Results Part II

Ok, so I went to have blood drawn at Labcorp 3 weeks ago and had my bone scan and MRI 2 weeks ago.

The bloodwork and bone scan were easy and uneventful, just required me to leave BG at home with Mr. MLACS and wait (and wait and wait).

But the MRI was not what I expected. I had previously had an MRI almost a year to the day prior to this MRI, when I had my 4th colonoscopy and 24 hours later spiked a 104.3 fever and had to go to the ER and be checked (via CT scan and MRI) for bowel perforations, lest the doctor doing my scope had punched a hole in my bowels. During my initial MRI in the ER, they just injected me with dye and I don’t remember much of it because I was mercifully given morphine.

So I was a bit disappointed when the nurse handed me 3 bottles of a suspicious looking liquid called “volumen”. I can tell you with confidence that anything you have to drink in order to have a test of your digestive system is going to taste like sh*t and you’re going to have to drink a lot of it.

The nurse informed me that I would need to drink one 450ml bottle every 15 minutes and confirmed my suspicion that it tastes like sh*t when she said “Some people find it goes down easier if they pour it over ice”. I accepted the cup of ice and the nurse returned me to the waiting room. I bravely took a swig from the bottle and immediately regretted it. It was sweet, with an unnatural citrus flavor and the consistency of watery slime (or for my infertility sisters–the consistency of EWCM). It was f*cking gross. But I’ve had worse. So I poured it over ice and started slamming it through a straw.

The waiting room was nice and I was seated in front of a theater-sized television which was tuned to my favorite channel–HGTV. There was no one near me so no one to see the twisted faces I was making or hear the profanity I was muttering in between swigs. I had to fast for a few hours prior to the MRI and I’m not sure if it was that or drinking the ice cold volumen or the thermostat of the office, but I began to feel very cold.

I was proud of myself that I managed to choke down the first two bottles in the alotted 15 minutes. Finally the nurse returned (slightly early) as I was struggling to finish the last half of my 3rd bottle. By this point I was struggling to finish in 15 minutes, or really, to finish at all. I pushed myself. I also considered tossing the last couple sips and lying about it. But *just* as I finished it the nurse came and saw me sipping and said “Ok we’re ready–it’s ok if you didn’t finish it all”. The irony.

She handed me a gown and showed me to a changing room. Instructed me to take anything off that had metal (my bra) but everything else was fine. Come to think of it, I took my shirt off when I put the gown on and I’m not sure I had to? Oh well. I realized I kind of had to pee, but I was freezing and my desire to lay down under a warm blanket trumped my need to pee, so I didn’t bother.

This was a mistake.

The nurse showed me to the MRI machine and had me lay down, then finally she placed the warm blanket I had been waiting for over me (side note: experience has taught me that hospitals and clinics such as this always have warm blankets–or at least blankets–so never hesitate to ask). I looked up to see a clear blue sky, as the room was crowned with a glass roof. It was sunny and welcoming, unlike the dreary basement where my previous MRI took place. I was in a good mood and chatted with the nurse as she placed my IV. She then offered me some earphones and asked if I’d like to listen to music. I asked what my options were–did they have any reggae? Well no, they didn’t. So I ended up with classic rock. (side note: I love reggae)

The nurse told me to listen for their instructions and placed a balloon-thingy in my hand, which she told me to squeeze if I needed anything during the MRI. She said the MRI would take 35 minutes. I felt very comfortable and told her I was ready.

Well… First thing they told me to do was take a breath and hold it. As I was still inhaling the machine started vibrating and making a loud rapid-fire “blip blip blip blip” noise. It jolted me. This was unfamiliar. It also felt like I held my breath for a long time. Then before I was even recovered from the first round, I was told to take a breath for the second round. Like seriously, I’m not an Olympic swimmer–I need to catch my breath after I hold it for awhile. At this point I began to feel a bit anxious. I also wondered how geriatric patients handled this–I’m an athletic young-ish woman–if I felt overwhelmed how must they feel?

So this process of holding my breath at intervals while being shaken like a martini and accosted with loud noises continued. And it wasn’t long before I realized the effect on my bladder–I needed to pee.

My anxiety was steadily increasing as I came to terms with the fact that I was stuck in this machine and doubtful that I could hold my pee for the duration. The question became: Do I notify the nurses and see what they say, or do I just pee in my depends adult diaper and hope for the best?

