Nervous...scared...anxious...

-
enigma57 said:
Doug, FWIW...... I understand exactly what you mean. Have been dealing with much the same for over 20 years now. Have not walked the same path as yourself the entire time, but took a different fork in the road some while back and have walked a parallel path since.

Two things we soon learned when I was a young grunt......
1. Do the best you can with what you have.
** I believe you are doing that and are making the best decisions you can, given your circumstances.
2. Learn to live in the moment, for life can be short and this moment may be all you have.
** I believe anyone who must live with constant pain understands living life moment by moment, hour by hour, one day at a time and you are no exception.

You will be fine. Just keep on keepin' on. Put your trust in G-d, your shoulder to the wheel and never say "Never".

In the words of Hans-Ulrich Rudel...... "Only he who gives up on himself is lost." Remember that always.

Best regards,

Harry
Click to expand...
Morning Harry
Both of your statements could not be more true. Some of us were dealt very miserable hands at birth, but you must play the hand you were dealt. Sitting back and complaining how others are more fortunate than you will get you absolutely no place.
"Learn to live in the moment". I used to work with a guy that had severe back problems. He was wheeled out of work at least once a month in a wheelchair. Rod was a private guy, did not share much with anyone...unless they had something, pain, in common. I spent many hours talking with Rod about suicide, I was honest with him about my attempt. He found it interesting that right at the very moment I squeezed the trigger of that revolver that I was at the most calmest moment in my life. Oddly enough that still applies. More than once, while we were alone in his work area he confessed to me to sitting on the edge of the bed, gun in hand. His wife, who was my boss for quite a while...well...was a very uncaring person. Rod was in severe pain, physically. As I am sure you are well aware of this pain did a number on him mentally as well. Rod, in looking for someone to care about his well being ended up cheating on Susan with multiple women. Confessed the whole thing to Susan. I can remember when Rod told me about confessing to her he said she did not even respond to him. Never did. Rod ended up being forced out of the USPS, just as my wife was...thanks to the now defunct "National Reassessment Program". Over the next couple of years every now & then I would get emails from Rod. Tried calling him several times, he never answered nor did he return my calls.
Fast forward a couple of years and I got a call from a mutual friend, Brian. Brian wanted to make sure that I knew Rod had passed, suicide. Brian was semi-friendly, if you want to call it that, with Susan. Found out that Rod had simply had enough of the pain. Rod was well beyond prescriptions. He confessed to me about grinding up his extended release Oxy and snorting it. For years he was buying cocaine from a fellow USPS employee. Rod had confessed to me that he had done ****** several times, just to escape the pain. Brian told me that Rod had went to the pharmacy and picked up his monthly "fix" of the 4 different pain meds he was on. Also picked up a bottle of whiskey. He went home, swallowed all of the pills and started chugging until he could not. Dead at 51 thanks the pain...

As to me....my clinical trial is technically over. Had my last call last night. Rebecca had me change the settings several times, some worked great, others did not. Last night she had me change the batteries and switch the device to the settings that worked the best for me. Tomorrow I go and turn the device back in, get paid the $1000 for participating in the clinical trial and have the leads removed. Then it is back to suffering. On the 10th I go for my pre-op visit. On the 24th I am scheduled for the permanent device to be implanted. Go back in 2 weeks to get it programmed and powered up. The device is implanted without a charge. Charging it generates heat so I have to wait until the incisions are healed prior to charging it.

Went to Costco the other day with my wife. For as long as I can remember I have leaned on the handle of the Costco cart, it is the perfect height to relieve some of my pain. The other day it was the exact opposite, it made me hurt some. I have noticed that on days where I walk a lot my hips hurt quite a bit. Last week I was at the PT place that saw me in the past, my wife was there for her PT. Joel, my therapist seen me sitting there and sat down, asking about the device. I told him about my hips. He went and found my chart. Asked me to walk. He said that my "weird gait" was no longer present..and that I was standing straight, without the slight forward and to the side lean that I used to have. He told me that the pain is from me now having a more normal gait. I told him I have every intention of coming to see him when I am all healed up. I want him to figure out what type of stretching I will be able to safely do. I am really looking forward to resuming some semblance of normalcy. Being able to train my 5 dogs, going for walks with my camera. I am not really looking forward to the next 5-6 weeks but what happens after will hopefully make it worthwhile.

