Category: Health

M.R.I. Inventor and Entrepreneur Earned Patent, But Was Denied Nobel Prize

(p. B10) Dr. Raymond Damadian, who built the first magnetic resonance imaging scanner, which revolutionized doctors’ ability to diagnose cancer and other illnesses — but who, to his dismay, saw the Nobel Prize for the science behind it go to two others — died on Aug. 3 [2022] at his home in Woodbury, N.Y.

. . .

The vision of scanning the human body without radiation came to Dr. Damadian in the late 1960s, he said, when he was working on nuclear magnetic resonance spectroscopy — which, until then, had been used to identify the chemical makeup of the contents of a test tube — at Downstate Medical Center (now SUNY Downstate Health Sciences University) in Brooklyn.

Working with rats, he discovered that when tissues were placed in a magnetic field and hit with a pulse of radio waves, cancerous ones emitted distinctly different radio signals than healthy ones.

He published his findings in 1971 in the journal Science and was granted a patent three years later for an “apparatus and method for detecting cancer in tissue.” It took 18 months to build the first M.R.I., originally known as a nuclear magnetic resonance scanner, or N.M.R. Its first scan, on July 3, 1977, was of Lawrence Minkoff, one of Dr. Damadian’s assistants — a vivid and colorful image of his heart, lungs, aorta, cardiac chamber and chest wall.

“Having birthed the original idea of the N.M.R. body scanner, we were intent on being the first to accomplish it,” Dr. Damadian said in the book “Gifted Mind: The Dr. Raymond Damadian Story, Inventor of the M.R.I.,” published in 2015, which he wrote with Jeff Kinley. “Failing to do so meant we might be denied the recognition for the original idea.”

But the technology behind the M.R.I. had several fathers.

Acknowledging that he was inspired by Dr. Damadian’s work, Paul C. Lauterbur of the State University of New York at Stony Brook had figured out how to translate the radio signals bounced off tissue into images. And Peter Mansfield of the University of Nottingham in England had developed mathematical techniques for analyzing the data, making the process more practical.

Employing the techniques he pioneered, Dr. Damadian’s company, Fonar, based in Melville, N.Y., produced the first commercial scanner in 1980.

. . .

While working at Downstate and later at Fonar, Dr. Damadian was aware of Dr. Lauterbur, a chemist who was also working on M.R.I. imaging and with whom he shared the National Medal of Technology.

In “Gifted Mind,” Dr. Damadian acknowledged that Dr. Lauterbur “realized that the N.M.R. signal differences in diseased and normal tissues I discovered could be used to construct a picture (image).”

But in 2003, when Dr. Lauterbur and Dr. Mansfield won the Nobel Prize in Medicine for their contributions to the science of magnetic resonance imaging, Dr. Damadian was enraged.

. . .

A year later, Dr. Damadian received one of the two annual Bower Awards given by the Franklin Institute, a science museum in Philadelphia. He was cited for his business leadership.

“There is no controversy in this,” said Dr. Bradford A. Jameson, a professor of biochemistry at Drexel University who was the chairman of the committee that chose the winners. “If you look at the patents in this field, they’re his.”

. . .

Dr. Damadian continued to innovate. He created open M.R.I. machines, which alleviate the claustrophobia patients can experience during scans when they are moved slowly through a tight tunnel, as well as mobile and stand-up scanners.

In recent years, he was focused on research that included imaging cerebral spinal fluid as it flowed to the brain.

For the full obituary, see:

Richard Sandomir. “Raymond Damadian, 86, Is Dead; Creator of the First M.R.I. Scanner.” The New York Times (Thursday, August 18, 2022): B10.

(Note: ellipses, and bracketed year, added.)

(Note: the online version of the obituary was updated Aug. 19, 2022, and has the title “Raymond Damadian, Creator of the First M.R.I. Scanner, Dies at 86.” Where there is a minor difference between the online and print versions, the passages quoted above follow the online version.)

Damadian’s biography mentioned above is:

Kinley, Jeff, and Raymond Damadian. Gifted Mind: The Dr. Raymond Damadian Story, Inventor of the MRI. Green Forest, AZ: Master Books, 2015.

Deregulation of Hearing Aids Will Lower Costs and Increase Innovation

(p. A1) The Food and Drug Administration decided on Tuesday to allow hearing aids to be sold over the counter without a prescription to adults, a long-sought wish of consumers frustrated by expensive exams and devices.

The high cost of hearing aids, which are not covered by basic Medicare, has discouraged millions of Americans from buying the devices. Health experts say that untreated hearing loss can contribute to cognitive decline and depression in older people.

