Tag Archives: vaccine

by

Less Long Covid if vaccinated

My cats are pound kitties, rescues that were still half-starved kittens when they arrived. They were supposedly six weeks old when I got them, so born in August 2021. This photo is from February 2022. They are still exploring and fascinated by water and faucets and showers. They are doing cat research. Meanwhile, Long Covid research continues.

https://dgalerts.docguide.com/ncov-home/article/lower-long-covid-prevalence-symptom-severity-in-vaccinated-individuals

This is a report on a study which started in October of 2020. “Participants were actively followed for severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) infection. In the study, Hannah E Maier, PhD, University of Michigan, Ann Arbor, Michigan, and colleagues compared the prevalence of symptoms and symptom severity between vaccinated and unvaccinated individuals.” People were enrolled for a year as they got infected, with demographic and health information recorded as they enrolled. They turned in information every two weeks and had blood draws every two months. After a year they were invited to continue for a second year. 3375 were enrolled, more than 1370 filled out Long Covid forms, and 1007 of the 1370 were vaccinated. Long Covid was defined after 90 days.

“At 30 and 90 days post infection, 38% and 13% of individuals reported persistent symptoms, and 6% and 2% reported ≥5 symptoms, respectively. Fatigue (19%), cough (15%), and cognitive dysfunction (12%) were the most commonly reported symptoms at 30 days, whereas loss of smell/taste (8%), fatigue (6%), and cognitive dysfunction (5%) were the most commonly reported symptoms at 90 days. The mean score of symptom severity was 3.6 and 3.9 at 30 days and 90 days post infection, respectively.

At 90 days post infection, 8% of vaccinated individuals reported persistence of any symptoms compared with 27% of unvaccinated individuals (relative risk [RR] = 0.31; 95% confidence interval [CI], 0.22-0.42). Similarly, vaccinated individuals were less likely to have ≥5 symptoms compared with unvaccinated individuals (RR = 0.34; 95% CI, 0.15-0.79).

Furthermore, vaccinated individuals had significantly lower average symptom severity scores at 90 days post infection compared with unvaccinated individuals (relative severity [RS], -2.70; 95% CI, -1.68 to -3.73).“

There also was more Long Covid in the pre Omicron group than Omicron and beyond.

This study is community based and most of the patients were not hospitalized. Overall it has a lower estimate of how common Long Covid is than studies in hospitalized patients. It is reassuring that Long Covid symptoms and prevalence are lower with vaccination, but some people are still severely affected even with vaccination. Vaccination does not stop Long Covid completely though I certainly wish that it did. Mixed good news, but vaccination still looks like the best bet other than moving to a bunker permanently.

The study is published in Open Forum Infectious Diseases: https://academic.oup.com/ofid/advance-article/doi/10.1093/ofid/ofae039/7585852. The quotations are from the DGAlerts article.

by

Vaccination talk

My cousin asks me once, why do doctors say, “This will only hurt a little?’ when they give a shot.

I thought about it. “It’s a matter of scale. Picture this: in room one, I have a woman who thinks her lung cancer is back and it is. In room two I have a mother and daughter crying because the daughter is pregnant and frightened. In room three, I have a well adult who needs a vaccination. Scale their levels of pain.”

Room one is very high, room two is very high, room three barely registers on my pain scale.

Poll: 1 in 7 parents have not talked about vaccines with their child’s doctor

I would give out a health department vaccination information booklet by 24 weeks to my pregnant patients, especially the first pregnancy. I previously had given it later, but then I had a woman who refused the child’s vaccines at visit after visit after visit, saying that they were still doing research. The child still had no vaccinations at 9 months.

Remember the woman who refused vaccinations for her children? She had more than four children. They all got whooping cough, pertussis. They whooped for months and were on quarantine. They were not allowed out of the household, any of them, until they were no longer infectious. The mother said she now was for vaccines and got them vaccinated.

I have seen adults with pertussis. Adults do not whoop but they cough. They can cough until they throw up or until they break a rib. For months. It is not fun at all. The adult Tdap stands for tetnus, diptheria, and acellular pertussis. I have never seen a case of diptheria and I don’t want to. It sounds horrible and can kill.

Have I seen a complication of a vaccination? One in 30 years of practice. And I know a person who had a complication, but they were not my patient.

