Smooth sailing with the knee surgery

I went through with the planned knee surgery yesterday to have my broken left tibial plateau fixed. And the day was remarkable for how easily everything fell in place and how simple and easy the whole experience was. 

I want to write about yesterday's experience in detail as I think it is worth describing the high quality of care I got and exploring what went into making it so. 

The idea of a possible surgery to fix the damage was first broached on the day of the accident itself on Saturday, June 24. The CT Scans and the X-Rays showed that the damage to the left tibial plateau was severe, and required handling by experts. If it was deemed an emergency that couldn't wait, the emergency folks might have arranged for the surgery to be performed the same day. However, they referred us to contact an Orthopedic Surgeon for further advice later on as the surgery could wait.

The emergency personnel had given me a red compression sock for the broken leg. That item was of immense amusement for Aisiri getting her to sing "Polka Dots, Polka Dots" many times. 👶😂

Since I was not supposed to bear weight on the broken legs, we decided to not walk up and down the two sets of stairs to our third-floor apartment, and instead take up on our ground floor neighbors/friends offer to stay at their home for a few days. While it was complicated managing with two homes, it did help us immensely to settle down while I was physically impaired to move around. 

We met with Dr. Gavin Bishop - the Orthopedic Surgeon at Longmont Clinic - on the following Tuesday - June 27th, and got more details and confirmation about the need for surgery. The date for the surgery was set for a week later at this discussion. The medical staff went through all the preliminary formalities required for the surgery at this time and made sure we were ready with all the required information.

The nursing staff from the Longs Peak Hospital - who would be part of the surgery team - called up over the phone on the day before the surgery to review the surgery procedures specifically around usage of anesthesia, usage of blood transfusions, medications I was on, allergies, etc. They also made sure we know where we had to go at what time and what to expect at each stage. 

On the day of the surgery, my nephew Shashidhar drove me to the hospital at 6:30am for the 8:00am scheduled surgery. I was checked in to a separate preparing area for the pre-surgery preparation. I changed to a hospital gown. Used a urinal bottle to pee. Scrubbed my body completely with anti-bacterial tissues. Met with the different members of the surgery team as each one came by to say Hello, and explain what they were doing, as well as ask me what I thought the procedure was for. 

Just as it was about to turn 8:00AM, the anesthesiologist administered a powerful anesthetic (they told me the name before, but I don't recall now). And it was like a Television blacking out on switching off the power. The nurse did tell me that I would co-operate with them when they ask me questions during the procedure or ask me to move over, etc., but would not recall any details. That was indeed the case. 

The next thing I remember was being fussed over by the nursing staff back at the same place where I had zoned out after the surgery was completed - around 11:00am-ish.

The surgeon told us everything had gone well with the surgery, and that I would need 6-12 weeks to completely heal. I had asked about the possibility of undergoing a brain surgery in the next 2-3 weeks. He recommended that we review the progress of healing from this surgery in two weeks and then decide on the brain surgery. Sounds like a plan.

While I had not had any solid food since 10pm the previous night, I wasn't really hungry at this time. The nurse gave me two cups of apple juice and that filled me up amazingly well. 

We left the hospital around 1:30pm. 

One final problem we had to deal with was about how I was to get to our 3rd-floor apartment on bum legs. Thankfully, my wife was able to get help from two of the folks who work in our apartment complex. They along with Shashidhar - all three of them carried me step by step over the two set of stairs rather easily, and I am all set for rest and recovery from home over the next few weeks!

In the background of all this is the amazing support shown by many generous donors to the fundraiser I had started a few days ago: https://www.gofundme.com/help-prakash-fight-glioblastoma

133 people have raised over $35K in 3 days! That took 'financial worries' off the list of things we had to worry about to provide us with a sense of financial safety during all the hospital runs over the last few days, and has made it easy on us to take on the challenging aspects of this experience with confidence.

Thanks a million for everyone who made a difference for us through this fund-raiser as well as through personal favors and helpful messages. 

Progression timeline of Beau Biden's Glioblastoma

Over the last week - while I have been bed-ridden because of the injuries from the accident - I completed reading the heartfelt, authentic and moving memoir by Joe Biden - Promise Me, Dad: A Year of Hope, Hardship, and Purpose. 