Under the F.D.A.’s new rule, people with mild to moderate hearing loss should be able to buy hearing aids online and in retail stores as soon as October, without being required to see a doctor for an exam to get a prescription.

. . .

“This could fundamentally change technology,” said Nicholas Reed, an audiologist at the Department of Epidemiology at Johns Hopkins Bloomberg School of Public Health. “We don’t know what these companies might come up with. We may literally see new ways hearing aids work, how they look.”

. . .

The change has been percolating for years. In 2016, a proposal for the F.D.A. to approve over-the-counter hearing aids for adults with mild to moderate hearing was released in a report by the National Academies of Science, Engineering and Medicine. The following year, Senators Chuck Grassley, a Republican of Iowa, and Elizabeth Warren, a Democrat of Massachusetts, introduced a bill enabling the agency to make the change. Congress approved the legislation and President Trump signed it into law.

Finalizing regulations has moved slowly since then, with some conflict over details, like how the federal rule would interact with state laws on hearing aid returns or warranty policies and how much the devices should amplify sound.

Mr. Biden issued an executive order last July calling for greater competition in the economy, which urged the F.D.A. to take action “to promote the wide availability of low-cost hearing aids.”

For the full story, see:

Christina Jewett. “F.D.A. Decides to Allow Over-the-Counter Sales of Hearing Aids.” The New York Times (Wednesday, August 17, 2022): A1 & A23.

(Note: ellipses added.)

(Note: the online version of the story was updated Aug. 23, 2022, and has the title “F.D.A. Clears Path for Hearing Aids to Be Sold Over the Counter.”)

Since Adderall Is “Highly Regulated” Pharmacies and Patients Can’t “Quickly Pivot” in Response to Scarcity

(p. A13) The Food and Drug Administration has declared a nationwide shortage of Adderall, a medication used to treat A.D.H.D. that has had surging demand in recent years.

. . .

Adderall, which contains the stimulant amphetamine, is a controlled substance and highly regulated, so it is difficult for pharmacies to quickly pivot and carry new brands, analysts said.

. . .

While a number of companies make Adderall and generic versions, pharmacies may find it difficult to pivot to other suppliers because of amphetamine’s status as a controlled substance that typically includes restrictions on its use and monitoring of prescription orders. Any given pharmacy might risk raising red flags with the Drug Enforcement Administration by doubling its supply, said Erin Fox, an expert on drug shortages at the University of Utah.

“With a controlled substance, it’s harder for patients to call around and find a pharmacy that has product for them,” Ms. Fox said.

For the full story, see:

Christina Jewett. “F.D.A. Confirms Widespread Shortages of Adderall.” The New York Times (Friday, October 14, 2022): A13.

(Note: ellipses added.)

(Note: the online version of the story has the date Oct. 13, 2022, and has the title “F.D.A. Confirms Wide Shortage of Adderall.”)

Periodic Fasting May Reduce Inflammation That Causes Multiple Maladies

(p. A15) Mr. Hendricks sees fasting as a way of combating a range of ailments. (“Surgery without a scalpel” was how some doctors once described the practice.) He cites studies showing fasting to be effective against arthritis, hypertension and fibromyalgia, among other afflictions. The medical logic in these cases is that fasting reduces inflammation—the source of multiple maladies—while promoting insulin sensitivity, stimulating DNA repair and generating antioxidants that neutralize a harmful molecule known as reactive oxygen species. Mr. Hendricks argues that fasting leads to better outcomes from chemotherapy, too—by causing healthy cells to go dormant and avoid the treatment’s toxic chemicals.

And, yes, fasting triggers weight loss. The fasting Mr. Hendricks has in mind is periodic, its frequency and duration varying from person to person.

. . .

A theme running through “The Oldest Cure in the World” is the author’s exasperation with the American approach to practicing medicine. Few physicians, he notes, are knowledgeable about fasting, despite the benefits it provides. He favorably profiles two researchers—Valter Longo and Satchin Panda, at the University of Southern California and the Salk Institute, respectively—who have conducted ground-breaking studies on the value of restrictive food consumption.

The book’s most compelling story features an infant who in 1993 started having daily seizures after his first birthday. Neither medications nor brain surgery provided significant relief. Pediatric neurologists told the parents that their son, Charlie, faced a life of mental and physical retardation.