The illnesses cause way more damage and disability than the vaccine. In residency I care for a young man in a group home. He can’t talk and has an odd skull shape. His mother got measles during the pregnancy. Measles is one of the infections that can cause severe birth defects. Get vaccinated before getting pregnant, though half the pregnancies in the US are “unintended”. That usually means “unbirthcontrolled”. I do not really understand that, since the risk of pregnancy in a fertile woman is one in four every time. Twenty five percent seems a pretty high risk to me.

I’ve written about my response to my last Covid-19 vaccination. It’s not a complication. It is an antibody response and it means that my immune system is WORKING, though admittedly it is weird and annoying. I don’t like the muscle dysfunction, but I will get the vaccinations anyhow.

I have a very alternative young woman in for prenatal care once. I give her the vaccination booklet. “Oh, my child is getting every vaccine there is,” she says.

“May I ask why? I was not expecting you to say that.”

“I was in the Peace Corps in Africa. I have seen kids die from every single one of the diseases we vaccinate for. My kid will get ALL the vaccinations.”

I said, “Please would you talk to my other moms?”

She smiled at that. “Maybe.”

I hope she did and does.

by

A good reaction

The last ten days sucked but the results are probably good.

What? Wait, why?

I saw the pulmonologist week before last on Wednesday. Her office does not give the new Covid-19 shot but does give flu shots. I got my flu shot. It didn’t seem to bother me much except that I felt a bit tired and grumpy.

I saw my family practitioner on Tuesday, after my pulmonary rehab. For the first time I did not improve in pulmonary rehabilitation (12 weeks, twice a week). I also seemed to have a faster heart rate, up to 140 beats per minute, on the treadmill. My doctor had me walked and even going around the block, my heart rate went to 115. Weird, I thought.

My family doctor did have the new Covid-19 vaccine so I got that. The next day I was more tired and grumpy. On Thursday I lost ground on the treadmill and felt awful and my heart rate just seemed high all the time.

Oh. This is an appropriate reaction for me to two vaccines one week apart. What? you say. Well, when I get pneumonia (four times), I have a fast heart rate response, shortness of breath, fatigue and I feel grumpy and wired. The theory is that I have antibodies to the dopamine receptors, that turn the receptors ON. Dopamine can raise your heart rate. At the same time, I have antibodies to tubulin. Those antibodies make my fast twitch muscles not work right, as well as lung cilia. So: fast heart rate, treadmill is much more difficult, and I started sleeping ten hours a day.

This means my immune system is working. It is making LOTS of antibodies, which is what I theoretically want it to do, though I would rather not have the dopamine and tubulin ones. Just antibodies to influenza and Covid-19. However, my immune system seems to have PTSD and when it makes antibodies, it makes them to EVERYTHING. This makes me very tired, grumpy, screws up exercise and gives me shortness of breath and a fast heart rate.

How long will it last? I am not entirely sure. With infections, antibodies rise and then fall over 3 to 6 or more months. The naturopaths say that food intolerance antibodies fall in three weeks if you stop eating the offending item. I want my Covid-19 antibodies to persist for 3-6 months or more, flu antibodies as well, but I’d like the ones that give me a fast heart rate and shortness of breath to drop right away!

I guess I will find out. At least my immune system works, however oddly.

Blessings and peace you.

I took the photograph of the Great Blue Heron just after she took off yesterday. I am trying to catch more birds in flight! Mostly I catch parts of birds, the tip of a wing, or feet. I am really pleased with this one.

by

how to protect codgers

A friend calls me yesterday, complaining that the new Covid-19 vaccine doesn’t prevent infection nearly enough for him to want to get it. He is in his 70s and says darn it, he’d still have a 60% chance of getting infected.

I thought about it and wrote back this morning:

Re the new vaccine the POINT is NOT to prevent infection, though it lessens it in codgers like me and you.

The point is that the vaccinated younger people shed a s–tload less virus if they get it, because their immune system kills it fast. This reduces the amount of circulating virus so that the codgers stop dying like flies. Also the codgers get less sick if their immune system recognizes B4 and B5.

Got it? Get the vaccine.

