I pity any doctor who faces so many treatment options for the seemingly never ending march of Covid variations, Dr. Hollander.
My wife is a CRNA with about 35 years of experience. During the worst of the pandemic she was always on the wrong side of the sterile barrier. Double N95 masks plus plastic welder style shields were the order of the day for anesthesia providers, and yes, she did having a pregnant woman fib about not having eaten. The result was vomit hitting my wife's mouth, nose and eyes.
I should mention that my wife is 15 years younger than my soon approaching 79 years, and thus much more healthy than me.
Being married to a medical professional at Advent Health in Ocala, FL made it possible for me to get my Moderna shots just after Christmas of 2020 and the end of January of 2021. In December of 2021 I received a Moderna booster.
After attending a national volleyball tournament in Orlando in June that included our granddaughter's team, I caught Covid for the first time.
Once again, Nurse Mary came to the rescue, opening a Covid test kit as soon as we got home.
She forced me to drink what seemed like a gallon of water and half a gallon of OJ.
She then called our family doctor to get access to the drug regime used at her hospital for patients who are within the first 24-36 hours of exposure.
Because of my age and my half century smoking habit she got a prescription for an 10 day course of antibiotics to keep my lungs functioning, 20 milligram of prednisone, and several other meds I cannot remember.
My fever and other symptoms cleared out within three days.
I'm sharing this information to illustrate how how many variables go into treating the Covid variations. I suspect I would not have fared so well had I not been married to a spouse with broad experience dealing with the pandemic.
When President Biden came down with Covid, my wife's initial reaction about Paxlovid was similar to yours.
I appreciate your articles dealing with Covid and other complex medical issues for those of us who barely crept up to a B- when we took Biology 101 and Chemistry 101 so long ago.
After two years of almost daily cringing at the arrogance, dishonesty, and incompetence of Fauci, Levine, Walensky and Birx, the notion that Biden is getting great medical care is laughable. These people have set the cause of trusted physicians back a generation.
Agree. There is clearly pressure to prescribe this medication. I can’t help but wonder whether some of this relates to profits for the manufacturer.
I have 3000 patients on my panel of whom about 80-85% are vaccinated. Out of all of these I’ve had a single Covid hospitalization since the beginning of last year, and that was in a patient who received her vaccines while on immunosuppressive medication. Anecdotal, I realize, but when you’re more or less batting a thousand, how much better can you do?
I read the original “Covid rebound” results. They said that the five per cent rebound with Paxlovid was identical in the control group. Paxlovid does not cause the rebound; it simply does not prevent it. I’ve never read a single article that refers to this. It seems that a Paxlovid rebound is an attractive story. Am I wrong?
It's an important question. I'm only aware of 3 sources on this; the Pfizer trial (claiming 2% rebound in Paxlovid and placebo), and 2 poor studies from Mayo (<1%) and Case Western (5%), neither of which compared to a control group not given Paxlovid (ie they did not answer your question). The problem w/ the Pfizer data is a) it's from Pfizer media reports and they never showed us the data and b) it does not match the bit of data they shared w/ the FDA which suggests >10% rate. The other 2 studies were retrospective and pulled from EHR records, which is an inherently terrible approach to getting an accurate answer (how often does a patient's rebound actually merit a correct ICD-10 code from their MD in an EHR?). I honestly believe any physician who actually prescribes Paxlovid will tell you the rate is over 10%. Now, to your question, how often does "viral rebound" happen on its own? A lot less, anecdotally. The pre-Omicron (like the Pfizer trials) data from the NBA bubble suggests positive-negative-positive testing virtually never happened. I haven't seen published data on Omicron, but have seen a couple anecdotes (out of 100s of cases!) where a patient seems to have cleared their covid symptoms and then they roar back after 1-2 days. I don't know that they would have tested negative dueing the symptom lull, which is a feature of Paxlovid rebound which makes it so insidious. I do think we'll have an answer fairly soon; an interesting teaming of Eric Topol and Michael Mina is apparently running a study on this. The concept is incredibly simple and easy as studies go: get a few hundred patients, randomize (or case match if you are not up for randomization) to Paxlovid or control, give them each a bunch of rapid tests, and get a daily test/symptom report for 2 weeks. It's frankly embarrassing that a major institution like Mayo published a retrospective, EHR-based study claiming an absurdly low number instead of doing this. The seduction of quick, cheap results from chart reviews...
