Читать книгу Living with Juvenile Arthritis - Kimberly Poston Miller - Страница 9
ОглавлениеPieces of the Puzzle
Anyone who has worked on a puzzle knows the satisfying feeling you get when those last few pieces fall into place. Until then, the image is often unrecognizable. Individually, the pieces may look generic and meaningless, but each one is necessary to form the complete picture. Diagnosing juvenile arthritis is a lot like that process.
If your child has been diagnosed with any form of juvenile arthritis (JA), you know it isn’t always a straightforward process. JA is often difficult to diagnose and can take weeks, months, or even years to determine definitively. Unlike many other medical conditions, there is no single test and no series of lab tests that will prove or disprove the presence of juvenile arthritis. In addition, JA is a sneaky opponent—sometimes it will show itself, and sometimes it won’t. To complicate matters further, there are many different forms of JA, all with diverse manifestations. Symptoms can be obvious or subtle, reactive or always present. JA has no steadfast rules, no absolute checklists, and no giant arrow that points to your child and says, “This kid has arthritis!” Every child is unique and, therefore, so is the path from onset to diagnosis and treatment.
To determine if a child has any form of JA, his or her healthcare provider must rely on information provided from a number of resources. Lab tests can be useful—blood work can prove the existence of some issues, but often a rheumatologic condition can be present without abnormal labs. Genetic testing is also helpful, but it does not determine the presence or the absence of a condition. It merely indicates the increased or decreased likelihood that a child may develop the illness. Familial history, parental input, and observation of the child all play a role in determining whether or not a child is suffering from juvenile arthritis. Discovery usually comes from repeated physical exams, a thorough medical history, and evaluation by a pediatric rheumatologist. All the pieces of the puzzle must be collected and then assembled by a healthcare practitioner before a definitive diagnosis can be made. For some, this can happen in a matter of days. For others, like our family, it can take months or even years.
COMMON SYMPTOMS OF JA
Children with juvenile arthritis may exhibit a variety of symptoms with various degrees of severity, which can make diagnosis difficult. Though not every child will experience these warning signs, the most common symptoms of JA include:
• swollen, tender and/or warm joints
• stiffness, especially in the morning or after periods of rest
• fevers
• rashes
• fatigue
• inflammation of the eye(s)
• slow or decreased growth
• joint contractures (shortening of a muscle that causes decreased joint movement or range of motion)
• pain
Grant’s Diagnosis—A Tale of Ten Years
Clues from a Toddler
To say things were crazy would be an understatement. In the fall of 2000, when my son Grant was turning two, our family was coping with several major changes, including the birth of our second child, a cross-country move, and a new employer for my husband, Fred, who had just joined the Tennessee Titans. We were renting and looking for a “permanent” home, becoming acquainted with an unfamiliar area, making new friends, and, of course, adjusting to the latest addition to our family. It seemed as though we were always on the go and enjoying very little downtime. Changing teams also meant a heavier media schedule with lots of extra appearances for both Fred on his own and us as a couple. There was never a dull moment.
Grant had always been a “go-with-the-flow” kind of baby. As an NFL kid, he was accustomed to crazy schedules and a good deal of travel, along with strange people and places. However, the most recent changes really threw him for a loop. At least, that’s what I thought it was at the time.
My sweet, bubbly baby boy was growing up. Barely out of diapers, he had a mind of his own and would tell me exactly what was on it. A few days after coming home from the hospital with his brother, he informed me that I was Evan’s mommy now, and he “had no more mommy.” He also missed his Dad, who was around more frequently during the off-season. NFL players often work 80 plus hours a week during the football season, and Grant was just too young to understand why his father was home so much, and then just wasn’t. Fred being on a new team took time from me as well, as the new guy and his wife are usually desirable guests on the charity and fund-raising circuits as ambassadors for the team. Even though I was still a stay-at-home mom, a new baby and added commitments were dividing my attention—things had drastically changed for my little guy.
So, I was not entirely surprised when Grant started to become crabby and acting out more often. Our pediatrician was new to us since the relocation, and his response to Grant’s huge shift in attitude was “welcome to the terrible twos” and a suggestion that we give him time to adjust. Considering all the big changes we had just made, coupled with the onset of the toddler era, I thought the doc was probably right, and things would get back to normal. I was confident that his irritability would work itself out with time, love, and patience. But, it didn’t.