This is an older video but pretty much explains how it is done.
 
Doug, I am glad to hear that the pain management unit was helpful to you. Wish you all the best with it following the permanent implant.

Yes, you are correct...... Life is like a card game in many respects. The important thing to remember is that regardless the hand you are dealt...... What determines the outcome (in life) is not necessarily the hand you are dealt...... Its how you play the hand you are dealt.

I have seen people who were dealt very good hands in life play them poorly....... Throw it all away. And conversely...... I have seen people who have been dealt what most would consider a bad hand...... Play them very well and have a better life than those who were dealt better hands..... But played them poorly.

Sad to learn of your friend's passing, Doug. Especially by his own hand. Myself and other vets who were dealing with PTSD and those same thoughts 30 years ago started a peer group following our unsuccessful attempts to find help from the VA. Quite honestly, I came away from that experience (the VA) frustrated...... The question in my mind being, 'Which was really our most formidable adversary...... Victor Charlie or Victor Alpha?'

I have not been around here posting on the Off Topic forum very long and did not know of your experience with attempted suicide. That being the case, I will share the following, which I sincerely hope will either help or at the very least, give you pause should you ever consider giving in to those impulses......

I learned a few things from my experience with our veterans peer group.

* If you are to survive...... You must have your head screwed on straight. And you weren't going to be able to think clearly nor make rational decisions if self-medicating (drinking & drugs). Anything that is mind altering messes with your brain chemistry and affects your thinking, your judgement and your resolve to one degree or another. Including your resolve to survive. That is why I said in my priour post......

In the words of Hans-Ulrich Rudel...... "Only he who gives up on himself is lost." Remember that always.
Click to expand...

An old cliche, yes. But it really is darkest before the dawn. When the voice in your head tells you to end it all...... Fight it! Never give up on yourself!

* Think of the movie where the guy is crawling through the sand in the desert and gives up just before the crest of the next sand dune. And the movie ends as the camera backs away and upward, showing a busy highway and buildings just over the dune. If only he hadn't given up, he would have made it. Life is like that, as well.

* Consider as well the Christmas movie 'Its A Wonderful Life' with Jimmy Stewart and Donna Reed. George Bailey (Stewart) has problems. Feels overwhelmed. And as a result, he is thinking of ending it all one Christmas. As the angels discuss George, we see his life in flashback. Then, as George is about to jump from a bridge, he ends up instead...... Rescuing his guardian angel, Clarence.

And Clarence gives George a great gift...... He shows George what his town...... And indeed the world...... Would be like if it hadn't been for him. And George comes to realize that like the ripples in a still lake when a stone is dropped in...... All the lives he has touched and how the world is truly a better place for his having been there. And having realized what a precious thing life is...... George comes to appreciate what he has. There is an old saying...... 'The fortunate man is not the man who has all he wants...... The fortunate man is the man who wants (appreciates) all he has.'

* Another old saying...... 'You can't think your way into right acting...... But you can act your way into right thinking.' I have found this to be true. Its pretty much as my Step-dad used to say...... 'You may as well spit in one hand and sh*t in the other...... And see which one fills up first!' Same rationale.

* If a person is going to get sober and stay that way...... They must believe that at least one other person in this world cares about them. You will notice that I said 'believe', not 'understand' (intellectually). There is a difference.

I can't count the number of times I rec'd a call from another vet at 0-dark thirty in the morning and talked them through things as they went about their apartment retrieving previously hidden pieces of their 1911 handgun and reassembling it whilst we talked with the stated intent of blowing their brains out. All I can tell you is that when you are ready to get clean and sober...... You must participate in your own recovery. The Great Eagle of Sobriety isn't going to swoop over and take a dump on you and cure you.

And part of that is...... When you reach the point where you can help others...... Do so. I don't know how many of those guys and yes, we had a woman vet in our group as well...... Don't know how many I was able to help at least for that one day or night. Or simply by example...... Staying alive myself one more day...... Showing others it can be done. But I realized later that helping others helped me stay sober and kept me alive, as well.

Staying alive is like staying sober, Doug. If you want to stay sober more than you want to drink or drug...... You will. And likewise...... If you want to live more than you want to die...... You will.