The last speech I saw Biden give a couple days ago, he had his sunglasses on even though he was in a shaded area facing the building, he was confused on whether or not he was the vice prez, and the left side of his mouth was drooping down while the right side remained straight. He was propped up in some earlier speeches and there were noticeable bug eyes and lack of blinking incidents along with slurring. Is there something more going on here? We may never know. At least not until the tell-all books start coming out long after the next election.
While suggesting benefit from paxlovid treatment, the overall severe covid rate was 0.5% in high risk patients, the vast majority of whom were not treated.
If Biden has such great care why no test as to whether he has dementia as he clearly does? Democrats insisted Trump get tested every five minutes. How about just once for Biden?
But since they know the answer there is no chance of Biden being tested. So we will continue to be led by a man with progressive dementia while who knows who is pulling his strings. It is almost cruel to watch except that it is hard to have sympathy for a man who sexually assaulted his own daughter - according to her diary.
That's a great question no one is asking. I assume it's because the mechanism of action of molnupiravir makes people nervous about unexpected problems with viral (and host!) genetic evolution. And because its modest efficacy vs Delta might imply almost none vs Omicron (although the few real world studies including molnupiravir showed some benefit, just much less than Paxlovid). I, and many others, questioned it even being approved under EUA, and can't imagine the circumstance under which I would prescribe it.
Such irony. Throughout the entire covid debacle, the Democrats used the virus to wage unrestricted economic and political warfare on the nation; while at the same time actively obstructing and sabotaging every effort to develop and distribute a vaccine. Yet, when that vaccine became available despite their efforts to keep it from being developed, they were the first in line to receive the vaccine; and in far too many cases, they pushed others out the way to be inoculated.
From what I saw it was Democrats who pushed everyone aside to get vaccinated. As for whether to get vaccinated or not that should be a personal decision - as Democrats claimed it would be, at first. It’s not as if the vaccines halted the spread of infection.
Of course we now know that the virus was created in a Chinese lab with poor safety protocols and the research was funded with US taxpayer dollars in violation of federal law. Fauci helped to kill over six million people - no wonder he is retiring. I can’t wait to hear his testimony before the House committee investigating his lies, omissions and means of enriching himself at taxpayer expense (all graphically laid out ina recent book) once we have a new Congress sworn in in January - that is, if the Democrats accept the election results or cheat their way to holding onto power.
Fauci is a monster - his actions during the aids epidemic should have landed him in jail. I am looking forward to seeing him squirm.
This is so bad that as a physician I am ashamed it is written by one. Where has Buzz been for the last 2.5 years? Over a million people have died prematurely and using a proven effective treatment (Paxlovid) is overreacting? Paxlovid has a very good risk/benefit ratio. The main side effect is a bad taste in the mouth but "Buzz" thinks giving it to people at risk for life threatening is questionable? Buzz claims to be an objective reviewer of medical data but he picks and chooses data. I don't see a MPH after his name. He should stick to areas he is trained in.
Over a million people have died prematurely because Fauci and CDC/FDA etc have forbidden and blocked in every way possible the use of safe, effective, cheap, generic early treatment drugs. When you recognize and discount the sham, rigged “trials” like Together, Recovery, Solidarity, and the others that either used toxic overdoses, ineffective under doses, omitted cocktail ingredients, started trials days after symptoms, dosed on empty stomach, conducted trials in areas already using the drug and not checking for drug use in control group, well when you get a level playing ground, both HCQ and IVM are highly effective.
The point I think the good Dr misses is that having covid is miserable; Paxlovid makes you feel MUCH better within ~12 hours of your first dose, and you are essentially symptom free within 36 hours. My experience was 100% positive, and I would happily pay $530 out of pocket if I had to. I take no medications, so no problems with stopping other medicines.
Honestly, how do you know you wouldn’t have felt better anyway without the Paxlovid? I’ve seen more than a few vaccinated patients in my clinic at this point who thought they had minor seasonal allergies or a slight cold and turned out to have Covid. They recovered completely within a day or two without any treatment whatsoever. I seem to recall one chortling husband with “allergies” who caught the virus from his vaccinated wife, who’d been entirely asymptomatic and only found out she was positive a week or two prior because she had to get a screening Covid test before her routine colonoscopy.