It felt as though I brought someone else’s child with us when we moved from St. Louis. Previously an excellent traveler, Grant would no longer tolerate his car seat, often arching his back or sobbing the entire time he was strapped in. I would grit my teeth and bear it, thinking it was just a stage. Besides, I had to do what was right and keep him safe. But it wasn’t just the car seat. I began to notice other things. He would squirm and complain about his high chair, and riding in the double stroller was a no-go. He would lie down to watch television. In fact, he would rather lie down than sit—anytime, anywhere. That’s when the first warning bell went off in my mind.
As I began to watch him closer, I noticed that sometimes he would hobble like a little old man, with his hand on his lower back, slightly stooped over. And yet at other times, he walked and played just like he always had. Although I tried to talk to him about this behavior, it’s difficult for a toddler to accurately explain what he or she is experiencing. Most of the time, Grant would simply say his back hurt or he had “owies,” but then act completely fine. While my concern blossomed, the pain didn’t seem consistent enough to be “real,” except when he was doing something he didn’t want to do (like being confined in the stroller, car seat, or high chair). I vacillated among thinking it was a ploy for more attention, typical terrible-twos behavior, or something that was seriously wrong. It was time to approach the pediatrician again.
This time, the doctor didn’t attribute Grant’s behavioral changes to the terrible twos. He suggested that in his very normal attempts to shift attention off his baby brother and back onto himself, he might simply be imitating his father’s behavior. Well, kind of. While my husband obviously didn’t cry every time he put on his seat belt, he did lie down on the couch to watch TV, exhausted at the end of the day from the physicality of his work. Every Monday (or Tuesday if there was a Monday night game) he would hobble around the house, battered and bruised from the game he had played the day before, often limping or holding his lower back.
Other possible explanations for Grant’s strange gait and discomfort included growing pains and soreness from playing or roughhousing, especially after playdates with other rowdy teammates’ kids. Intellectually, I wanted to believe these innocent explanations. It made sense—toddlers do imitate their parents. He did play hard. He was growing. And, since Evan was only a few months old, he did take up much of my time. Grant had been through a lot of big changes, and it would be normal for him to try to get my attention any way he could. It was all very logical but, in my heart, I think I knew it was more.
How Could This Happen?
When the off-season rolled around and Fred wasn’t doing the “grandpa shuffle” around the house every week, Grant’s behavior didn’t change. My husband and I were in the middle of launching a new foundation in Middle Tennessee to help at-risk mothers and newborns when I offhandedly mentioned Grant’s behavior to a colleague. She was a pediatrician who had agreed to become our pro bono medical director. Her response shocked me. While she remained calm and quiet, her demeanor indicated this was serious. She felt our son should be evaluated at Vanderbilt Children’s Hospital very soon, because the type of changes and symptoms I described were not acceptable or common for a two year old, even under the circumstances.
The next few weeks were a blur. I was numb, terrified that I could have overlooked something that could potentially affect my child’s ability to survive. I hated myself when they told me he needed an MRI of his spine to rule out a tumor and blood work to make sure it wasn’t cancer. How could this happen? How did I allow it? How long did I let it go while it was taking hold of my baby?
As they say, hindsight is 20/20. At the time, I thought I did all the right things. I took him to the doctor and justified the explanations. They were all very plausible. No one wants to believe their child is “the one.” When you have a healthy baby, with no other problems, you never think the bad stuff you read about can happen to you, but it can.
As I was battling my guilt over not knowing sooner, and not taking action when I heard that first nagging voice in the back of my head, we got some good news. The lab tests ruled out cancer, and the MRI showed no abnormal mass or tumor. They did notice a few abnormalities in Grant’s spine, but recommended we see an orthopedist, who then referred us to a rheumatologist. We learned that some of Grant’s vertebrae were compressed, and his muscles were thickened and shortened on either side of his spine. The labs they did for rheumatologic conditions were normal, but his MRI findings, physical exam, and symptoms still worried the rheumatologist.
We were referred to a physical therapist, and Grant was started on a regimen of nonsteroidal anti-inflammatory drugs (NSAIDs). We held this course for almost a year. When all of his symptoms vanished, the rheumatologist told us to keep an eye on him, and if his symptoms came back we should be seen again. She didn’t feel he had a true case of autoimmune disease; so monitoring him at home was the best option. There was a good chance that, with his normal lab work and “new” alignment, all the original problems were mechanical in nature and may not ever bother him again. We were released from the practice, happy and confident that Grant’s issues were behind us.