Wish you all the best,

Harry
 
Last edited:
enigma57 said:
Doug, I am glad to hear that the pain management unit was helpful to you. Wish you all the best with it following the permanent implant.

Yes, you are correct...... Life is like a card game in many respects. The important thing to remember is that regardless the hand you are dealt...... What determines the outcome (in life) is not necessarily the hand you are dealt...... Its how you play the hand you are dealt.

I have seen people who were dealt very good hands in life play them poorly....... Throw it all away. And conversely...... I have seen people who have been dealt what most would consider a bad hand...... Play them very well and have a better life than those who were dealt better hands..... But played them poorly.

Sad to learn of your friend's passing, Doug. Especially by his own hand. Myself and other vets who were dealing with PTSD and those same thoughts 30 years ago started a peer group following our unsuccessful attempts to find help from the VA. Quite honestly, I came away from that experience (the VA) frustrated...... The question in my mind being, 'Which was really our most formidable adversary...... Victor Charlie or Victor Alpha?'

I have not been around here posting on the Off Topic forum very long and did not know of your experience with attempted suicide. That being the case, I will share the following, which I sincerely hope will either help or at the very least, give you pause should you ever consider giving in to those impulses......

I learned a few things from my experience with our veterans peer group.

* If you are to survive...... You must have your head screwed on straight. And you weren't going to be able to think clearly nor make rational decisions if self-medicating (drinking & drugs). Anything that is mind altering messes with your brain chemistry and affects your thinking, your judgement and your resolve to one degree or another. Including your resolve to survive. That is why I said in my priour post......



An old cliche, yes. But it really is darkest before the dawn. When the voice in your head tells you to end it all...... Fight it! Never give up on yourself!

* Think of the movie where the guy is crawling through the sand in the desert and gives up just before the crest of the next sand dune. And the movie ends as the camera backs away and upward, showing a busy highway and buildings just over the dune. If only he hadn't given up, he would have made it. Life is like that, as well.

* Consider as well the Christmas movie 'Its A Wonderful Life' with Jimmy Stewart and Donna Reed. George Bailey (Stewart) has problems. Feels overwhelmed. And as a result, he is thinking of ending it all one Christmas. As the angels discuss George, we see his life in flashback. Then, as George is about to jump from a bridge, he ends up instead...... Rescuing his guardian angel, Clarence.

And Clarence gives George a great gift...... He shows George what his town...... And indeed the world...... Would be like if it hadn't been for him. And George comes to realize that like the ripples in a still lake when a stone is dropped in...... All the lives he has touched and how the world is truly a better place for his having been there. And having realized what a precious thing life is...... George comes to appreciate what he has. There is an old saying...... 'The fortunate man is not the man who has all he wants...... The fortunate man is the man who wants (appreciates) all he has.'

* Another old saying...... 'You can't think your way into right acting...... But you can act your way into right thinking.' I have found this to be true. Its pretty much as my Step-dad used to say...... 'You may as well spit in one hand and sh*t in the other...... And see which one fills up first!' Same rationale.

* If a person is going to get sober and stay that way...... They must believe that at least one other person in this world cares about them. You will notice that I said 'believe', not 'understand' (intellectually). There is a difference.

I can't count the number of times I rec'd a call from another vet at 0-dark thirty in the morning and talked them through things as they went about their apartment retrieving previously hidden pieces of their 1911 handgun and reassembling it whilst we talked with the stated intent of blowing their brains out. All I can tell you is that when you are ready to get clean and sober...... You must participate in your own recovery. The Great Eagle of Sobriety isn't going to swoop over and take a dump on you and cure you.

And part of that is...... When you reach the point where you can help others...... Do so. I don't know how many of those guys and yes, we had a woman vet in our group as well...... Don't know how many I was able to help at least for that one day or night. Or simply by example...... Staying alive myself one more day...... Showing others it can be done. But I realized later that helping others helped me stay sober and kept me alive, as well.

Staying alive is like staying sober, Doug. If you want to stay sober more than you want to drink or drug...... You will. And likewise...... If you want to live more than you want to die...... You will.