I get it. But I also see many patients who don’t take anything at all and also feel better within literally hours.
Bottom line, there should be a study done.
Tamiflu HAS been studied that way and the conclusion was that it shortens the course of influenza by about one day. That’s not nothing but it’s not a huge decrease either.
All of this ignores the fact that doctors are being pushed to prescribe Paxlovid not so much for symptom relief as for prevention of hospitalization / death. I have to say I tend to agree with Buzz that for most vaccinated individuals it probably doesn’t really do that. I also agree that stopping an anticoagulant in order to prescribe an antiviral of questionable benefit in a patient at risk for thrombosis, infected with a virus with known procoagulant tendencies, seems hazardous.
I do think the best we'll ever get is the incomplete EPIC-SR study, and the lack of symptom improvement in the Paxlovid group in a largely vaccinated population over placebo tells me all I need to know: on a population level, Paxlovid won't help much with symptom resolution. That said, I don't want to deny anyone's anecdotes! I'm sure some immune people really benefit from a sudden down-ramp of viral replication; but suspect most don't, and others have any short-term benefit counteracted by rebound, hence the lack of overall benefit in the trial in this regard. The problem is we don't know who the responders will be! And I agree, Mike - lots of people turn around "on a dime" without any meds; it's just some people's Covid disease course, and can make a placebo look really good.
“Tamiflu HAS been studied that way and the conclusion was that it shortens the course of influenza by about one day. That’s not nothing but it’s not a huge decrease either.”
Elderberry syrup. Vitamin D3. Vitamin C. All highly effective for the flu. And Covid. And I would try on RSV as well. And IVM.
Of course it is impossible to say with certainty on the basis of one patient that Paxlovid made any difference. That said, I have had my share of viral illnesses over 71 years, and I can say with certainty that I have never had any viral illness improve as mine did after 12 hours on Paxlovid. Could be coincidence, but based on the mechanism of function, it would be surprising if symptoms did *not* improve rapidly. I am pretty sure rapid improvement was also frequently observed in controlled trials. I do have a second data point: my younger brother (67) reported exactly the same rapid improvement with Paxlovid. His wife (64, double vaccinated and double boosted, but did not 'qualify' for Paxlovid) suffered 7 days of miserable symptoms, followed by gradual improvement over 7 days. I'd take the Paxlovid over that every time. BTW, my fever had reached 102.7F within 24 hours of first noted symptoms, with a terrible headache, dry cough, and all-over body aches..... and all symptoms were getting worse before the Paxlovid.
Please, Florida has a much larger fraction of the population over 65..... and those are the people who die from covid. Florida has the oldest population of any state (except maybe Maine... depends on the source), so simple comparisons with states with younger populations are neither accurate nor informative.
When 3/4 of Americans are obese or overweight, and we only have 13 % African Americans, there is one hella way more other people stuffing their gullet with donuts and mayo laden salads.
Since by 2030 over 85 % of Americans will be overweight or obese, we can't keep blaming it on poverty levels. There are not that many in that category.
All Americans overeat. They just don't want to admit it. Most don't want to admit they are overweight. Just pleasingly plump or stocky.
I pity any doctor who faces so many treatment options for the seemingly never ending march of Covid variations, Dr. Hollander.
My wife is a CRNA with about 35 years of experience. During the worst of the pandemic she was always on the wrong side of the sterile barrier. Double N95 masks plus plastic welder style shields were the order of the day for anesthesia providers, and yes, she did having a pregnant woman fib about not having eaten. The result was vomit hitting my wife's mouth, nose and eyes.
I should mention that my wife is 15 years younger than my soon approaching 79 years, and thus much more healthy than me.
Being married to a medical professional at Advent Health in Ocala, FL made it possible for me to get my Moderna shots just after Christmas of 2020 and the end of January of 2021. In December of 2021 I received a Moderna booster.
After attending a national volleyball tournament in Orlando in June that included our granddaughter's team, I caught Covid for the first time.
Once again, Nurse Mary came to the rescue, opening a Covid test kit as soon as we got home.
She forced me to drink what seemed like a gallon of water and half a gallon of OJ.
She then called our family doctor to get access to the drug regime used at her hospital for patients who are within the first 24-36 hours of exposure.