Out of Sight, Out of Mind
We had almost seven years of smooth sailing. Well, seven years on the rheumatology front, that is. We had many years of normal childhood with all the regular ups and downs one would expect. Grant was thriving. He was doing well in school, playing team sports, and generally happy. At nine, he was a fairly big kid for his age, which came as no surprise with an offensive lineman for a dad! In general, things had been going very well. We hadn’t given a second thought to his possible diagnosis, but then slowly things began to change.
In the fourth grade, Grant started to complain of ankle pain. He was shooting up like a weed, so we assumed it was just growing pains. However, the stiffness and pain were getting worse, affecting his ability to walk to school in the mornings, especially if he had played sports the day before. Since Grant was never really a complainer, I took his concerns seriously, but didn’t want to overreact. I addressed the issue with his new pediatrician (we had since moved to the Chicago area) and took the steps they suggested to alleviate his pain.
By the time he started fifth grade, his ankles weren’t any better despite visits to the doctor, podiatrist, and orthopedist. The general consensus was that the problem was mechanical in nature, but I had my doubts. Custom orthotics weren’t making a difference, and he was starting to have back pain as well. I also noticed that Grant wasn’t doing as well in school, and the boys he previously towered over were catching up or overtaking him in height. Since he was prepubescent, I didn’t think too much about the sluggish growth at the time. He was so close to puberty, and slow growth before the big spurt is pretty common. Besides, everyone matures at a different rate in the tween years. Yet, given his history and the fact that other treatments were not making positive changes, our pediatrician agreed it was time to see a rheumatologist again, just in case.
Seeing a pediatric rheumatologist is not easy. We were stunned to find that the wait to be seen, even with a referral, can be months due to a shortage of practitioners in the field. Grant did get lucky and was able to see a pediatric rheumatologist on a cancellation, about two months after our initial inquiry, just as he was starting the sixth grade. We secured the earlier visit with the help of our pediatrician, who was insistent on his being seen. In many practices, the wait for a new patient can often be in excess of six to nine months!
Living in Chicago, we were lucky to have an excellent team of rheumatologists in our own backyard. Grant had more testing done, and his rheumatology labs were still in the normal ranges. Because he was an athlete playing multiple sports, we couldn’t rule out mechanical issues, stress injuries, or just plain growing pains. However, given his history, rheumatology did want to follow him and help us manage the pain. Grant started on another course of NSAIDs, physical therapy, and rest from sports.
Arthritis is a disabling and painful disease that affects 50 million Americans, including 300,000 children. Nearly 1 in 250 children are living with a form of arthritis. Currently, there are less than 250 board-certified practicing pediatric rheumatologists in the United States and about 90 percent of those are clustered in and around large cities. As illustrated on the map, there are currently 11 states (dotted) that do not have a single board-certified practicing pediatric rheumatologist, 19 states (lines) with three or less, and the remaining states have 4 or more. Source information from the Arthritis Foundation.
From Bad to Worse
Despite our combined efforts to alleviate his suffering with the mildest drugs and therapy, things just continued to get worse. As the weather got colder, the pain escalated. His back hurt so badly that he would wake up in the middle of the night in excruciating pain, unable to get out of bed unassisted. Since my husband was a pro athlete, frequently dealing with chronic pain/injuries, we had the ability to give alternating hot tub/ice bath soaks in our own home. It was helpful, but definitely no fun. By the time the holidays rolled around, Grant was rarely sleeping more than an hour or two at a time, and he was begging for ice baths in the middle of the night, just to take the edge off the pain. I knew this was more than mechanics or sports. Seeing your child in that much pain regularly is almost beyond the scope of what any parent can take. We needed to find out what was going on and fast.
As Grant worked his way up to unbearable pain levels, rheumatology had changed his medications several times, in the hopes that a different drug would be more effective. Most of these medications take a few days or weeks to kick in, so we would hold our breath, watch, wait, and hope for any relief. It didn’t come. After a round of the flu made its way through our house, things seemed to accelerate in the wrong direction. Even though the virus was gone, Grant never felt that much better. He was in even worse pain than before, his back would stay red and hot, and he was running low-grade fevers of “nonspecific origin.”