Wish you all the best,

Harry
Click to expand...
What an awesome post!
I can't put into words how much it moved me...........
Thank you, thank you very much.
 
inkjunkie said:
Morning Harry
Both of your statements could not be more true. Some of us were dealt very miserable hands at birth, but you must play the hand you were dealt. Sitting back and complaining how others are more fortunate than you will get you absolutely no place.
"Learn to live in the moment". I used to work with a guy that had severe back problems. He was wheeled out of work at least once a month in a wheelchair. Rod was a private guy, did not share much with anyone...unless they had something, pain, in common. I spent many hours talking with Rod about suicide, I was honest with him about my attempt. He found it interesting that right at the very moment I squeezed the trigger of that revolver that I was at the most calmest moment in my life. Oddly enough that still applies. More than once, while we were alone in his work area he confessed to me to sitting on the edge of the bed, gun in hand. His wife, who was my boss for quite a while...well...was a very uncaring person. Rod was in severe pain, physically. As I am sure you are well aware of this pain did a number on him mentally as well. Rod, in looking for someone to care about his well being ended up cheating on Susan with multiple women. Confessed the whole thing to Susan. I can remember when Rod told me about confessing to her he said she did not even respond to him. Never did. Rod ended up being forced out of the USPS, just as my wife was...thanks to the now defunct "National Reassessment Program". Over the next couple of years every now & then I would get emails from Rod. Tried calling him several times, he never answered nor did he return my calls.
Fast forward a couple of years and I got a call from a mutual friend, Brian. Brian wanted to make sure that I knew Rod had passed, suicide. Brian was semi-friendly, if you want to call it that, with Susan. Found out that Rod had simply had enough of the pain. Rod was well beyond prescriptions. He confessed to me about grinding up his extended release Oxy and snorting it. For years he was buying cocaine from a fellow USPS employee. Rod had confessed to me that he had done ****** several times, just to escape the pain. Brian told me that Rod had went to the pharmacy and picked up his monthly "fix" of the 4 different pain meds he was on. Also picked up a bottle of whiskey. He went home, swallowed all of the pills and started chugging until he could not. Dead at 51 thanks the pain...

As to me....my clinical trial is technically over. Had my last call last night. Rebecca had me change the settings several times, some worked great, others did not. Last night she had me change the batteries and switch the device to the settings that worked the best for me. Tomorrow I go and turn the device back in, get paid the $1000 for participating in the clinical trial and have the leads removed. Then it is back to suffering. On the 10th I go for my pre-op visit. On the 24th I am scheduled for the permanent device to be implanted. Go back in 2 weeks to get it programmed and powered up. The device is implanted without a charge. Charging it generates heat so I have to wait until the incisions are healed prior to charging it.

Went to Costco the other day with my wife. For as long as I can remember I have leaned on the handle of the Costco cart, it is the perfect height to relieve some of my pain. The other day it was the exact opposite, it made me hurt some. I have noticed that on days where I walk a lot my hips hurt quite a bit. Last week I was at the PT place that saw me in the past, my wife was there for her PT. Joel, my therapist seen me sitting there and sat down, asking about the device. I told him about my hips. He went and found my chart. Asked me to walk. He said that my "weird gait" was no longer present..and that I was standing straight, without the slight forward and to the side lean that I used to have. He told me that the pain is from me now having a more normal gait. I told him I have every intention of coming to see him when I am all healed up. I want him to figure out what type of stretching I will be able to safely do. I am really looking forward to resuming some semblance of normalcy. Being able to train my 5 dogs, going for walks with my camera. I am not really looking forward to the next 5-6 weeks but what happens after will hopefully make it worthwhile.

This is an older video but pretty much explains how it is done.
Click to expand...

I'm glad that you are on your way to healing in all ways, Doug.
What an excellent post.
We all are here to cheer you on your quest to be off the meds and get back to a semi-normal life............
Thank you, and keep perservering...........
 
The most painful part of getting the trial stimulator leads removed was having the stitches snipped. The permanent one will be implanted on the 24th. Stimulator was turned off around 2 this afternoon....the pain is very slowly making its return. Going to be a long few weeks.....
 
inkjunkie said:
I am in tears right now. For the first time in 35+ years I do not hurt....other than the incision. I can actually stand up straight. Absolutely amazing...
Click to expand...

Man that's badass.
 
inkjunkie said:
The most painful part of getting the trial stimulator leads removed was having the stitches snipped. The permanent one will be implanted on the 24th. Stimulator was turned off around 2 this afternoon....the pain is very slowly making its return. Going to be a long few weeks.....
Click to expand...
It’s coming and you now know what it can do for you.