I decided to squeeze my ballooon-thingy and see what the nurses had to say.

Nurse: Yes?

Me: Um, how much longer until we’re finished?

Nurse: About 20 minutes.

Me: Oh, ok, well then…

Nurse: Do you need something or can we continue?

Me: Well I really have to pee and I’m not sure I can hold it… But I’m wearing depends so if I do go it would be ok, but would it mess up the test? I will try to hold it though.

Nurse: Uh, well if that (me peeing myself) happens let us know

Me: Um, ok. Thanks.

Aaaaaaand that was awkward. I decided to try my best to hold it. But with the machine vibrating me and the added pressure of having to breath in and hold it, I was using every ounce of mental and physical strength. It was impossible. Like this should a million dollar challenge on some reality tv show.

I tried to focus on the music–Pearl Jam, followed by The Eagles… but the radio DJ banter in between songs was incredibly annoying and ruined my concentration. I started kicking my feet as some kind of distraction, and that helped a bit. I kicked faster and faster as my bladder swelled and my discomfort grew. In desperation I squeezed the balloon-thingy and asked the nurse how much time was left?! And she answered 3 minutes. I said I would try my best but I really doubted I could hold it. And then shortly thereafter, my bladder burst and I began to trickle, then stream…

I squeezed the balloon-thingy and simply said “I couldn’t hold it” and the nurse said “I’ll be right there” and the machine stopped…

What?!

I was under the impression that you can’t stop an MRI once it’s started. Hence my resignation to suffer. Hence my humiliating admissions that:

1. I am wearing adult diapers

2. I am currently wetting my pants

And if you read the above conversations between myself and the nurse, then you can see that she never mentioned stopping the MRI to allow me to use the restroom. To her credit, the nurse rushed to get me out of the machine after she asked if I had already pee’d (yes, yes I did) and if I still needed to pee (yes, yes I do). After she unstrapped me (my midsection was immobilized) and unhooked my IV, she informed me that they had scrub pants I could wear if I needed them. I thought I might need them, but was relieved to find that my depends were *dependable* and had spared my pants.

I suppose I ought to have been mortified, but I wasn’t. In fact, upon realizing that my pants were dry and knowing that I had stashed a spare pair of disposable underpants in my purse, I practically skipped back to the MRI room and finished my procedure in a state of calm and relief.

On my way home I called my sister and told her the whole story while we laughed hysterically. I hope it gave you a chuckle too. But if you can take away some useful information then that’s all the better. Lessons here are:

  1. Always pee before your MRI.
  2. If you need to pee (or poop) during your MRI, don’t be afraid to stop the procedure and do what you need to do.
  3. Depends adult diapers rock. Don’t hesitate to use them during a flare or for any other occasion. They are so discreet that I even wear them under leggings. And comfortable too! Seriously, I should do endorsements for them.

So then here are the results:

  1. Bone scan was normal. This means I’m no worse for the wear even with my prolonged use of high-dose Prednisone. I’ve always taken calcium/magnesium/D3 and I suggest anyone with IBD do the same, as IBD hinders our absorption of nutrients and we are often deficient in these 3 in particular. Take these in addition to any multivitamin.
  2. My blood tests showed that I do not have elevated IgA or IgG–this supports my UC diagnosis as 80% of Crohn’s patients test positive for one or both, but only 10% of UC patients test positive for either. Yay!
  3. My test to see if I possess the enzymes to metabolize 6MP says that I am an “intermediate metabolizer”. My GI said this indicates that the medicine may not “clear completely from my system”. I take this to mean that I *can* take 6MP, but it’s better if I don’t. Well, alrighty then. Scratch that.
  4. Rather than adding 6MP, GI decided it would be best to increase my frequency and/or dose of Humira. I’m all for that because I have felt better after taking it for 3 weeks in a row.
  5. Best of all, my MRI showed only showed mild inflammation in my rectum and lower colon! Also consistent with a diagnosis of UC–so my GI changed his tune from “I think you have Crohn’s” to “It’s UC”. I called it! And what’s more, the MRI didn’t even detect my fistula. I hope that means that it is healing and that I might not need a seton or other procedure. On the other hand, I worry that I should have a seton placed anyway, as I do not want another abscess–have yet to discuss my concerns with my GI.