I am waiting for the top ten causes of death for 2021 to come out. Over one million US people have died of Covid-19. In 2020, there were between 300-400,000 deaths from Covid. That means that we lost 600-700,000 in 2021. If we lost close to 700,000 people, then Covid-19 would beat out heart disease as the number one cause of death in the US. When did that last happen? During the 1918-1920 influenza, the “Spanish” flu that has been traced to a chicken farm in the US midwest.

Here is a provisional and not final list: https://www.cdc.gov/nchs/data/health_policy/provisional-leading-causes-of-death-for-2021.pdf. Hmmm. The numbers are not adding up unless a lot of US people died of Covid-19 in early 2022. And cancer is higher than it’s ever been and creeping up on heart disease. But these are not the final numbers, sigh.

Here is a fascinating chart: https://www.cdc.gov/nchs/data/dvs/lead1900_98.pdf. If you scroll to the end, the top two causes of death in 1900 were pneumonia first and tuberculosis. Heart was fourth. Heart rises to first in 1910 but then pneumonia is back at the top in 1918-1920. I think that the heart has been number one ever since, in the US. World top ten is not the same.

This is not the first pandemic and it won’t be the last. It is horrible. I think that everyone is doing the best they can, though some responses seem saner than others. Remember the old doctor joke about what to do in a code (when someone’s heart has stopped). First: check your own pulse. It’s a corollary that if the patient is dead, you can try to bring them back, but you can’t make them more dead. Also, my latest Advanced Cardiac Life Support class, on line, told me that sometimes I do not have to do cardiac life support. Their example was a decapitated patient. Really? Ouch, doctor humor. But truly, if you are freaking out or want to scream at someone or feel like the world is nuts and you have to do something, first check your own pulse. Slow it down. Breath in four and out four. I can drop my pulse from 101 to 71 in 20 seconds, just by slowing my breathing. You can learn to too.

My recommendation is that if you are due for the booster, get it. And thank you for protecting me and my friend and the other codgers.

No, it is not snowing here yet. But codger seems to be a word for an old GUY. Humph. Would a grumpy hummingbird be a grummer? What is a female codger? I am using codger for any gender, to heck with it.

by

Vaccine refusal folly

Who should NOT get vaccinated for Covid-19?

This is supposed to be humor. You may not find it funny.

Clearly oppositional defiant people do NOT get vaccinated. Here are a list of the reasons that I have heard, most of them said to my face or on email:

Hyper Conservative:
1. God will take care of me.
2. It’s false news. All made up by the media. The media is liberal. Even Fox News. Even CNN. They don’t know the true meaning of conservatism. I honor the flag.
3. We do our own research. We have better and deeper sources even than QAnon. If you don’t know what I am talking about than you don’t know! Why are you so stupid?
4. Alien lizards made the vaccine and it has tiny nanobots and it is tracking us and will take over our brains. Some people have ALREADY HAD THEIR BRAINS TAKEN OVER BY LIBERAL MEDIA AND NOW QANON! It’s probably best to bunker down.
5. No I don’t vote. Where is my medicaid check? Those evil government people are trying to take away my mother’s social security. If I voted, I would be part of the problem.
6. Masks kill you. Because you breathe your own breath. It’s not the CO2. You didn’t realize that your breath was THAT foul, did you? EEEEEEE-YUK.
7. No one can tell me what to do. If they do, I won’t do it. I won’t die. So there.

Hyper Liberal:
1. Goddess will take care of me.
2. Antibiotics are evil. Vaccines are evil. If you live NATURALLY, you will live forever. But I ordered that book that tells you how to cook your own medicines on your stove!
3. There is this HERB. It fixes everything. What do you MEAN, my kidneys are failing? But I live NATURALLY.
4. Doctors are evil. Well, not naturopaths. The government is evil. Yeah, I’m on medicaid. My mother NEEDS her medicare check. WTF is WRONG with you people? Why would I VOTE on the evil government?
5. Scientists are evil. If they would use NATURAL remedies, we’d all be fine. No, I don’t get labs checked. I don’t need to. Yes, these are shoes. Whaddaya MEAN shoes aren’t natural? These are handmade with hemp processed in a massive factory and NO LEATHER because LEATHER IS EVIL. I have bamboo towels, too, bamboo is natural. What do you MEAN it takes a fungkload of chemicals to process bamboo into fabric? It’s NATURAL.
6. Humans are evil. We should live naturally. Yes, I live in a house. Houses are natural. If you use natural cleansers and only allow natural fabrics and toys and crystals and foods. I don’t approve of logging. Yes, my house is made of wood, what of it?
7. No one can tell me what to do. If they do, I won’t do it. I won’t die. So there.