I was advised to take him to the emergency room (ER) at the children’s hospital when I thought he was at the height of his pain, in the hopes that labs taken during an episode would give the doctors better insight into the root of his condition. The ER doctors observed all the same things I did at home—swollen and red ankles, extreme sensitivity and excess warmth near his spine, but no abnormal lab results. He was a mystery.
To tell you the truth, at this point I didn’t even care about a diagnosis. The only thing that mattered was finding a way to relieve Grant’s pain. Watching your child suffer, with no end in sight and no treatments that seem to work, is something I wouldn’t wish on my worst enemy. The days dragged on like years. We were sleep deprived and emotionally spent, completely wrapped up in Grant; finding him relief and finding a way for him to get better. I think these may have been our darkest days.
The Problem Revealed
At this point, the possibility of juvenile arthritis, specifically spondyloarthropathy and juvenile idiopathic arthritis (JIA), was mentioned, but my focus was less on a diagnosis than getting the pain under control. I wanted some semblance of a normal, comfortable life back for our son. We tried stronger drugs with more side effects and risks then waited for them to take effect. As mentioned, many arthritis drugs take days or weeks to work at their optimal levels, which means treatment can be frustratingly slow. I was grateful, at least, that we were dealing with all this during winter break, so that missing school and the stress of catching up were not issues.
Miraculously, we found a drug that worked. Slowly but surely, Grant felt a little better with each passing day. By the time six weeks had passed (the amount of time we were told it would take for the drug to be full strength in his system), his pain had almost vanished. We were thrilled. And, for the first time, his rheumatologist believed we were in fact dealing with a form of juvenile arthritis or childhood autoimmune disease. Although his labs had always been normal, his symptoms and the length of time he endured them, along with his response to treatment, all pointed in that direction. We had also ruled out all the common reasons for his problem.
At long last, ten years after the initial onset of symptoms, we had a diagnosis. It was a relief to finally know what was wrong, but we soon learned that having a diagnosis is only the beginning. We had one answer, but a lot more questions.
My Kid Has JA, Now What?
The Big Umbrella
If you’re anything like me, you probably knew very little about arthritis in children before the JA diagnosis. That’s an old person’s problem, right? When most people hear the term arthritis, they think of osteoarthritis; the kind your grandparents have; the kind you get after you’ve lived a long life and worn down your joints. The fact is arthritis in children is often misunderstood as a “pain only” syndrome—something they should be able to get over or grow out of.
However, juvenile arthritis is far bigger. It’s actually an umbrella term used to describe the many autoimmune and inflammatory conditions that can develop in children age 16 or younger. The definition of arthritis is joint (arthro) inflammation (itis), but JA can be much, much more. It can involve the eyes, skin, and gastrointestinal tract. It can be systemic, involving the internal organs, or localized in one or several joints. There are also many types of JA, including juvenile dermatomyositis, scleroderma, lupus, and juvenile spondyloarthropathies. The most common form of JA is juvenile idiopathic arthritis (JIA), historically referred to as juvenile rheumatoid arthritis (JRA). According to the Arthritis Foundation, JIA is defined as swelling in at least one or more joints, lasting at least six weeks. That’s why for most it takes at least six weeks to diagnose! JIA is further broken down into six categories: oligoarthritis, polyarthritis, systemic, enthesitis-related, psoriatic, and “other,” which includes children who exhibit features from two or more types or have symptoms in excess of six weeks that do not meet the criteria of any other form.
So what does all that mean? It means that JA is an umbrella term that covers a multitude of afflictions. It also means that your child’s JA diagnosis and treatment plan are probably going to look a lot different than my child’s. There are so many different types of juvenile arthritis with diverse symptoms and manifestations that very rarely will two cases look alike. This is probably one of the most important things I can tell you if your child has been newly diagnosed: Do not let yourself get wrapped up in someone else’s case, thinking that’s what will happen in your family!
We live in the information age, which can be both a blessing and a curse. One of the first things many of us do is perform a Google search to find out all the facts. If you search for juvenile arthritis, you will find some pretty dramatic stories. For every one of these, there are just as many cases that aren’t as serious. The things you read about JA and the other children you meet may or may not have things in common with your child.