So no bad news! *fist bump* I got the results a week ago and since then I’ve been stable but haven’t improved. Still having 3 BM’s per day, partially formed but definitely abnormal and accompanied by a fair amount of dark blood tinged with red. So I’m still actively flaring. But grateful to have energy and stamina and to be able to control my bowels (hold it) and to not have pain and cramps and… I could go on but the gist is that my quality of life has improved exponentially but my colon still needs to heal.

I’m still weaning off Prednisone and went down to 25mg last week. But haven’t been feeling so good (BG has been sick so I probably have it). Maybe I’m sick, maybe my body isn’t ready to step down to 20mg yet, or possibly both. So I’m holding at 25mg for now until I figure it out. I’ll just throw it out there: I’m a bit concerned that I might have Lupus–not drug-induced from Humira, but legit Lupus. Don’t want to think about it though so will try to push that to the back of my mind.

XOXO,

MLACS

 

 

 

 

 

 

 

 

 

WordPress Tech Support

Ok, so wordpress won’t let me comment on any of your blogs! I can’t comment and I can’t read anyone else’s comments. When I click the comment icon, it just refreshes the page but no comments appear. I tried changing my settings to “allow pop ups” but that didn’t work. This is driving me NUTS! Heeeeeelp! I know some (most, if not all) of you are more tech-savvy than me.

 

Getting Results

Two-fold: I’ve received the results of my recent bloodwork and I’ve been seeing results from my current treatment plan.

I won’t keep you in suspense–it’s all GOOD NEWS!

First off, I feel great.

I mean f*cking awesome. Seriously haven’t felt this good since… I can’t remember… and even then it would require a trenta iced coffee and it would only last 24 hrs. I have been winning at life for over a week now.

Do you know what I did yesterday? I actually emailed/made the calls I needed to make first thing. Then got myself and BG ready and out of the house by 9am. I took her to the mall and we rode the carousel for the first time and ate lunch and shopped. Then BG fell asleep in the car and I went to the specialty pet store and grabbed dog food. Then drove and parked in Trader Joe’s parking lot while BG finished her nap. Then did our shopping (smoothly, even with my todddler in tow, because my mind is much sharper and my anxiety is less). Then drove to our UPS box and got our mail. Then came home AND unloaded groceries AND made a healthy dinner AND played with BG.

Even before I was officially sick, I unofficially felt like sh*t most of the time. I would aim to do 2 or 3 things per day (in addition to caring for my kid). Since I have to commute from the ‘burbs to go shopping it adds an extra 1.5 to 2 hours to my errands. So going to trader joe’s, putting away groceries and making dinner were, like, my big accomplishments for the day–even prior to my health crisis.

It’s sad, I know, and I felt embarrassed and ashamed and I blamed myself for being lazy. I seriously felt lucky that Mr. MLACS tolerated my underachieving a** when he works his a** off (literally he gets between 15,000 to 25,000 steps per day even though he has a white collar job). He never made me feel bad–I did that all on my own.

Me now feels bad for me then. Why did I just accept that? I didn’t feel good and I wasn’t happy. My answer is that I was too exhausted to go digging for answers and solutions. And I bought into the idea that if I just ate better and exercised more then I would eventually be “healthy”. You know, like any other regular person. Because I don’t generally regard myself as a”sick” person. Because our society is prejudiced against sick people.

I was prejudiced against myself.

How sad is it that I was more comfortable identifying myself as lazy than I was admitting than I was chronically ill?

So I’m pleased to learn and pleased to inform you that I am NOT lazy. Au contrare, I am a self-disciplined and self-motivated powerhouse…

When I’m not sick.

I believe that God’s plan is perfect even when life sucks. Even as I sat on the toilet crying in existential misery, I knew there was a reason.

I imagined myself like Captain Dan in the movie “Forrest Gump”, up on the mast of his ship during the storm. Raging. Warring. Except this was going on inside of me, not externally.

I had to confront my fears–who am I if I am mentally and physically incapacitated? am I still loveable? am I still valuable? will I ever get better? will I ever be able to live the life I envision? if I can’t create my perfect life for myself and my family can I ever be happy? Etc.

I had to confront deep-seated feelings of inadequacy and self loathing.

I had to apologize to myself and my body for all my negativity.