Charlie’s father discovered an obscure clinic at Johns Hopkins University that offered a treatment that involved brief fasting followed by a high-fat, ketogenic diet. The family’s neurologist dismissed the treatment as unworkable, but the family tried it anyway. On the second day of Charlie’s fast, the seizures stopped. Over time, his physical and mental development returned to normal, and he has grown up to be as healthy as his siblings. Later research has shown that fasting and a high-fat diet is a potent method for reducing seizures in epileptic children.

For the full review, see:

Matthew Rees. “BOOKSHELF; No First Helpings.” The Wall Street Journal (Friday, October 7, 2022): A15.

(Note: ellipsis added.)

(Note: the online version of the review has the date October 6, 2022, and has the title “BOOKSHELF; ‘The Oldest Cure in the World’ Review: No First Helpings.”)

The book under review is:

Hendricks, Steve. The Oldest Cure in the World: Adventures in the Art and Science of Fasting. New York: Harry N. Abrams, 2022.

Covid-19 Health Effects Will Keep Reducing Labor Force

(p. A1) As the United States emerges from the pandemic, employers have been desperate to hire. But while demand for goods and services has rebounded, the supply of labor has fallen short, holding back the economy.

. . .

(p. A20) Morning Consult found in August [2022] that prime-age adults who aren’t working cited a variety of often overlapping reasons for not wanting jobs. In a monthly poll of 2,200 people, 40 percent said they believed that they wouldn’t be able to find a job with enough flexibility, while 38 percent were limited by family situations and personal obligations. But the biggest category, at 43 percent, was medical conditions.

Other data suggest some of that is due to long-term complications from Covid-19, although estimates of how many people have been knocked out of the work force by Covid range tremendously.

Katie Bach, a Brookings Institution fellow, put the impact at two million to four million full-time workers, based on her interpretation of the Census Bureau’s Household Pulse Survey and other research. (The total affected may be larger, with many who suffer from long Covid reducing their hours rather than stopping work.) A Federal Reserve economist didn’t specify a number, but observed that even as Covid-related hospitalizations and deaths receded, the share of people saying they were not able to work because of illness or disability had remained elevated in Labor Department data after spiking in early 2021.

Another analysis, in a paper published by the National Bureau of Economic Research, found that people who’d taken a week off for health-related reasons in 2020 and 2021 were 7 percent less likely to be in the labor force a year later — which equates to about 500,000 workers.

Whatever the magnitude, the effects are likely to be significant and long-lasting. Vaccines provide imperfect protection against getting long Covid, studies suggest, and other post-viral diseases have proven difficult to recover from. “I certainly don’t think the worst is behind us,” Ms. Bach said.

For the full story, see:

Lydia DePillis. “Pool of Labor In U.S. Stays Bafflingly Low.” The New York Times (Saturday, September 13, 2022): A1 & A20.

(Note: ellipsis, and bracketed year, added.)

(Note: the online version has the date Sept. 12, 2022, and has the title “Who Are America’s Missing Workers?”)

The NBER paper mentioned above is:

Goda, Gopi Shah, and Evan J. Soltas. “The Impacts of Covid-19 Illnesses on Workers.” National Bureau of Economic Research Working Paper No. 30435, Sept. 2022.

Proposed 20 Years Ago, Heart Polypill Is Safe, Effective, and Easier to Take, but Is Not Allowed by FDA

(p. A7) Heart disease kills more people than any other condition, but despite advances in treatment and prevention, patients often do not stick to their medication regimens. Now researchers may have found a solution: a so-called polypill that combines three drugs needed to prevent cardiovascular trouble.

In what is apparently the largest and longest randomized controlled trial of this approach, patients who were prescribed a polypill within six months of a heart attack were more likely to keep taking their drugs and had significantly fewer cardiovascular events, compared with those receiving the usual assortment of pills.

The participants also experienced one-third fewer cardiovascular deaths, although their overall risk of death from all causes was not significantly changed.

The study of more than two thousand heart patients, who were followed for three years, was published Friday morning in The New England Journal of Medicine, as the findings were presented at the European Society of Cardiology Congress in Barcelona.

. . .

The polypill combines a blood-pressure medication, a cholesterol-lowering drug and aspirin, which helps prevent blood clots. The idea was first floated two decades ago in a more radical form: Advocates proposed giving a daily polypill to everyone once they turned 55, saying it would slash cardiovascular events globally by 80 percent.

. . .

The polypill used in the study has not been approved by the Food and Drug Administration and is not available to patients in the United States right now. Dr. Fuster said the results of the new trial would be submitted to the agency shortly in an effort to obtain approval.

