info in those stickies.

Finally - you say the vet is going to start Johnny on 2 units twice a day. Usually the recommendations here for lantus start at 1 unit twice a day and work up. Sticking with the same dose for 6 cycles. (See the stickies over in Lantus Land) Often a cat, especially one who has just had a major diet change, doesn't need 2 units to start. By giving 2 units you might end up with too low of numbers and then get rebound high numbers. Sometimes you don't even realize the cat has gone low - you just see the higher rebound numbers and assume they need more insulin - I would urge you when you see the vet tomorrow to ask them - or tell them- that you would really like to start out at this lower number - 1 unit twice a day - and see how that works first. Copy the Rand and Tilley protocols from Lantus land and take with you to vets.....

Good luck, there is lots of us around to give you support!
 
I'm also new to this board but have had type 1 myself for over 46 years. Must add my 2 cents on Lantus and starting on a lower dose. Insulin is a potent hormone and too much of it in the blood stream can be very dangerous, Better to start low and build than start with higher doses and have hypos and rebounds especially since you are moving and will not be able to keep a close eye on your cat with all that stress and activity. Let the vet know you are moving as well and want to start a little lower until you are more settled and can keep a closer watch on things.

Also, Morgaine was diagnosed with a BS of 292. A week after changing her diet to low carb wet food she is holding her own at BS between 114-160 without insulin. She is actually testing a little lower each time for the most part. Of course using small amounts of insulin is recommended if her BS is higher and I am so new to feline diabetes that my opinions are not really valid yet but please know my cat is doing very well with this diet change. Go slow and test at home. As a long term type 1 diabetic, testing is the major tool before administering any insulin. I would never know how much insulin I need without testing myself and I would not give my cat insulin without knowing what her BS is first,

Good luck and educate yourself as much as possible.
 
Johnny's diagnosis BG was 491 (last Friday). Would that warrant 2 units at first? I've had a second opinion (friend who is a vet) say they'd also start at 2 units for a number over 350.

I'll print out the protocol though and bring with me.

ETA: I didn't know the number when I first posted or I would have shared that then.
 
Hi there,
I am one of those that the diet change, alone, has worked for. My vet wanted insulin too, but I declined, changed her food, got the meter and ketone test strips and in two weeks her numbers were no longer diabetic. Sweety had previously only been fed dry too and I saw a change like you did - being more active, jumping up on things again.
491 is pretty high though. Sweety's was 2- eighty-something. Her fructosamine turned out to be borderline so I chose the diet change first, to try.
Did you have a fructosamine test done? (the average of bg levels in the pervious weeks) That could tell you more about where he stands than the stress-raised vet level.
My vet was not onboard with hometesting - almost laughed at me. If you do start insulin, ask your vet how he/she feels about it. Maybe you could teach him/her something!

You're in the right place here - read everything.
Good luck.
 
High BG at diagnosis does not necessarily correlate to the starting dose of 2u bid (bid means 2x/day).

Neither does weight of cat.

Every cat responds differently to insulin. If you start too high right out of the shoot, you risk either
a hypo (too much insulin = dangerously low blood sugar)....

...or 'rebound' in which the BG keeps climbing
because the LIVER is dumping sugar into the blood to counteract too much insulin.

Once the Liver runs out of reserve sugar, you can have a very serious hypo-glycemic event.

Start low and work up to the ideal dose. Start too high and you may be already past the ideal dose
and not know it until a serious condition develops.

Home test !!!!
 
Thanks for all the feedback today. We gave our first injection tonight. Johnny did very well with it. Prior to injection (and after eating), we measured his BG...it was 392. (It was 491 six days ago at diagnosis; we've changed to high protein/low carb diet in the last few days).

I appreciate any and all feedback. I did feel okay starting at 2 units after getting a 2nd opinion from a vet friend, esp. due to such high numbers. We have a monitor and we'll keep a close eye on his levels.

We bought a Reli-On micro and free-poked for the sample tonight.
 
with the diet change PLEASE be very careful with that 2 units dose....I hope you've checked in with the Lantus ISG (insulin support group) on this board with your dosing.
 
Try to get some mid cycle /nadir checks to see how Johnny is responding. Remember that Lantus is dosed based on nadir numbers not the preshot numbers. Also - remember, it takes a few days to build up "the shed" of insulin. So you may not see much change to first few days and then start to see dramatic results.
 