Let me put this in writing:

12 year old self, I’m sorry I told you that you were fat and lied to you that if you were just skinny, then everyone would love you and admire you and want to be your friend.

12 year old body, I’m sorry I starved you and then hated you when you still weren’t skinny. You never deserved that.

I could go on but this was the beginning of a pattern of self loathing and self torture that has gone on, to a greater or lesser degree, for decades.

And part of my healing has involved saying to myself, over and over again,

I am enough.

This horrible flare has taught me that even at my worst I am valuable and I deserve to be loved…

By me.

And then I started getting better.

Now I want to say that there were many other factors besides my emotional baggage that contributed to me getting sick.

Just like there are many other factors that have contributed to me getting well–I am grateful for traditional Western medicine and I believe Humira has been critical to my healing.

But God’s plan wasn’t for me to start Humira and feel all better and go back to trying to achieve my “perfect” life.

His plan was for me to learn to love and accept myself, even at my worst. His plan was for me to learn to let go of what is “supposed” to be and to accept what *is*.

Truth be told, I’m still working on it. I had a huge burst of energy this weekend and even though I knew I was overdoing it, I found myself OCD cleaning the kitchen. And I was angry, because Mr. MLACS was just sitting on the couch watching tv. Didn’t he care that I was busting my a** and trying to play catch-up so our house can be perfectly clean? Couldn’t he help so we could get it done quicker? Because as soon as the house is perfectly clean then I will feel ok.

And I knew I was being OCD and I knew that I needed to stop but I couldn’t. So instead I griped at Mr. MLACS. And then I burst into tears. And when he asked what was wrong, I found the words to tell him… “I know I need to rest but I can’t stop because I just want everything to be perfect! Like I feel like I have to make up for all that time I spent feeling sick and worthless… and I think I need you to tell me that I’ve done enough and you’re proud of me and that I should go lay down”. And he came into the kitchen and held me, and I took off my rubber gloves and wiped my eyes. Took a breath and said to myself “I am enough”.

I’ll have to write about the lab results in another post. This post has surprised me as I didn’t intend to write about all this emotional sh*t. But I’m glad I did.

XOXO,

MLACS

My Rainbow Is Two!

It’s overwhelming to reflect on these last few years. I say few years because, while my two years as a mother have been transformational and my focus of this post, I can never separate my experience of motherhood from my experience with infertility and loss. It would be like omitting the first chapters of a book–it wouldn’t make sense.

I met my baby when she was just a follicle, via ultrasound, in Dr. Angel’s office.

And prior to that I crossed oceans of grief and loss.

This is all part of our story.

And it’s all too much.

I can only glance at the 5,000 pictures I’ve taken of BG, because my heart feels like it will burst.

I can only briefly conjure memories–both euphoric and pitiful–from these past two years, because my heart begins to ache.

To yearn for those tender moments and exciting firsts I’ve shared with BG.

And to lament my experiences with PPA and and the myriad other ways in which I struggled as a new mother.

It’s confusing as hell.

These two years have been THE BEST years of my life.

And also the hardest. The most terrifying. The most physically taxing. And at times, the loneliest.

Oh, but the love I have for this kid.

She is everything to me and to Mr. MLACS.

The Weight of Coffee

We all take a lot of things for granted. Being sick and having my life turned upside-down, I was given an opportunity to see a wealth of things that I have taken for granted. Now that I am healing I am full of gratitude for every. little. thing.

I don’t even know where to begin, but just to give you an idea:

  1. Ability to sit upright on the couch instead of laying down.
  2. Ability to cook a meal, plus now I can make an entire meal without having to sit down and rest (can be on my feet in the kitchen at will).
  3. Ability to go to target or the grocery store by myself.

Of course there are more significant things that I am grateful for, but I list the mundane things to point out how much we (I) actually take (took) for granted. My list could go on for days.

One of the things I grieved the loss of during the thicke of this flare, was coffee. I haven’t had a cup of coffee in 12 weeks, maybe longer.

Prior to this flare, I would have at least 2 (large) cups per day. My keurig carousel was always stocked with a great selection of flavored coffees, and I would always have multiple containers of SO Delicious coconut milk creamer (vanilla flavor) in my fridge. If there was one thing I would make an emergency trip to the grocery store for, it was coffee. And anyone who knows me knows that I am a die-hard starbucks patron–have been since 2002–and strategically plan any outing such that I can hit up an SB drive thru.