In this impactful and gripping book, Biden chronicles his son Beau Biden's journey through Glioblastoma with presidential, national, and international politics as a background.

Beau Biden is one of the few high-profile victims of Glioblastoma. I think it is awe-inspiring and praise-worthy that the Biden family have left such a public record of their very private and harrowing journey with this terminal cancer. Hopefully, more such records of patient journeys will help in finding a breakthrough for curing Glioblastoma forever in the near future.

Here is the progression timeline of Beau Biden's Glioblastoma as I have gathered from the book:

•  From Wikipedia: In May 2010, Beau Biden was admitted to Christiana Hospital in Newark, Delaware, after complaining of a headache, numbness, and paralysis; officials stated that he had suffered a "mild stroke". Later that month, Biden was transferred to Thomas Jefferson University Hospital in Philadelphia and kept for observation for several days.
• From Wikipedia: In August 2013, Biden was admitted to the University of Texas MD Anderson Cancer Center in Houston and diagnosed with brain cancer, after experiencing what White House officials called "an episode of disorientation and weakness".^[36] A lesion was removed at that time. Biden had radiation and chemotherapy treatments, and cancer remained stable.
• From the book (Pages 28-30): August 2013: We were drawn to M.D. Anderson by the reputation of Dr. Raymond Sawaya, a neurosurgeon who was regarded as the best in the world at a procedure called awake craniotomy. The operation allowed the surgeon to remove the greatest part of a brain tumor without doing damage to speech, cognition or motor skills. The patient was actually conscious through most of the surgery, naming simple objects drawn on flash cards or in casual conversation with the anesthesiologist, while Dr. Sawaya probed the outlines of the tumor with tiny electrodes. If Beau suddenly couldn't identify a picture of an elephant or a car, felt a loss of strength, or couldn't talk at all, Sawaya knew he could not cut in that spot without doing serious damage. Beau had to be strong enough to endure hours of this very disconcerting procedure.  [....] When Dr. Sawaya got 98 percent or more of the tumor, there was a much better chance for the patient to beat the odds. Anything less made a difficult battle that much harder. [....] Dr. Sawaya was obviously pleased with how the surgery had gone. He had removed a tumor slightly larger than a golf ball, and Beau had come through without a single complication; except for the scar on the side of his head, he would be as he was before. His speech, his cognition, and his motor skills were unharmed. But the news had not all good. The Tumor was slightly diffuse, and Sawaya had not been able to get all of it. He had detected some microscopic cancer cells right against the wall of an artery, and he knew if he tried to cut them out Beau would have been left with serious and irreversible damage. Then the news got worse. Much worse. The lab results, Dr. Sawaya explained, confirmed the medical team's expectations: Beau's tumor was definitely a glioblastoma. Stage IV.
• From the book (Pages 16-17): November 2014. Biden Family Thanksgiving Getaway in Nantucket, MA: Beau Biden was easily fatigued and increasingly shy to interact with people. He was losing feeling in his right hand and it wasn't strong enough for a good firm handshake., and he had been wrestling with a condition called aphasia. Radiation and chemotherapy had done some damage to the part of his brain that controlled the ability to name things. Beau retained all his cognitive capabilities, but he was struggling to recall proper nouns. He was working like hell to win back his strength and to reverse the aphasia. He was going to Philadephia most days for an hour of physical therapy and occupational therapy and then an hour of speech therapy, above all and beyond his regular chemo treatments. 
• From the book (Pages 80-81): From the very beginning, way back in the late summer of 2013, Beau had opted for the most aggressive course the oncologist could chart. When Dr. W. K Alfred Yung of M.D. Anderson recommended that Beau endure triple the amount of standard chemo drug, called Temedor, while also taking part in the first field trial of an experimental drug treatment designed to boost the effect of Temedor, Beau said, "Let's do it." A few months later, when Dr. Yung suggested adding an unapproved but promising new drug to combat one of the mutations that made his tumor especially virulent, Beau said, "Let's do it." Dr. Yung cautioned that while there was evidence in animal studies that the drug worked, there were no human studies to back it up. There could also be uncomfortable side effects. "If there's a skin rash, "Beau said, "I'll just wear long sleeves and a baseball cap. All good."