This a.m. (8:45 CT) before dosing, his BG was 311. Twelve hours later, before we did another shot, we tested his BG before his big meal (he had been eating high protein/low carb hard food throughout the day). We did two readings b/c it seemed so low. First reading was 93. Second was 107. We were both terrified and grateful we bought a meter. You guys suggested it, NOT our vet. THANK YOU. We would have just given it...and I hate to think what that could've done. THANKYOU THANKYOU THANKYOU!!We called the ER vet clinic, they confirmed that we should not give him his shot. Said to call the vet in the a.m. and that they might want to change the dosage. And to keep an eye on him tonight. I'm nervous about *sleeping* now! I'm glad he has a good level, but he's only had two shots. God help the vet if she was negligent. We felt more supported by you all than the vet. And it's a top-rated Chicago animal hospital.

I'm not a typical drama queen, but we are MOVING tomorrow a.m. Movers are showing up at 8. We planned the shot to be 1/2 hour before they arrived. Now, I have no idea what the test will say. I guess even if it's higher, I'm going to wait to talk to the vet. He survived for a while with higher levels (unbeknownst to us), so it's better high than low right? I'm super nervous about a lot. I know that he's the #1 priority and will remain so. But we are expected to move out and in somewhere else tomorrow. Johnny will actually love our new place lots more, but that's a post for later. We ranked apartments by a few things, but KQOL (kitty quality of life) was key...we're good kitty parents. :)

Just wondering what you all think. I think 2 units must have been too high. We had a second opinion, but based on the initial reading of 491, they both said 2.
 
I have a couple of quick thoughts...

1 dose is not based on initial bg

2 initial dose is typically 1 unit twice a day

3 that he was so low 12 hours post shot is encouraging and alarming. I would definitely drop the dose. Complicating things though is the likely stress from your move.

My suggestion is to drop to 1 unit bid and stay there for a week or longer unless you need to drop it more...you need things to settle down. Further advice than that re dosing you should get from lantus regulars

Good luck!

Jen
 
We just tested him again just now and he was 285. We'll be calling the vet in the a.m. I'm not convinced about giving him another shot, esp not 2 units. We'll see what tomorrow a.m.'s # is.
 
Hi and welcome to FDMB :mrgreen:

Just throwing my 2 cents worth in.

Kudos to you for being so open to the advice you've had here and getting stcuk right in with hometesting. Can be a real leap of faith listening to cycber beans (what humans are fondly referred to here on the board-you'll get used to the jargon :mrgreen: )

I actually think it is excellent that you switched food before starting insulin-makes it much easier on dosing.
As Cindy et al have said-would definitely recommend next shot is no more than 1u (even if that means going against your vet-I mean, how they going to know?)

Lantus is an insulin that builds what we call a shed. Like a petrol tank it stores the insulin it doesn't use-this is why you had your sudden drop-not unusual even on an intial 1u dose. What then happens (usually) is numbers creep up again. However, to find ideal dose from the 1u, we increase in increments of .25u. Yes a slower path but a far safer one. The sugar dance is a marathon, not a sprint.

You will then be looking for your breakthrough dose. So you could increase a little or need to go right up to 4 or 5 u over time. Then suddenly you start seeing blue and green numbers (that's if you use the spreadsheet-you'll see if you look at setting up your ss in tech forum) and you start reducing by .25u each time. This can best be achieved by monitoring. Then you either get to an on-going stable amount (often around the 1-2u mark) or get a shot at remission (lot of work and dedication from bean required due to the low numbers kitty surfing at). Kitty then is diet controlled.

Lantus has shown excellent results if used within 6 months of diagnosis.
Appreciate your moving (have my sympathies!) but once that's clear, if you can set up ss, come and post in LL (Lantus forum) and lots of hands will guide and support you.

Your right as well, would not be surprised if kitty's bg is high through stress of move. Lucky's always shot up when we had to travel (think she thought she was going to the vet!).Don't let this influence what dose you give. Bg's will settle again. It's like fight or flight-glucose there ready to respond as required.

Your doing great. :mrgreen:
ps-for now, just post what numbers you have e.g
amps 3000
+2 280
+4 etc am is morning preshot, pmps is evening preshot. Preshot tests need to be where kitty not had food in about 2 hours.
 
Welcome! I'm just seeing your thread for the first time, and it seems like you're off to a great start. I'd just like to add my 2 cents about dose. I think you've seen that 2 units was too high a starting dose. We like to start lower than that, for safety sake, then work up methodically.