Martians:
1. It makes their brains explode in their helmets.

Alien Lizards posing as humans:
1. Well, actually we need to get the vaccine. I got it.

Gorillas:
1. They get the vaccine too, even the oppositional defiant ones. Except for the wild ones that are really canny and who we can’t catch and dart gun with the vaccine.

This is supposed to be humor. You may not find it funny. Don’t use it as proof that you shouldn’t get the vaccine, though people with really crazy ideas shouldn’t get it. Did you hear that they are about to send all the remaining vaccine supply to Africa because people here are refusing it? Is that a rumor or is it true?
The CDC has other ideas. But we don’t trust them, right?

For the Ragtag Daily Prompt: folly.

by

Covid-19: omicron

So far, it looks like the Omicron variant is more infectious and less virulent.

“This is good, right? you say, “We can all just get it, then we are immune, move on with our lives.”

There are three, no, four major problems that I can think of right off the bat.

1. Long Haul Covid. We do not know if Omicron will cause Long Haul Covid. This is a big deal. The numbers right now are suggesting that one third of the people who get Covid-19, even a mild case, still have problems at six months out and twelve months out. Are you willing to take a one in three chance? Not me! We do not know how to fix Long Haul Covid-19, we don’t know what it is (even though I have suspicions) and some people can’t even get out of bed. This is bad.

2. Omicron will be happily playing with Delta and trading genes and making NEW babies. As one math joker says, “hey, don’t screw up Pi for us.” We could get a version with the infectious capacity of Omicron and the virulence of Delta. This is also bad.

3. We don’t know what it will do to small children and babies and the very old and the immunosurpressed and Covid-19 turns out to infect fat cells which is theoretically why overweight and obese people in their thirties are dying with it. The doc group I am in on Facebutt is reporting a 5% survival with long term ECMO (heart lung bypass machine) and that people may need to be on the machine for months. Like, eight months. This requires two nurses at all times, not to mention a specialist. A few places report 30% survival, but they also say that they say NO a lot and refuse people they think will not survive. Might as well pick the ones that might survive, right?

4. We don’t know if the drugs we have right now work against it. Some may, some may not. Starting over.

So, I still say get immunized if you haven’t and get boosted if you have. Get your influenza shot too. The masks are helping with influenza this year too, but if flu really got a hold, flu in post-covid would be a very very effective killer. And if you are 65* you should get your prevnar vaccine, for pneumococcal pneumonia. It used to be called “the old man’s friend” because it’s such an effective killer of people 65 and up. The new shingles vaccine, yeah, get that too. Do you feel like a pincushion yet?

No word yet from my immunologist. If I am not making antibodies to Covid-19, do I cancel my Christmas trip? Dunno. Will wait to hear.

Happy whatever you celebrate.


1. https://www.cnn.com/2021/12/02/world/south-africa-omicron-origins-covid-cmd-intl/index.html?utm_source=fbCNN&utm_medium=social&utm_content=2021-12-02T13%3A31%3A02&utm_term=link&fbclid=IwAR0NySrFr-I_ieYmVMQawstw6-oEGlxf32MgcbKyLz8RvpdHHGfzZ678XTY

2. https://robinschoenthaler.medium.com/everything-you-ever-wanted-to-know-about-omicron-that-we-dont-know-yet-d85bdd64d76e

3. https://longbeach.gov/press-releases/omicron-variant-of-covid-19-virus-found-in-long-beach/. Yep, in my state.

4. https://www.cdc.gov/coronavirus/2019-ncov/variants/omicron-variant.html

* Or are younger and have heart disease, lung disease or anything really complicated, like cancer, lupus, autoimmune stuff, etc, etc.

by

Covid-19: in flew Enza

Survey shows 6 in 10 Americans will delay or skip flu shots this year.

Oh, dear. Not going to get your influenza shot? I am. Well, you say, YOU are on oxygen and have tricky lungs and keep yammering about imaginary Pandas.

Yes, and you should get your vaccine anyhow, even if you are healthy as a hoss.