Because of my age and my half century smoking habit she got a prescription for an 10 day course of antibiotics to keep my lungs functioning, 20 milligram of prednisone, and several other meds I cannot remember.
My fever and other symptoms cleared out within three days.
I'm sharing this information to illustrate how how many variables go into treating the Covid variations. I suspect I would not have fared so well had I not been married to a spouse with broad experience dealing with the pandemic.
When President Biden came down with Covid, my wife's initial reaction about Paxlovid was similar to yours.
I appreciate your articles dealing with Covid and other complex medical issues for those of us who barely crept up to a B- when we took Biology 101 and Chemistry 101 so long ago.
Thank you for "Buzzing" us periodically.
You were lucky to have your wife treating you for Covid.
Yes, Veronica, I am blessed in more areas than just her medical expertise.
Thank you for your comment.
Really lucky that she’s 15 years younger than him! Woot!
That's what happens when you become a widower in your mid 50s. The pool of compatible ladies becomes quite limited.
Once you get past 40, a 10 or 15 year difference is not as worthy of "Woot!" 😄
After two years of almost daily cringing at the arrogance, dishonesty, and incompetence of Fauci, Levine, Walensky and Birx, the notion that Biden is getting great medical care is laughable. These people have set the cause of trusted physicians back a generation.
Agree. There is clearly pressure to prescribe this medication. I can’t help but wonder whether some of this relates to profits for the manufacturer.
I have 3000 patients on my panel of whom about 80-85% are vaccinated. Out of all of these I’ve had a single Covid hospitalization since the beginning of last year, and that was in a patient who received her vaccines while on immunosuppressive medication. Anecdotal, I realize, but when you’re more or less batting a thousand, how much better can you do?
I read the original “Covid rebound” results. They said that the five per cent rebound with Paxlovid was identical in the control group. Paxlovid does not cause the rebound; it simply does not prevent it. I’ve never read a single article that refers to this. It seems that a Paxlovid rebound is an attractive story. Am I wrong?
It's an important question. I'm only aware of 3 sources on this; the Pfizer trial (claiming 2% rebound in Paxlovid and placebo), and 2 poor studies from Mayo (<1%) and Case Western (5%), neither of which compared to a control group not given Paxlovid (ie they did not answer your question). The problem w/ the Pfizer data is a) it's from Pfizer media reports and they never showed us the data and b) it does not match the bit of data they shared w/ the FDA which suggests >10% rate. The other 2 studies were retrospective and pulled from EHR records, which is an inherently terrible approach to getting an accurate answer (how often does a patient's rebound actually merit a correct ICD-10 code from their MD in an EHR?). I honestly believe any physician who actually prescribes Paxlovid will tell you the rate is over 10%. Now, to your question, how often does "viral rebound" happen on its own? A lot less, anecdotally. The pre-Omicron (like the Pfizer trials) data from the NBA bubble suggests positive-negative-positive testing virtually never happened. I haven't seen published data on Omicron, but have seen a couple anecdotes (out of 100s of cases!) where a patient seems to have cleared their covid symptoms and then they roar back after 1-2 days. I don't know that they would have tested negative dueing the symptom lull, which is a feature of Paxlovid rebound which makes it so insidious. I do think we'll have an answer fairly soon; an interesting teaming of Eric Topol and Michael Mina is apparently running a study on this. The concept is incredibly simple and easy as studies go: get a few hundred patients, randomize (or case match if you are not up for randomization) to Paxlovid or control, give them each a bunch of rapid tests, and get a daily test/symptom report for 2 weeks. It's frankly embarrassing that a major institution like Mayo published a retrospective, EHR-based study claiming an absurdly low number instead of doing this. The seduction of quick, cheap results from chart reviews...
Maybe Hunter should share some of his meds - 10 for the Big Guy.
There's never any left over...
The last speech I saw Biden give a couple days ago, he had his sunglasses on even though he was in a shaded area facing the building, he was confused on whether or not he was the vice prez, and the left side of his mouth was drooping down while the right side remained straight. He was propped up in some earlier speeches and there were noticeable bug eyes and lack of blinking incidents along with slurring. Is there something more going on here? We may never know. At least not until the tell-all books start coming out long after the next election.