No Two Cases Are the Same
It could be better, it could be worse, or it could cycle somewhere between the two. The more friends you make in the rheumatology clinic waiting room or the JA community, the more you will find pieces of their experiences that mirror yours. This can provide you with valuable information and support, but it’s just another piece of the puzzle. Over time, you will become the expert in your child’s symptoms, reactions, and responses. Gaining this knowledge, learning as much as you can, and conveying it to your child’s healthcare team is what will make the difference in his or her treatment, regardless of the type of JA that has been diagnosed.
Déjà Vu—Well, Not Really
A perfect illustration of how different two cases can be is the story of my two sons. Genetically, they are pretty similar. They have the same parents, they are both boys, and they were born less than two years apart, so many of their experiences and environmental exposures were the same. Just as two children raised similarly in the same family can have completely opposite personalities, the way JA has “shown” itself to each of my boys could not be more different.
Grant’s diagnosis took more than ten years to nail down. Even after that determination and treatment, things spiraled out of control and got so much worse. He had a severe allergic reaction to one of the medications (ironically, the only one that was working on his rheumatologic issues) that nearly cost him his life. He developed DRESS syndrome (a type of severe drug reaction), non-viral hepatitis, eosinophilia, and a whole host of other serious issues. He spent time as an inpatient in the hospital and subsequently missed nearly four months of school. In this weakened state, JA took an even greater hold on him, and it felt as though we would never get him back to “normal.”
Calculating the Odds
Over the next two years, as I watched him struggle to get back to the life he used to have, I had a new respect for what JA could do and the kind of opponent with which we were dealing. I was also very worried it could happen to my younger son, as well. Even though it is fairly uncommon for siblings to develop JIA (Grant’s diagnosis), it was still a concern. Every little ache or pain Evan mentioned seemed like a red flag, and every time he walked off the playing field looking stiff or sore, I wondered if I was overlooking something, just like I had with Grant. I never knew if I was worrying too much, or just making sure I didn’t make the same mistakes twice.
Many studies have been done on the subject, and the generally accepted consensus, as reported by the Arthritis Foundation, is that 1 out of every 1,000 children under the age of 16 has JIA. In families where one child has already been diagnosed, the risk of siblings developing JIA could be up to 12 times higher than in the general population and up to six times higher for first cousins. Dr. Sampath Prahalad, a medical doctor and associate professor of Pediatrics and Human Genetics at Emory University, conducted one of these studies and states, “With a population prevalence of JIA at one in 1,000, a 12-time greater risk may sound like a lot but it’s only equal to 1.2 percent.” That would mean that even a full sibling of a JIA child has a 98.8 percent chance of not developing the disease. Knowing these statistics made me feel that watching Evan so closely for signs of JIA was akin to waiting for lightning to strike him while he held a metal bat at baseball practice … it could happen, but probably not.
Grant required so much of my attention and energy at the time that I felt worry was a wasted emotion. Worrying wouldn’t fix anything, it wouldn’t guarantee that Evan didn’t have JA, or get him diagnosed faster if he did. The best I could do was to keep an eye on him, let the doctors observe him more frequently, and have him treated if unexplained symptoms popped up.
When Evan was 11½, just about the same age as Grant when he was diagnosed, I started to notice that he was complaining more about joint pain. Truthfully, learning those odds, being armed with the doctors’ assurances, and knowing that his pediatrician was monitoring him made me think there was probably nothing to worry about. His lab work had been fine, his physical exams unremarkable, and his personality, well, that was a factor, too.
Like Night and Day
I love both my children dearly. I often joke that in my life, if Grant is the sugar, Evan is the spice. He is witty, humorous, and definitely a fun guy to be around. Part of what makes him so entertaining is his ability to put himself 110 percent into whatever he is doing or feeling, and along with those characteristics comes a flair for the dramatic. Even as a baby, Evan was the loudest belly-laugher and the biggest wailer—a stubbed toe was nearly equivalent to the end of the world. Most of the time I would get a pretty accurate picture if I took what Evan described and then reduced it by half. That’s just Evan. So, you can see why I might take some of his aches and pains with a grain of salt.
The same way I convinced myself that the two-year-old Grant was jealous over his new brother, I convinced myself that Evan just needed some special attention after all my energies had been focused on Grant. He had been seeing the doctor regularly, so I felt all my bases were covered.