The wait is short and you will get through...you got this!

The future is within your grasp.
 
Perseverance, Doug.
You've gone this far, keep it up!
We're all rooting for you and the others that have posted on this thread with similar experiences..........
 
inkjunkie said:
A friend in AZ...he has been clean & sober for 25 years or so. His wife and kid packed up, left in the middle of the night, never to be seen again. He had Hep C, which the VA was treating. He was on some sort of shots/pills. VA knew of his addiction problems and were giving him bottles of codeine. He would give the bottle to me and I would take them to the pharmacy I was using for disposal.
Bit concerned with getting off of the meds. But I will cross that bridge when I get there.
Click to expand...


Get your doc to do a referral to a pain clinic. Virginia Mason in Seattle has a premo facility
 
I live on the eastern side of Washington, about and hour west of Spokane. I was seeing one pain clinic...and well...they had very little interest in a long term fix, more just throwing darts (epidurals/RFA/Si joint injections) at me. Last MRI results..my anti-surgery doc told me it was time to go see a surgeon. First one I saw told me that Medicare Protocol was I had PT prior to them doing anything....considering that this injury is older then the doc was I simply refused. Docs office caved in and said they would schedule me surgery. Given that my pain spreads from just above my butt crack, across my entire butt and down both my legs, biased more to the left I asked them don't they think trying to figure out where the pain is actually originating from may be a good idea? Oddly enough never heard back from them. My doc sent me out to see another surgeon, this guy is pretty highly regarded. Seen his PA, she did a complete exam and said that the pain in my ***,, literally, was all coming form a particular muscle that spans our entire pelvic region. She had me go out for some CT guided epidurals. First was L4&5 second was L5-S1. Was 100% pain free. I slipped off of a curb one day, normally this would have dropped me to my knees and bought out some interesting vocabulary. Instead, I just walked away. Explained all this to the PA, she said it was time for me to see the cutter. He took one look at my MRI and said that IF he were to cut on me I would end of on the wrong side of the statistics, the failed side. He said that surgery was not an option. They sent me to see another pain clinic. Pretty sure they are the only ones that do the Vertiflex (back jacks), spinal cord stimulators and pain pumps.
Spoke with my rheumatologist about all of this, Dale is one of those docs that just tells you the truth. He told me that the clinic I am seeing is the one they send all of their various arthritis patients to when they need pain management.
Pain clinic has a plan. They are not real big fans of long term oral pain med usage, largely because of the very problems I am having. I feel emotionless. Have close to 0 interest in doing much of anything. Anyways, the plan is to get the stimulator put in. Then my primary care doc, the one who is prescribing the Dopioids, is going to work with me in getting me off of the meds. If I do have any pain after I get off the oral meds I am just going to have to suck it up as I want to have a pain pump put in. Dosage will be micro-grams, not milligrams. And the meds will not be effecting the pain receptors in my brain, they will be effecting those where the pain is originating from. Or at least that is the plan. I am hoping for the best...I don't know how much longer I can tolerate being on oral drugs, they are doing a number on me mentally....
Apologies for rambling. My pain is creeping back in rather quickly...and...well....life is really starting to suck again. With the pain returning I am back to sleeping no more than 90 minutes at a time. Not getting enough sleep just makes me hurt even worse.
Putting the cart in front of the horse here a bit. I will be buying one of those FitBit watches. Soon as the stimulator is put ion I am going to start walking again. Plan is to increase my distance slightly every day. I need to make some lifestyle changes. Get back to doing what ever I can in regards to exercising. Clean up the way I eat. Being 80 pounds over weight is not helping me in anyways.
Ernestina is on me to "get up off my ***" lol. She fell a while back and dislocated her elbow. Doc & therapist are less than pleased with where she is in the recovery process. She is having an MRI done with contrast of her elbow today...
I do appreciate your comments...and anyone who has us in their prayers...
Hope all of you have a great day...
 
Thanks for keeping us up to date on all of the stressors and your experience with your pain problems and how you have been treated and how you are dealing with it.
I am not nearly as bad off as you are, but I have degenerative disc disease, and it's a challenge to keep mobile and working.
I take it one day at a time, and I go to a good chiropractor once a month and he gives me a ''tune up'' to keep me going.
He never has cracked my back, he just manipulates the muscles in my back and my legs, and it's working out for me in that way.
His approach is that I don't need an adjustment which is ''cracking'' and that I need regular manipulation.
I've been seeing him for 4 years now, and he has given me a lot of pain relief.