• From the book (Page 82): Beau held his own all through the summer, until August 2014, exactly a year after his diagnosis, when he had a sudden loss of strength and numbness in his right arm and right leg. He didn't complain. He didn't panic. "What's next?" He asked his oncologist. "How do we fight this?" Dr. Yung suggested a more potent drug, with likely side effects including nausea, fatigue, mouth sores, and diminished appetite. The drug would also increase his risk for infection, anemia, and even more serious blood issues. "Okay, Doc," Beau said, "let's do it."
• From the book (Page 123): March 2015. The news [from M.D. Anderson about the new scans] could not have been worse. This was all new tumor growth. The cancer cells in Beau's brain were multiplying fast and in new places. This was the day we had been dreading from the day Dr. Sawaya removed the original tumor. [....] The doctors explained the disconcerting architecture of the new growth. There was a large mass in front of the space where Dr. Sawaya had removed the original tumor. Sawaya was prepared to go in and remove it as soon as possible. But there was also growth well beyond the original tumor, which Dr. Sawaya could not safely remove.
• From the book (Pages 123-124): March 2015. ... could try the promising new experimental immunotherapy we had talked about a few months earlier. The medical team at M. D. Anderson had prepared Beau for the therapy a month earlier by drawing his blood and collecting some of his T cells - the white blood cells that identify and destroy malicious foreign agents in the body. The idea of this new immunotherapy was to identify the specific protein in the tumor cells that was triggering the growth and to engineer the patient's natural T cells to attack that specific protein only. The T cells would, in theory, gobble up the cancer cells and leave all the nearby healthy brain cells untouched. But it turned out they couldn't make that work. Beau's cancer cells had proven too diabolical; the doctors had been unable to identify and isolate the unique protein in Beau that was triggering the growth.
• From the book (Pages 124-125): March 2015. ... another possible treatment. [...] Dr. Sawaya would surgically remove the cancerous nodule in front and then a few days later, another specialist at Anderson would inject a specially engineered live virus into the new tumor growth in the back. The purpose of the injection was to activate Beau's own immune system and let it attack the cancer cells. They had already had extraordinary success in a few of the twenty-five patients who had received the live virus injection. Dr. Yung also explained that they also wanted to try something else in combination - a separate immunotherapy treatment designed to hypercharge the organic attack on the tumor. Beau would be the first person to ever have this combination, and the risk was enormous. There was a possibility that Beau's immune system would overreact and start eating healthy brain cells, too. [...] The surgery would have to wait three or four weeks, the doctors explained, to allow time for the chemotherapy drugs Beau was now taking to clear his system, so he would be able to heal after another major brain surgery. The doctors decided to do the first injection of the immunotherapy - called anti-PD-1 antibody - as soon as possible. Dr. Yung wanted to do the procedure in the middle of next week, on Wednesday, March 4.
• From the book (Pages 141-142): March 4, 2015. ... The procedure to inject Beau with the anti-PD-1 antibody pembrolizumab - or pembro, as the doctors called it - had gone well. The procedure itself was a simple one. They put in an IV in his arm, shot about 150 milligrams of pembro into his bloodstream over the next thirty minutes, and it was done.
• From the book (Page 154): Beau came through the surgery on March 27 just fine, with no ill effects to his cognition or his motor skills. Dr. Sawaya had excised all he had hoped to, but the tumor appeared to be growing fast now, and Beau was weak. The medical team had decided to wait until the next Thursday, April 2, to do the injection of the live virus. That was still six days away. But Dr. Yung and Dr. Lang wanted to be sure Beau was strong enough to handle it. So all we could do now was wait.