If not for yourself, for everyone else. Because usually influenza kills 12,000 to 61,000 US citizens a year and gosh, guess what it will do to post-Covid long haulers. Um, kill, I would expect. And with a very low influenza winter last winter, because covid and masks and social distancing, immunity is down and the infectious disease folks are anticipating that it could be a worse than usual influenza year. How many people have long covid? This just in: More than half of covid survivors experience post acute sequelae to covid 19 (PASC) at 6 months after. ““The most common PASC involved functional mobility impairments, pulmonary abnormalities, and mental health disorders,” wrote Destin Groff, Penn State College of Medicine and Milton S Hershey Medical Center, Hershey, Pennsylvania, and colleagues. ”These long-term PASC effects occur on a scale that could overwhelm existing health care capacity, particularly in low- and middle-income countries.”

AND not only that, even if you or your friend or mother or grandmother don’t die of influenza, far more people clog up emergency rooms and doctor’s offices. The “CDC estimates that influenza has resulted in between 9 million – 45 million illnesses, between 140,000 – 810,000 hospitalizations and between 12,000 – 61,000 deaths annually since 2010.”* And the doctors and nurses and emergency people and nursing home employees and first responders are already short staffed and tired. So if you won’t get your flu vaccine for the general public, get it for the first responders.

AND before you tell me that “the vaccine gave me flu”, hello, it takes up to two weeks for the flu vaccine to confer immunity, and so if you got influenza two days later, you didn’t get it from the vaccine, you got it because you got the vaccine too late. Vaccine complications, well, I have seen one complication in my 30 years of Family Medicine, and it was someone I knew, not a patient. And half the people who tell me that “the vaccine gave me flu”, stomach flu with diarrhea and barfing is not influenza. It’s more likely to be a hangover than anything else. I see a lot more post alcohol “stomach flus” than true food poisoning. Quit drinking so much alcohol, ok?

And while you are at it, you’d better get the Covid-19 vaccine while it is still available free. And before you get on an airplane for Thanksgiving or go Trick or Treating with all those little germ spreaders or fly off to see family at Christmas/Kwanza/Winter break/whatever. Two weeks before, at least. Like, NOW. Or don’t, whatever, just don’t whine to ME about more deaths.

This public service message has been brought to you by a beneficent alien lizard. Feel free to send money.

*https://www.cdc.gov/flu/about/burden/index.html

by

On vaccination: rock stubborn

A friend in his 30s was working on my car the other day. “Are you immunized?” I ask. “No.” he says. “I wish you’d get immunized,” I say, “Also, I can’t ride in the car with you because if I get the Delta variant, I’ll probably die.” He responds, “I hate doing what other people tell me to do.” “Oh,” I say, “Oppositional defiant, just like me. Fine. Don’t get the vaccine.”

Two days later I text. “Don’t get the vaccine today. Or tomorrow.”

I hear back. He got vaccinated the day I sent the text. I don’t know if it was me saying don’t do it, or me getting out of the car and staying a good ten feet away after that. Please don’t kill me, not today, ok?

Maybe we should try it nation wide. “DON’T GET VACCINATED. DON’T DO IT TODAY. OR TOMORROW.”

Unvaccinated thirty year olds are getting really sick and getting intubated and dying. One in five hospitals in the US now is 95% full, on divert. I used to heave a sigh of relief when I was in residency and we were on divert. That meant no admissions until beds opened back up. We are full. But one in five is really bad. Virginia Mason in Seattle is on divert. Our rural county has more covid infections than we’ve had the whole time, mostly unvaccinated. About 15% vaccinated. We are starting to see the breakthrough infections, around 8 months after the vaccine. Makes sense, because the vaccine riles up the immune system for 8 months and then quiets down. I am 8 months out, no immune system, high bleeping risk. The head of the heart lung bypass part of Virgina Mason was interviewed. “We have been full for ten months (?or a year) and have turned away over 150 patients.” So heart lung bypass could save lives in covid. But it takes round the clock two ICU nurses and the ICU nurses are burning out, quitting, dying. If they get too tired, their immune systems don’t work, they are more at risk for covid and they could die. The nurses and the doctors KNOW this. So…. how many unimmunized people are you willing to die for? Just curious.

Kids have been at home, quarantined, small groups. So then they started school or daycare or even a few more playdates and hello: when you get them together, they trade viruses. There is an outbreak of RSV and other viruses. RSV won’t kill most kids but some babies need the hospital and it can kill premies. And the beds, remember, are full.