Keep up the faith and promise of a life without much meds and suffering.

Also, I hope your wife has a full recovery as well.
 
:) You are making great progress, Doug! You've come a long way towards being pain free in just the short time I have been here on the forum corresponding with you.

I wish you all the best with your treatment and hope that you will soon be either pain free or at the very least living with greatly reduced levels of pain so that in time, you can begin reducing your pain meds under your doctors supervision.

Keep up the good work and before you know it things will be so much better. A new lease on life and no more being muddle headed from the pain meds. What a blessing that will be! You're almost there, man! Hang in there!

All the best to you and to your wife,

Harry
 
Dartnut said:
Thanks for keeping us up to date on all of the stressors and your experience with your pain problems and how you have been treated and how you are dealing with it.
I am not nearly as bad off as you are, but I have degenerative disc disease, and it's a challenge to keep mobile and working.
I take it one day at a time, and I go to a good chiropractor once a month and he gives me a ''tune up'' to keep me going.
He never has cracked my back, he just manipulates the muscles in my back and my legs, and it's working out for me in that way.
His approach is that I don't need an adjustment which is ''cracking'' and that I need regular manipulation.
I've been seeing him for 4 years now, and he has given me a lot of pain relief.

Keep up the faith and promise of a life without much meds and suffering.

Also, I hope your wife has a full recovery as well.
Click to expand...
"degenerative disc disease"....Sadly this is one of those things we will all have to face as we age. Some of us....well...it just got an early start on. It is not uncommon for "DDD" to advance to Stenosis...

"Spinal stenosis is a narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine."

Thing I would like to stress to all you younger folks....is that you MAY be able to delay the onset of DDD. Lift correctly. Avoid repetitive motion jobs. Avoid being hung over a fender all day. Use a bit of common sense in your life.

Most of what is torn up on me is from repetitive motion injuries. For years my job with the USPS was to separate incoming trays of letter mail. For years, being left handed, I used my left arm for all of the pulling. Might explain the torn bicep. Might also explain why the carpal tunnel in my left hand was in labeled as extreme versus my right hand only being moderate. Thing about repetitive motion injuries is the big A, arthritis, will tag along with it. As many of us aging folks are well aware of once "Arthur" shows up the best that can be done is to slow its progress.

All you younger folks....please take care of your back and joints. While being a mechanic may be your dream job....well....it may make your later years less than a dream.

My docs have all told me that all of the crap I am dealing with was going to happen to me, sooner or later. I have several genetic issues that helped speed things up a bit.

Really wishing that I had listened to the folks that tried to educate me when I was younger. Educate me on how to lift correctly. On how to bend and twist correctly.

It is what it is. The pain is slowly returning. But it feels different this now, which is completely normal. Only have to tolerate it for 5 weeks or so. I am fighting off taking any additional pain meds.
 
I sure know what you are going through, I have all of the above plus a congenital defect in my neck that I never knew I had until my first MRI 2 years ago.
 
Mopar-Mitch said:
I sure know what you are going through, I have all of the above plus a congenital defect in my neck that I never knew I had until my first MRI 2 years ago.
Click to expand...
Does it cause you any pain? Few years back...I fell out of bed :rofl::rofl:. More like I bounced off the side of it. Was staying at a hotel. Got up to pee. Thought I was close enough to the bed to more or less fall back into it but I was not. Hit the corner of the mattress and ended up with my arm jammed between the night stand and the bed :lol::lol:. After the Pain clinic gets me the stimulator dialed in they are going to look into it. Doc has warned me that while it is not causing me any real pain it may cause incontinence problems....or put me in a wheel chair. Go figure, 50 years old and I still need rails on the bed :realcrazy::realcrazy::realcrazy:
 
Yes, I have lots of pain and cant stand very long, my arms and hands go numb if I use them very much, I've had epidurals and I've been lucky to stay off opioids my pain medication is tramadol and I take flexiril muscle relaxers, I'm going to have surgery on my neck hopefully around the end of the year.
 
You must log in or register to reply here.
-

Back
Top