Effectiveness of Paxlovid in Reducing Severe Coronavirus Disease 2019 and Mortality in High-Risk Patients
Ronza Najjar-Debbiny, Naomi Gronich, Gabriel Weber, Johad Khoury, Maisam Amar, Nili Stein, Lee Hilary Goldstein, Walid Saliba Author Notes
Clinical Infectious Diseases, ciac443, https://doi.org/10.1093/cid/ciac443
Published: 02 June 2022
While suggesting benefit from paxlovid treatment, the overall severe covid rate was 0.5% in high risk patients, the vast majority of whom were not treated.
If Biden has such great care why no test as to whether he has dementia as he clearly does? Democrats insisted Trump get tested every five minutes. How about just once for Biden?
But since they know the answer there is no chance of Biden being tested. So we will continue to be led by a man with progressive dementia while who knows who is pulling his strings. It is almost cruel to watch except that it is hard to have sympathy for a man who sexually assaulted his own daughter - according to her diary.
Monulpiravir, a Merck antiviral from Merck, does not interact with Eliquis. Why wasn't he put on that?
That's a great question no one is asking. I assume it's because the mechanism of action of molnupiravir makes people nervous about unexpected problems with viral (and host!) genetic evolution. And because its modest efficacy vs Delta might imply almost none vs Omicron (although the few real world studies including molnupiravir showed some benefit, just much less than Paxlovid). I, and many others, questioned it even being approved under EUA, and can't imagine the circumstance under which I would prescribe it.
Such irony. Throughout the entire covid debacle, the Democrats used the virus to wage unrestricted economic and political warfare on the nation; while at the same time actively obstructing and sabotaging every effort to develop and distribute a vaccine. Yet, when that vaccine became available despite their efforts to keep it from being developed, they were the first in line to receive the vaccine; and in far too many cases, they pushed others out the way to be inoculated.
From what I saw it was Democrats who pushed everyone aside to get vaccinated. As for whether to get vaccinated or not that should be a personal decision - as Democrats claimed it would be, at first. It’s not as if the vaccines halted the spread of infection.
Of course we now know that the virus was created in a Chinese lab with poor safety protocols and the research was funded with US taxpayer dollars in violation of federal law. Fauci helped to kill over six million people - no wonder he is retiring. I can’t wait to hear his testimony before the House committee investigating his lies, omissions and means of enriching himself at taxpayer expense (all graphically laid out ina recent book) once we have a new Congress sworn in in January - that is, if the Democrats accept the election results or cheat their way to holding onto power.
Fauci is a monster - his actions during the aids epidemic should have landed him in jail. I am looking forward to seeing him squirm.
Pidgeon hole much?
I thought Lefties were *nuanced.*
Ah, yes. I remember now.
Well, M. Gene, You are an exception, then, to that famous rule, "if it walks like a duck, and talks like a duck...."
And you've fooled me twice now. Shame on me!
Best answer concerning Paxlovid;
Ivermectin. Better in every way but one; pharma profit. Which is more important, their profit or your health?
Best appraisal of the reality of Covid I have ever read.
This is so bad that as a physician I am ashamed it is written by one. Where has Buzz been for the last 2.5 years? Over a million people have died prematurely and using a proven effective treatment (Paxlovid) is overreacting? Paxlovid has a very good risk/benefit ratio. The main side effect is a bad taste in the mouth but "Buzz" thinks giving it to people at risk for life threatening is questionable? Buzz claims to be an objective reviewer of medical data but he picks and chooses data. I don't see a MPH after his name. He should stick to areas he is trained in.
Over a million people have died prematurely because Fauci and CDC/FDA etc have forbidden and blocked in every way possible the use of safe, effective, cheap, generic early treatment drugs. When you recognize and discount the sham, rigged “trials” like Together, Recovery, Solidarity, and the others that either used toxic overdoses, ineffective under doses, omitted cocktail ingredients, started trials days after symptoms, dosed on empty stomach, conducted trials in areas already using the drug and not checking for drug use in control group, well when you get a level playing ground, both HCQ and IVM are highly effective.
You respond with much, too much, vitriol "Donny."
My name is not Donny.
And you miss my point.
The point I think the good Dr misses is that having covid is miserable; Paxlovid makes you feel MUCH better within ~12 hours of your first dose, and you are essentially symptom free within 36 hours. My experience was 100% positive, and I would happily pay $530 out of pocket if I had to. I take no medications, so no problems with stopping other medicines.