Now the AAFP is calling for emergency authorization for kids age 2-11 to get the vaccine. Because they are dying too and there bloody won’t be room in the hospitals at this rate. Or well, you can build a tent, but if you don’t have any ICU nurses, the tent is not too helpful.

For the governors saying “No mask mandate at school,” yeah, well, I think they should refuse the vaccine and refuse treatment and refuse intubation and refuse oxygen.

Meanwhile, I am hiding under the bed. Roll up the sidewalks, lock the doors, I am sorry not to be useful but I am not useful dead. I could telemedicine if our area gets shorthanded enough. I suppose I should call the hospital and say that. They aren’t that desperate… yet. We have four ventilators last I checked. And 32,000 people in the county and we are the only hospital. Bummer.

I am in a physician mothers Facebook group. The stories are getting grimmer and grimmer. A physician put up the list of hospitals she called to try to transfer a patient: over 30. All no. Another is in North Carolina and got a call from Texas to transfer a patient. But… they were on divert. No.

Take care. Don’t get your immunization if you are against it. Whatever.

by

Covid-19: A gentle answer

I went to have a hair cut today and went in three shops since I was downtown anyhow.

There are lots of tourists and visitors walking around without masks.

In one shop the owner asks if I am Dr. O, and it turns out her daughter babysat for my children 19-20 years ago. We had a nice discussion about our offspring. We are both wearing masks.

In a mineral store somehow the covid-19 subject comes up. I say that I am wearing a mask because I am on oxygen and vulnerable, and even though I am vaccinated, if I get covid-19, it might kill me.

The two owners are not wearing masks. The woman says, “We are both vaccinated, but I am just really confused about what to do.”

I say, “Well, I am a Family Physician. Let’s take chicken pox. If someone is exposed, it can take 21 days for them to break out in the rash. They will be contagious for 1-2 days before they have symptoms. The problem is that it can be ANY of those 21 days. After they break out in the rash, they are contagious until every pox is crusted over. So it can be six weeks that they are possibly or certainly contagious. With Covid-19, the Delta Variant is so infectious and again people may not have symptoms yet, so I am wearing a mask any time I am around strangers.”

The woman says, “Thank you for telling me about it. It’s helpful to hear from a professional.”

“You’re welcome.” I say, gathering my bag to go.

“Look,” she says, “I am putting on my mask now!”

I look and she is.

by

Covid-19 Delta Variant

This article: The CDC warns that the delta variant is as contagious as chicken pox and can make people sicker than the original Covid-19

Chicken pox has up to 21 days before you break out after exposure. It is really really contagious. And it is infectious until every pustule has scabbed over. And it can kill people, especially adults. It can also cause some pretty awful birth defects, which is why we ask every patient who is pregnant if they have had chicken pox or the vaccine. If not, we check antibodies. If they have no antibodies and are exposed, they are to get VZIG within 48-72 hours, an antibody to the virus to try to stop the birth defect. In my small town, it’s flown in by the health department.

So as contagious as chickepox is really bad. Chickenpox is worse than influenza. Tuberculosis is a very small bacteria and can be airborne as well.

The delta variant kills people who are unvaccinated at a higher rate than the original Covid-19. The 30-50 year olds are dying.

The delta variant can infect vaccinated people though rarely. The vaccinated people are way less likely to be hospitalized and die. However, someone walking around with delta (vaccinated or unvaccinated) apparently sheds 1000 times more virus than the original Covid-19. This means that we all need to put our masks back on unless we are in our homes with the very small groups we should stick with. If we do not do that, we may have more deaths this winter than last winter.

I double masked on the plane, one flight from Chicago to Seattle, two days ago. I kept the mask on in the taxi and waiting for the ferry. I felt most exposed waiting for the ferry because fully half the people were ignoring all of the mask signs. Ah well. I was going to travel in late August again but the prediction is for a big Covid-19 wave starting to peak in 4-6 weeks. Seems like a bad time to go anywhere, much less on oxygen.

Gather up whatever you need to get through the winter and get ready. Enjoy the August sun, but store up things for this winter. I think it is still going to be a hard one.


There is lots of detail on the CDC website.
will the unvaccinated change their minds in time?