Here is a link to the latest/greatest dosing protocol for Lantus: http://www.tillydiabetes.net/en_6_protocol2.htm This protocol has been used on the German feline diabetes forum for years, and we are using it with some slight modifications in the Lantus forum here. The protocol has recently been published by Dr. Rand, who is the big name in Lantus at the University of Queensland. Note especially the section on Starting Dose.

Phase 1: Starting dose
In many cases, the starting dose of Lantus or Levemir has been 0.25 IU per kg of the cat's ideal weight and is always dosed BID (two times a day, 12 hours apart). If the cat received another kind of insulin previously, the starting dose should be raised or lowered by taking this information into account. When selecting a starting dose, it is important to know that while Lantus and Levemir have a longer duration than other insulins, they also have a lower potency in most cats.

0.25 IU per kg of the cat's ideal weight usually works out in the neighborhood of 1 unit for most cats. Some vets seem to misinterpret that as 0.25 IU per kg of the cat's current weight, and that leads to too high a starting dose. I believe that is due to the fact that the previous Rand protocol set a starting dose of 0.5 IU per kg. However, that protocol was designed for cats who are being monitored in a clinic and is generally not safe for home use.

Congrats on the great start, it looks like you guys are going to do very well on Lantus. :smile:
 
I'm back online tonight (snafu with transferring service after Saturday's move). I have the template and want to create my spreadsheet, but I have questions. Is there an FAQ? I'm sorry if it's obvious, I really did try to look around! :) I'm wondering what "AMPS" means and "U"...
 
Hi,

amps= morning pre shot
pmps=evening preshot.
U=units

Here is the frequently asked questions:
http://binkyspage.tripod.com/faq.html

It is in a sticky at the top of this forum.
There is another jargon list that gets posted intermittently (I think by Melissa and Popcorn?) If you scroll down through old posts in this forum you should come across it.

Good luck :mrgreen:
 
starfishj said:
I'm back online tonight (snafu with transferring service after Saturday's move). I have the template and want to create my spreadsheet, but I have questions. Is there an FAQ? I'm sorry if it's obvious, I really did try to look around! :) I'm wondering what "AMPS" means and "U"...
Click to expand...

"U" is used in two different ways:

u = 'units' as in the dose given, like 1u bid = 1 unit twice per day (from the Latin 'bis in die').

U = as in U-100 insulin, meaning 100 units of insulin per ml of liquid.

You will also see this on the syringes...it will say 'for U-100 Insulin' or 'for U-40 insulin".

Some veterinary insulins are U-40, 40 units of insulin per ml of liquid (more dilute than U-100).

Lantus, Levimir, Humulin and all human insulins are U-100.

PZI Vet, Vetsulin are U-40. I presume the new Pro Ziinc is also U-40, but I don't know for sure.

You should always use U-100 syringes with U-100 insulin.

You MAY use either U-40 or U-100 syringes with U-40 insulin. BUT...if you use U-100
syringes with U-40 insulin, you must use a conversion chart to draw the correct dose.
 
Ahhh! Thanks for the answers. I plugged Johnny's numbers in and the SS link is in my signature now. It doesn't look like a foreign language anymore! Since tonight is one week from the first shot, I sent a copy to the vet and left her a voicemail asking her to look at it today.

You'll notice we haven't been giving him any insulin when his number is below 200. We just weren't sure how much the insulin might lower it and figured "better safe than sorry." I'd love any feedback here. I know others have already advised us to go down to 1 unit instead of 2 for Johnny. I'm just not comfortable adjusting the dose myself yet (only been injecting/tracking one week), but if the vet doesn't have a good reason to stay at 2 all the time, I will certainly consider it. I'm just SO scared of his BG level becoming too low as a result.

Does the info on my chart provide any sort of a picture about how he's reacting? I think it's positive, as he is coming down quite a bit, but I'm wondering about the curve I've seen others talking about. Is that only something that can be ascertained by testing throughout one day...or are there different kinds?

Note: Johnny eats mostly canned (low carb/high protein) food, but has access to low carb/high protein dry food at all times. He seems pretty satisfied with the canned though, so I don't think he's eating tons of the dry.
 
Jen & Squeak said:
Great start! But you really need to know what is going on between shots....
Click to expand...

Thanks, Jen. I just went over to Lantus Land and am reading the stickies. There's a really good one about the importance of collecting other numbers. I'm so disappointed in our vet, but so glad to have found this place. I'll read up on this tonight. Thanks for the good feedback!
 
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