• From the book (Pages 161-162): April 12, 2015 - Beau had come through the injection of the live virus ten days earlier without a single complication. He was moving well. His appetite was still good. And he was mentally sharp. But the two fresh, angry scars on his scalp put us all on the edge; the entire family was dreading the coming effects of the untested experimental treatment. Dr.Yung and Dr. Lang had warned us that Beau would get much worse before he got better. Maybe much worse. They said he would likely be at his most vulnerable point in the third or fourth week when the virus and Beau's own immune system were at war with the tumor. The inflammation could be painful and debilitating. There would be no predicting how low he could get, or if he would survive the onslaught. The climb up from the physical nadir could take a long time, too, and we wouldn't know for sure until then if the treatment had been successful and Beau's tumor was gone. The next six or eight weeks would tell all.
• From the book(Page 165): April 15, 2015 - Beau went to M. D. Anderson so Dr. Yung and Dr. Lang could assess the early results of the live virus injection, and Dr. Yung could administer the second injection of pembro. The news was potentially incredible. The scans showed inflammation, but it looked like the tumor growth had really slowed. There was clear evidence of necrosis on the edge of the tumor, which meant the virus was probably already exploding the cancer cells. Beau was in good shape, not showing any ill effects from the virus, and there was already evidence of tumor destruction.
• From the book(Pages 165-166): April 19, 2015  - Beau was badly dehydrated and had not gotten out of bed in 3 days. So the doctors packed him off to Thomas Jefferson University Hospital in Philadelphia. This was likely the start of the first serious symptoms of the virus. Beau was still badly dehydrated when they admitted him, and his sodium levels were dangerously low. He couldn't keep his eyes open. He was barely responsive. The best he could do in response to a question was a thumbs-up, or a barely audible "Yes.". This was it now. We were in the worst of it, and unsure how long the worst would last. The effects of the virus were beginning to punish Beau. The swelling in his head was intensifying and the pain would have been excruciating, so the doctors kept him heavily sedated most of the time. 
• From the book (Page 171): Early May 2015 - Beau held steady for ten or twelve days, and there was some evidence on the scans that the tumor might be shrinking. His appetite was still bad, so the doctors inserted a feeding tube. But in the first few days of May, he started showing a little improvement. [...] If Beau was on the upswing, we decided he should go to Walter Reed, the military facility just outside Washington, where he would be able to restart his physical, speech, and occupational therapy once he rebounded from his temporary virus-induced illness. 
• From the book  (Page 171): Beau arrived at Walter Reed on May 5, 2015 - almost immediately the feeding tube caused an infection and he was rushed to an emergency surgery to replace the feeding tube and clean out the infection. Complications piled up for the next two weeks and brought him more suffering and more pain. [...] There was fluid buildup in the left ventricle fo his brain, and every time the doctors drained it the fluid just came back, which meant he was in pain or disoriented when he was conscious. Later he had a bout of pneumonia requiring a jolt of powerful antibiotics.
• From the book  (Pages 178-179): On May 17, 2015, Beau got out of bed for something approaching physical therapy. He was able to stand upright, with some help from the nurses, for five minutes. [...] The next day he was strong enough to sit up in a motorized wheelchair for a spin around the nurses' station. [...] Seven weeks after the live virus injection, it looked like Beau had finally started to climb out of the dark hole. 
• From the book (Page 187): Beau had a bad night on Wednesday, May 29th, 2019, and by the next afternoon he was barely responsive. 
• From the book (Page 189): The End - May 30th, 2015, 7:51 PM. It Happened, I recorded in my diary. My God, My boy. My beautiful boy. 