Honestly, how do you know you wouldn’t have felt better anyway without the Paxlovid? I’ve seen more than a few vaccinated patients in my clinic at this point who thought they had minor seasonal allergies or a slight cold and turned out to have Covid. They recovered completely within a day or two without any treatment whatsoever. I seem to recall one chortling husband with “allergies” who caught the virus from his vaccinated wife, who’d been entirely asymptomatic and only found out she was positive a week or two prior because she had to get a screening Covid test before her routine colonoscopy.
I felt better within hours - before that it was three days of misery. My friend got it earlier and it stopped the disease right away
I get it. But I also see many patients who don’t take anything at all and also feel better within literally hours.
Bottom line, there should be a study done.
Tamiflu HAS been studied that way and the conclusion was that it shortens the course of influenza by about one day. That’s not nothing but it’s not a huge decrease either.
All of this ignores the fact that doctors are being pushed to prescribe Paxlovid not so much for symptom relief as for prevention of hospitalization / death. I have to say I tend to agree with Buzz that for most vaccinated individuals it probably doesn’t really do that. I also agree that stopping an anticoagulant in order to prescribe an antiviral of questionable benefit in a patient at risk for thrombosis, infected with a virus with known procoagulant tendencies, seems hazardous.
I do think the best we'll ever get is the incomplete EPIC-SR study, and the lack of symptom improvement in the Paxlovid group in a largely vaccinated population over placebo tells me all I need to know: on a population level, Paxlovid won't help much with symptom resolution. That said, I don't want to deny anyone's anecdotes! I'm sure some immune people really benefit from a sudden down-ramp of viral replication; but suspect most don't, and others have any short-term benefit counteracted by rebound, hence the lack of overall benefit in the trial in this regard. The problem is we don't know who the responders will be! And I agree, Mike - lots of people turn around "on a dime" without any meds; it's just some people's Covid disease course, and can make a placebo look really good.
“Tamiflu HAS been studied that way and the conclusion was that it shortens the course of influenza by about one day. That’s not nothing but it’s not a huge decrease either.”
Elderberry syrup. Vitamin D3. Vitamin C. All highly effective for the flu. And Covid. And I would try on RSV as well. And IVM.
Of course it is impossible to say with certainty on the basis of one patient that Paxlovid made any difference. That said, I have had my share of viral illnesses over 71 years, and I can say with certainty that I have never had any viral illness improve as mine did after 12 hours on Paxlovid. Could be coincidence, but based on the mechanism of function, it would be surprising if symptoms did *not* improve rapidly. I am pretty sure rapid improvement was also frequently observed in controlled trials. I do have a second data point: my younger brother (67) reported exactly the same rapid improvement with Paxlovid. His wife (64, double vaccinated and double boosted, but did not 'qualify' for Paxlovid) suffered 7 days of miserable symptoms, followed by gradual improvement over 7 days. I'd take the Paxlovid over that every time. BTW, my fever had reached 102.7F within 24 hours of first noted symptoms, with a terrible headache, dry cough, and all-over body aches..... and all symptoms were getting worse before the Paxlovid.
That's right. It's all about you, your (anecdotal) case, and what "change" you are fortunate to be able to carry around.
We’ll dismiss comment #3 as you were probably jabbed and now have brain damage.
touché...
only time will tell…. check VAERS
Please, Florida has a much larger fraction of the population over 65..... and those are the people who die from covid. Florida has the oldest population of any state (except maybe Maine... depends on the source), so simple comparisons with states with younger populations are neither accurate nor informative.
Most imortant - OBESITY which nobody is supposed to talk about since in USA 3/4 of the population is overweight or obese.
When 3/4 of Americans are obese or overweight, and we only have 13 % African Americans, there is one hella way more other people stuffing their gullet with donuts and mayo laden salads.
Since by 2030 over 85 % of Americans will be overweight or obese, we can't keep blaming it on poverty levels. There are not that many in that category.
All Americans overeat. They just don't want to admit it. Most don't want to admit they are overweight. Just pleasingly plump or stocky.
Low information Commenter
Nothing matters if you are obese. Stuffing your gullet with 2 dozen donuts by 8 A.M>
I guess being a left wing racist sexist snowflake must be fun for you. Enjoy!
You sure speak like a lefty…name-calling, generalizations, assumptions…