Then one night, while I was giving Grant one of his regular injections, Evan came into the room, angry, complaining that he hurt, too. He told me, “Grant isn’t the only one dealing with pain every day.” He was upset and said he knew I didn’t care. He had visited the doctor a few days before with his mystery pains, but we had found nothing. Evan and I had talks from time to time about the difference between JIA pains and everyday annoyances caused by overexertion on the playground or the ball field. While I finished up with Grant, I was getting ready to have “the talk” with Evan again. But, as he turned to walk out of the room, I saw it: Both of his elbows were red and swollen.
I asked him to hold on and tell me more about the pain. Since he was in between sports, did he do something out of the ordinary in gym class? Was something new hurting him? He told me his shoulder and elbows were the problem this time, and that I never wanted to listen. He hadn’t “done” anything, but everything still hurt. I felt his elbows and got that sinking feeling in the pit of my stomach. They were swollen with fluid and had that familiar warm feeling of a JA afflicted joint.
It took three visits before Evan’s elbows were red and swollen at the same time he was at the doctor. Remember how I said JA is sneaky? Sometimes it shows itself and sometimes it doesn’t? Well, in this instance, we outsmarted JA. I took pictures of his joints when they were at their worst and kept track of the cycles for the doctors. By April 2012, just a few months after he experienced his first symptoms, Evan was diagnosed with JIA.
At first, I was just sick. I thought I knew what we were in for. We had just been on a wild and crazy ride with Grant’s problems, and I was bracing myself for the worst. I had no idea how I would handle two children with JIA. Emotionally, how could I bear watching both of them go through it? I felt sorry for myself for a little while, and even sorrier for my sons. Then do you know what I did? I picked myself up and moved on. Worry didn’t make a difference before, and I knew it wouldn’t make a difference the second time around. But a funny thing happened as I prepared for the worst—nothing ever really happened. Evan’s case could not have been more different than Grant’s.
Research indicates that with siblings who have JIA, the onset is usually around the same age and of the same subtype. Well, that certainly held true for us: The ages and subtypes were spot-on, but the symptoms and severity were far different. Grant had chronic inflammation and pain, needing a number of daily medications just to control his symptoms. With Evan, every couple of months we might see some swelling, redness, warmth, or increased pain in a joint, at which time we administer medication. In his case, only mild doses of NSAIDs are necessary to head off a flare and then can be discontinued in a few days. Unlike Grant, we also found Evan to be neutropenic (more susceptible to infections), but although it takes him longer to get over a cold or other virus, it doesn’t really change his everyday life. JA has not affected his school work, his sleep, or his ability to participate in activities. In fact, other than it just being “out there” for us to think about and treat briefly every now and again, the JA is almost a non-factor in Evan’s life. Almost, because we still have a healthy respect for what it can do and we know the enemy is close. Still, it’s hard to believe it’s even the same disease!
Developing Your Own Strategies
The sooner you understand how unique your child’s case of JA is, the better you will be able to focus on his or her specific issues and facilitate the best possible care and treatments. I want you to skip over the stage where you try to have everything make sense in someone else’s frame of reference. I don’t want you to buy into the “cousin so-and so’s kid had a friend who had JA and they did xyz so that’s what little Johnny needs, too,” or the “I knew someone at work whose kid nearly died from that disease,” or the well-meaning neighbor who says “little Jane a few blocks over is supposed to have that, but it’s not real in kids, she just fakes it.” Don’t let yourself go there because none of these scenarios will be completely accurate. JA simply doesn’t work that way.
Let me use a sports analogy. In 1972, Don Shula led the Miami Dolphins to the only perfect season in football history. In 2007, the Miami Dolphins only won one game. What happened? It was still the Dolphins. They still had players and coaches. It was still football. The reason why the 2007 team didn’t have a perfect season is because they had different players, different coaches, different weather conditions, and different opponents. JA is like the Miami Dolphins. It morphs with the players and the circumstances.
Expecting the same thing from JA for every kid is like expecting the Miami Dolphins to have a perfect season (or not-so-perfect season) every year. The 2008 Dolphins improved their season to 11-5 by making adjustments and knowing what they were up against. Every child is a whole other ball game, and when they are diagnosed, it starts a whole new season with a unique set of challenges. I’m here to help you develop your own strategies to make it the best season possible.