Clearly, I drank too much coffee.

I was addicted.

And I loved it as much as any addict could love their addiction. It was more than just caffeine. It was more than just habit.

It’s what got me out of bed in the morning.

It was a warm and cozy cup between my hands when they were cold.

It was how I treated myself–a white chocolate mocha after a long day.

It’s fueled many deep and wonderful conversations with friends–laughter and tears.

It’s memories of my Mom, who was a coffee addict too.

It’s my ritual to go to starbucks every time I go to the airport–even if I have to trek to another terminal.

I could go on, but suffice to say that coffee punctuated every day of my adult life and without it nothing felt right.

It is doubly depressing to be sick and simultaneously have one of your biggest coping mechanisms taken from you. Like if you had stolen a little kid’s pacifier.

I had to give it up at the very beginning of my flare–even before I realized I was sick–because I’d be running to the toilet after the first sip and every sip thereafter.

And I missed it.

But as the flare unfolded, coffee was further and further from my mind. I hardly thought about it except for when I noticed the dust on my keurig or opened my wallet to see the unused $25 starbucks gift card from Mr. MLACS.

But…

As I’ve started to feel better these past few days, the stagnant boxes of k-cups sitting on my pantry shelves have begun to catch my eye.

BG woke me up at 5:40am and I begrudgingly climbed out of bed to serve her breakfast and turn on her cartoons. It was cold and that further eroded my motivation. I thought “If I wasn’t so cold, I’d be a lot happier”. And suddenly I had a flashback of myself curled up on the couch, holding a warm cup of coffee on a cold day. And my gut told me I would be ok if I had some…

So I dusted off my keurig and filled it up with water, and I took out one of my favorite pottery barn great-white-collection coffee cups, loaded my k-cup, and pressed the button.

It felt surreal.

After the coffee was made, I added a splash of coconut creamer. Then I curled up on the couch, cup between my hands, and took a sip.

Not as good as I remembered, but not bad.

I drank maybe 1/3 of the cup and I am happy to report that I have not had to go to the toilet at all!

It’s a miracle! Hallelujer! Amen!

While I have no intention of drinking as much coffee as I did before, it feels like a REALLY BIG DEAL to be able to have any at all.

Like, a sure-fire sign that I am healing and also the comfort of being able to resume my life as it was before the flare.

Things are looking up guys. I am so so so sooooooo grateful.

Cheers!

XOXO,

MLACS

 

 

 

 

 

Asking My Colon To Choose Life

Saw my GI today and he very matter-of-factly said “Your colon is a mess. Either it heals or you’ll be having surgery soon”.

I actually looked and felt much better today than I did when I saw him a month ago–when he told me “Oh you don’t want surgery!”–so it felt ironic that he wanted to discuss it today, now that I’ve improved and it finally seems like I have a shot on hell at remission.

But yeah, I agree: either the colon gets it’s sh*t together (ha, see what I did there?!) or I’ll be scheduling a colectomy. When he said that I was struck with both fear and relief; fear of surgery, but relief that my GI fully understands what a burden my colon is and how devastating this flare has been. He based his opinion on my recent lab tests, which showed my inflammation is “off the charts”.

I’m definitely better now than I was when I dropped off those lab tests 2.5 weeks ago, so I feel hopeful that (with a new treatment plan) I can get and stay in remission.

Here is what we discussed regarding a new treatment plan:

  1. GI wants me off the Prednisone. I want off the Prednisone. I dropped from 40mg to 35mg three days ago without issue. I intend to continue to wean 5mg per week until I’m down to zero.
  2. Since the Humira is working, albeit slowly, he has consented to increase the frequency of my injections from bi-weekly to weekly, pending a blood test to measure serum levels to be sure that wouldn’t be overdosing. Meanwhile, he gave me a Humira “booster shot” to take this Saturday in between my scheduled doses. I’m a little confused as to why he consented to this booster shot prior to seeing my bloodwork, but I’m definitely not arguing. Humira is working now so the more, the better IMO.
  3. GI also enthusiastically agreed to put me on an immunomodulator, either 6MP or Imuran, my choice, pending a blood test to see if I can metabolize it–apparently some people genetically lack an enzyme that is required for the medicine to work, and without it the medicine is toxic and can kill you. Yikes. I chose 6MP because it’s been around longer (more studies) and is proven safe in pregnancy and breastfeeding (still breastfeeding BG and still hoping for baby #2). I have to go to labcorp for bloodwork though *groan*.
  4. GI looked at my fistula from the outside and ordered an MRI to see what is going on inside. Pending insurance approval, I’ll have that done next week. He also ordered a bone density scan to see what, if any, damage my repeated use of Prednisone has caused over the years–this is long overdue. I should have this test the same day I have the MRI.
  5. GI threw me for a loop when he suggested I have Crohns and not UC, based on the fact that I have a fistula and he never sees those in UC patients. But I beg to differ–I’ve had this disease for 13 years and never once has it ever acted like Crohns–and in fact–all 4 of my colonoscopies have shown that my entire digestive tract is immaculate, save for the last 6 inches (my anus) which is perpetually inflamed to a greater or lesser degree. I’ve read plenty of research and personal accounts of people with UC that have fistulas, so I was shocked when he suggested that I must have Crohns because UC patients don’t get fistulas. But I’ll let it slide because he’s 90% genius and only 10% crazy.
  6. GI wants to put me on Uceris foam (a foam enema to be administered rectally). When I last saw him, I asked him about steroid enemas and he poo-poo’d the idea saying he “doesn’t like them”. But apparently he is ready to throw everything *and* the kitchen sink at my colon. I’m game, but nervous about sticking things in my super tender and inflamed anus.

I feel better now that my GI is clued in on the magnitude of this flare and has created a plan of action. I was going to flip out if he didn’t DO something today.

And while I accept surgery as an option, I am hoping that my colon is going to heal and stay in remission.

I am asking my colon to choose life.

XOXO,

MLACS

Tired

I took my 3rd Humira injection last night (Mr. MLACS did it for me) and I was up and down all night due to that and BG waking up.

I was SO exhausted this morning, and then Mr. MLACS tells me he has to go into work, but hopes to be home by lunch.

Today was hard.

I was tired and anxious, irritable and uncomfortable. Did I mention tired? So, so tired.

By lunchtime I was crashing and I freaked out when Mr. MLACS told me he had to stay at work, because I was feeling unstable and super guilty because I pacified BG with cartoons all morning while I laid on the couch, expecting that Mr. MLACS would be home by lunch and take her to the park. He was going to take her to Little Gym this morning and I felt bad that she missed that too, but I wasn’t fit for it today.

After I argued with Mr. MLACS and he said some really mean sh*t, I cried and BG cried and then she agreed to take a nap. So we took a 1.5 hr nap, and I woke up feeling groggy but more stable.

I fed BG lunch and we watched more cartoons and she played a bit. But then she wanted to go outside (and I wanted her to go outside) so we went out in the backyard for a bit and threw the ball for our dog, blew some bubbles, and messed around. But then I had to go inside and BG was awfully disappointed–more guilt.

I fed her snack and laid on the couch. Looking around at my house there’s so much I would have liked to accomplish–vacuming, laundry, clean the kitchen, clean the patio (it’s filthy), etc. etc. There is a neighbor down the street who has 2 toddlers and a newborn, and her house is immaculate and I know for a fact she has no help and they are selling their house and the pictures showcase how orderly everything is… and I look around my house and I feel disappointed in myself. And guilty.

Will I ever be able to live the life I want to live? On my terms?

Mr. MLACS didn’t get home until 6:15pm. I had him pick up mexican food for dinner (because of course I didn’t cook today–didn’t even consider it). I was SO hungry I just stuffed my face. And now I’m laying on the couch about to pass out while Mr. MLACS feeds BG dinner.

When I get better and our dream home is repaired, I am burning this f*ing couch.

Oh yay, Mr. MLACS just took a call and now he has to go back into work. BG is going to be very disappointed that he won’t be here for our bedtime routine, especially since he was gone all day. And obviously I can’t take my sitz bath.

It’s hard to have such a good (well, better) week and then have everything blow up unexpectedly on a Saturday.

I don’t know how I’ll handle it if Mr. MLACS has to go into work tomorrow. I need to get out of the house but I’m anxious and scatterbrained and I don’t know if I can do it by myself. But if I don’t get off this couch I will lose whatever is left of my mind.

XOXO,

MLACS