One sentence that jumped out at me in the memoir is the following:

And we believed, like he did, that if he could just hang on long enough, science might outrun his disease.

This same sentiment was expressed in John Gunther's book 'Death Be Not Proud' about his son's fight with brain cancer back in 1946 with the sentence: if only we could stave off Death for a few weeks or months, something totally new might turn up.

Hopefully, the cure for Glioblastoma is really within reach and will be available to all patients very soon!

Knee surgery tomorrow; Brain surgery in a couple of weeks

I was hoping that both the surgeries I need in the near future - knee joint replacement surgery to fix the broken left knee joint from the accident, and brain surgery/craniotomy to debulk the brain tumor recurrence could be done together or back-to-back this week to make it convenient and easy for me and my family. Not happening. The surgeries will be spaced 2 to 3 weeks apart because of procedural and recovery reasons. 

First up is the Knee Joint Replacement surgery with Orthopedic Surgeon Dr. Gavin Bishop scheduled for tomorrow - Tuesday, July 3, 2018 - at 8:00 AM at Longs Peak Hospital in Longmont. We are told it will be a day-surgery and I will be able to get home after the surgery around 1pm-ish in the afternoon.

Based on Dr. Bishop's recommendation about recovery from the surgery, the brain surgery will be scheduled a few weeks after that. 

Neuro Surgeon Dr. Sharad Rajpal - who operated on my brain during my first surgery - is of the opinion that I should recover from my left knee surgery enough before going under the knife for brain tumor removal. The new tumor is very close to the motor cortex controlling motion on the right side of the body. If we are not very careful, I could end up with two bum legs - one from the leg surgery, and one from the brain surgery. 

For now, the assumption is that Dr. Bishop will okay the brain surgery to go ahead 2-3 weeks after the knee surgery, and I will undergo a craniotomy at Boulder Community Hospital during the week of July 23. My Birthday Week! Awesome way indeed to celebrate a birthday. 😂😂

Getting serious about moving to Durham, NC for GBM treatments

Last week I got to know there is a recurrence in my GBM related brain tumor. Since then I have been exploring the possible options to deal with the situation and have concluded upon moving to Durham, North Carolina to be near Duke University for the wide array of cutting-edge treatment options available for treating Glioblastoma there as the best option.

While my medical team in Longmont, CO are capable enough to keep me going when things are normal, I don't think they provide access to the most recent in glioblastoma treatments. The only one clinical trial I am being offered in Longmont is the Study of DSP-7888 Dosing emulsion in combination with Bevacizumab. I am not too excited about this option as Bevacizumab (trade name - Avastin) is considered to be a last-resort option for GBM patients. 

Since my head is about to be cut open to deal with the tumor recurrence, I would rather it happen while being part of this innovative and highly successful treatment from Duke University where a genetically modified form of the poliovirus is infused directly into the brain tumor via a surgically inserted catheter. 

One of my GBM friends on facebook travels to Durham, NC from her home in Florida every 3-4 months for a 45-minute office visit. That is an example I would have liked to emulate. However, the insurance complications make it not an option for me. I am on an HMO plan through the Obamacare exchange in Colorado, and that makes the consultation at Duke an out of network expense. It would help if I can switch to a PPO plan, but there are none offered through the Obamacare exchange in Colorado. 

Hence taking the next available option - though at a high personal and financial cost - of moving to Durham, NC for getting treated at Duke University. 

Here is what my medical insurance agent recommends about moving to North Carolina:

Good Afternoon Mr. Murthy
If you are considering a move to North Carolina it will be something you have to really commit to. Do the research to get onto their ACA. So we know when we need to cancel your state coverage here. This will give you a special enrollment event to move onto their state coverage and they will have to cover your preexisting condition. Right now any options off the ACA will not cover cancer or will only cover a low dollar amount that would not be adequate to your needs.
This is the best advice I can give you if you are seriously considering relocating. 

So the main thing is I should continue to be under state coverage through the Obamacare exchange for the sake of pre-existing condition coverage. Moving to employer insurance will not likely have the same coverage. 

Hence the first thing I am working on is to figure out how I can transfer my medical coverage from Colorado Obamacare exchange to North Carolina Obamacare exchange. All other things can be handled when this important step falls in place. 

The other things to handle are as follows:

• Finding freelance work/full-time job: There are quite a few good job opportunities for ruby on rails developers in the Research Triangle Park Area; so it should not be too difficult for me to get myself well-situated work-wise.
• Building a network of friends: Couple of my college friends live in the area, thankfully. They will be our gateway for building a good community of friends in the area. Also, I am sure we will find it easy to build friendships in a community with a dozen Indian grocery shops and a dozen south Indian restaurants.
• Daycare for Aisiri: Google maps throw up a lot of options for Daycares in the RTP area; so we should have no difficulty finding one that is convenient for us.
• Apartment to stay: Same case as with Daycares & Indian Grocery shops, we will have a good set of options to choose from.
• Cost of moving: Will probably cost around $10K to do a full-service move of a full 2-bed apartment with a car across the country; this will be one of the items towards which I will need to raise money through a GoFundMe campaign with financial help from friends and well-wishers.
• My wife's medical professional exams: My wife will continue with her efforts at completing the US Medical Licensing Exams from Durham, NC and take up her Residency next wherever she gets it, and that would probably involve another move across states for us. 

That is all I can think of now. Next step: Setting up a GoFundMe account to raise money to help me with the immediate future.

A Moment's bad judgment leads to serious consequences

Yesterday, on Saturday, June 23,2018, I started from my home at around 5am with the intention of running the 11 miles round-trip route from my place to McIntosh lake and back. I did not get too far in that journey as I got hit by a car within 5 minutes.

Just as I exited Willow Farm Park and was crossing 89th street and getting to Creg road, a car was coming towards me very slowly. Seeing as it was coming slowly, I assumed the driver had seen me and would either stop or turn. That did not happen. The Car hit me very forcefully and made he hit my head and legs very hard on the pavement. The driver offered to call 911 and get me to the hospital. I refused the offer as I did not want to take a very expensive ride to the hospital in an ambulance. Also, I was thinking my injuries were not very serious and that some first-aid is all I needed. The driver accompanied me to my home. My wife - a medical professional (gynecologist in India examined my injuries and concluded I was in need of professional care. So she drove me to the emergency room and into the care of capable folks. A CT Scan and X-rays confirmed there was no intra-cranial bleeding. And that there were two broken bones in my legs. Additionally, there were two serious injuries at the back of my head and over my left eyebrow requiring a few staples and stitches.

The stitches will be removed in 5-6 days. It will take 5-6 weeks for the broken bones to heal. So, I will be an invalid for the next 4-5 weeks at least.

Since my legs are broken it is advisable that I don't walk around and put weight on the broken bones.

thankfully, some good friends who live in the ground floor of a neighboring apartment have made it easy for me by accommodating us at their apartment and preventing the need for me to climb up and down two sets of stairs to our 3rd-floor apartment.

One silver-lining from this unfortunate incident is that this experience of being an invalid is a good rehearsal run for the series of brain surgeries coming up in the near future to deal with the glioblastoma recurrence.

The monster rears its ugly head

Yesterday, I had my regular MRI. Today, the doctor's office made an unusual & unexpected call to inform me that there is a recurrence!



Understandably, both my wife and I are devastated by this bit of bad news even though as I mention in the Ignite Boulder talk, a recurrence is highly expected for a Glioblastoma patient. As of now, we know that the new lesion is about 2.5 cm wide/long/deep and is in the left parietal lobe. The original tumor was in the right temporal lobe.

We will know more about what the next steps are and what we can expect in the upcoming days/weeks/months when we meet with our Oncologist next Thursday.

For now, we will keep our hopes up and try to be positive.

And I am Stayin' Alive! 

Getting serious about training for the fall/winter marathons

It has been almost a month since I ran the full marathon at Colfax Marathon 2018. Ever since then I have not been actively training, and have been lacking the usual motivation to run on a regular basis.

Come on, Dude! We don't want you slacking off now. This is more than about running marathons. A lot depends on me continuing to train for and run marathons.

This is a fight for my life. 

Being fit enough to run marathons will help me better handle another brain surgery - which is likely due soon as I am 19 months past the initial craniotomy and in a fertile period for a tumor recurrence. Also, committing to run marathons later will help me rebound quickly from a surgery.

So can we get serious about training for the 6 marathons I have lined up in the fall/winter?


After running 3 marathons in Spring, I have lined up 6 marathons in fall/winter. From being someone who had completely sworn off running marathons, I have successfully transformed myself into someone with multiple seasons of marathoning per year. 😆

It is 13 weeks to Cheyenne Marathon and 15 weeks to Chicago Marathon - my next two marathons.

Here are the main aspects of my training plan for these upcoming marathons:

• Main Goal: Accomplish a Negative Split: This is the main goal because I have not been mentally and physically ready to run the full marathon at each of the marathons I have run so far. Even at the Colfax marathon, the most recent of my marathons, my thinking was along the lines of "I should finish the first half. If I do so, I can then somehow make it to the end." Taking on the goal of accomplishing a negative split will make me stretch the scope of my thinking and preparation to the full distance of the marathon. The splits for the 3 marathons so far are as follows:
• Los Angeles Marathon on Mar 18: Finish time of 5h07m35s split in two as 2h33m33s and 2h34m02s. Almost an even split between the two halves!
• Eisenhower Marathon on Apr 7: Finish time of 4h55m51s split in two as 2h12m40s and 2h43m11s. A highly uneven split; a very fast first half, and a slower by half an hour second half. 
• Colfax Marathon on May 20: Finish time of 5h07m11s split in two as 2h25m48s and 2h41m23s. The second half is around 16 minutes slower than the first half. Not as bad a split as at the Eisenhower Marathon
• Every training run is an opportunity to accomplish a negative split: Yes. I will accomplish a negative split at the upcoming marathons by making it a habit everytime I am out running. In the few training runs over the past few days, I have been able to put in extra effort in the second half of the run to finish strongly and get a negative split. Example: Yesterday's 6.1-mile effort with a finish time of 1h07m10s had a split of 34m37s and 32m33s. This emphasis on a negative split is helping me train better with tired muscles and also become faster by incorporating some sprinting in the later half of the runs. 👍
• A lot of easy miles, and a minimum of 20 to 30 miles per week: As I have documented elsewhere, the good performances in the spring marathons were built on a solid foundation of minimum 30 miles run every week for 10 weeks leading up to the Los Angeles Marathon. I will continue with that habit with just a little relaxation of the weekly minimum to 20 miles instead of the original 30 miles. A significant portion of this running mileage - around 90 percent - will be at an easy conversational pace. A small part of it will be for sprinting, tempo runs, and other variety I can add to make the training runs less boring. 
• A long run every weekend: In the 13 Saturdays/Sundays remaining till Cheyenne Marathon, I tentatively plan to run the following distances: 
1. June 23-24: 8-mile
2. June 30-July 1: 8-mile
3. July 7-8: 9-mile
4. July 14-15: 9-mile
5. July 21-22: 10-mile
6. July 28-29: 10-mile
7. August 4-5: 11-mile
8. August 11-12: 13-mile
9. August 18-19: 15-mile
10. August 25-26: 18-mile
11. September 1-2: 20-mile
12. September 8-9: 12-mile 
13. September 15-16: 8-mile
14. September 23: Cheyenne Marathon!
• One-way long-runs: Due to my dual restrictions of 1. Not being allowed to drive since I had my first seizure in January 2018, and 2. The need to minimize the time I am without Optune, I have been making all my runs start and end at my home. That has worked well so far as the three successful marathons show. Only down-side has been that I haven't been able to train at high-altitude and with significant altitude gain. That was one of the main reasons for me to drop out of the Mt. Evans Ascent I had signed up for. For this upcoming training cycle, I plan to make some of the runs one-way running towards the foothills, thereby gaining significant altitude through the run. One route I have identified for that purpose is to run from my home to Greenbriar Inn on Route 36 and Nelson road - a distance of around 11 miles with an altitude gain of 636ft! I guess I can have someone pick me up at Greenbriar Inn and drop me back home.
  
• Strength training two times every week: I have discovered a very good strength training plan for runners with the book Quick Strength for Runners: 8 Weeks to a Better Runner's Body. The workouts detailed in this book are perfect for me as they can be performed even with Optune on. I plan to stick to this easy-to-follow strength training plan and improve my strength by steadily making the exercises more difficult (by adding repeats or by taking on the more difficult versions of the exercises).
• Faster finish time is not important: Sometime ago I was entertaining the possibility of finishing one of the fall marathons in 4h30m. I don't think that is realistic. In fact, I would rather not focus on the finish times and just focus on finishing the marathon. Trying to run a faster marathon - as I have learned from experience over the past 10 years - is a surefire recipe to get demotivated and totally give up on running marathons. My goal is to keep running marathons for a long time. Not finish one marathon in a quick time and give up running forever. I hope to become a faster runner and turn myself from a 5-hour marathoner to a 3-hour marathoner and qualify for Boston Marathon over a few years. And I hope to document that journey in an upcoming memoir - How I turned myself from a 5-hour marathoner to a 3-hour marathoner and qualified for Boston Marathon as a middle-aged man. With that goal in mind, there is no speed goal for the upcoming marathons - the goal as I stated at the beginning is TO FINISH STRONG AND ACCOMPLISH A NEGATIVE SPLIT.

OK! That is all. Now let's go kick some asphalt!