He called the results of the new study “striking,” and said the benefit of the polypill for prevention rivaled that of low-dose aspirin, which is now routinely prescribed to people who have already had a heart attack or other cardiovascular event.

And since participants became even more likely to keep taking the polypill over time, he said, “The potential results could be even better with more follow-up.” Several studies have shown that only about half of patients, or even less, take all their medications as instructed.

The new study, a randomized controlled clinical trial, enrolled just under 2,500 patients at 113 sites in Spain, Italy, France, Germany, Poland, the Czech Republic and Hungary.

. . .

Over three years, 12.7 percent of the patients taking an assortment of pills experienced another heart attack or stroke, or died of a cardiac event or needed urgent treatment to open a blocked artery, compared with 9.5 percent of patients taking a polypill, for a relative reduction in risk of 24 percent.

There was no difference between the two groups in overall mortality, however, as the reduction in cardiovascular deaths in the polypill group was offset by deaths from other causes.

For the full story, see:

Roni Caryn Rabin. “Heart Disease Patients Are More Likely to Stick to a One-Pill Daily Regimen, Researchers Say.” The New York Times (Saturday, August 27, 2022): A7.

(Note: ellipses added.)

(Note: the online version of the story has the date Aug. 26, 2022, and has the title “How to Get Heart Patients to Take Their Pills? Give Them Just One”)

Stimulating Brain with Electrical Currents Can Improve Long-Term Memory for Older Adults

(p. A5) Zapping the brain with weak electrical currents that mimic normal neural activity can boost memory in healthy older adults, at least over the short term, researchers said in a study published Monday [Aug. 22, 2022] in the journal Nature Neuroscience.

. . .

The researchers found that repeated delivery of low-frequency currents to a brain region known as the parietal cortex—located in the upper back portion of the organ—improved recall of words toward the end of the 20-word lists. When the researchers targeted the prefrontal cortex at the front of the brain with high-frequency currents, the study participants saw improvements in their ability to remember words from the beginning of the lists.

. . .

The electrical stimulation improved both short- and longer-term memory lasting minutes by about 50 to 65 percent over four days of treatment, Dr. Reinhart said. The improvements persisted one month after the treatment sessions. Short-term, or working, memory involves storing information over a period of seconds like remembering a phone number someone just gave you. Long-term memory involves storing and then retrieving information over minutes, days, months or years.

. . .

Though the apparatus used in the experiments is lightweight and easy to use, Dr. Reinhart said, it hasn’t been cleared for clinical use by the U.S. Food and Drug Administration and for now is available only in research settings.

For the full story see:

Aylin Woodward and Daniela Hernandez. “Electrical Brain Stimulation Is Shown to Boost Memory.” The Wall Street Journal (Tuesday, Aug. 23, 2022): A5.

(Note: ellipses, and bracketed date, added.)

(Note: the online version of the story has the date August 22, 2022, and has the title “Improve Memory by Zapping Your Brain? Study Says It’s Possible.”)

The academic article summarized in the passages quoted above is:

Grover, Shrey, Wen Wen, Vighnesh Viswanathan, Christopher T. Gill, and Robert M. G. Reinhart. “Long-Lasting, Dissociable Improvements in Working Memory and Long-Term Memory in Older Adults with Repetitive Neuromodulation.” Nature Neuroscience 25, no. 9 (Sept. 2022): 1237-46.

Costs of Covid Lockdowns and Mask Mandates Exceeded Benefits

(p. A15) The Centers for Disease Control and Prevention belatedly admitted failure this week. “For 75 years, CDC and public health have been preparing for Covid-19, and in our big moment, our performance did not reliably meet expectations,” Director Rochelle Walensky said. She vowed to establish an “action-oriented culture.”

. . .

U.S. states with more-restrictive policies fared no better, on average, than states with less-restrictive policies. There’s still no convincing evidence that masks provided any significant benefits. When case rates throughout the pandemic are plotted on a graph, the trajectory in states with mask mandates is virtually identical to the trajectory in states without mandates. (The states without mandates actually had slightly fewer Covid deaths per capita.) International comparisons yield similar results. A Johns Hopkins University meta-analysis of studies around the world concluded that lockdown and mask restrictions have had “little to no effect on COVID-19 mortality.”

. . .

In 2006 he and colleagues at the University of Pittsburgh considered an array of proposed measures to deal with a virus as deadly as the 1918 Spanish flu.

Should schools be closed? Should everyone wear face masks in public places? Should those exposed to an infection be required to quarantine at home? Should public-health officials rely on computer models of viral spread to impose strict limitations on people’s movements? In each case, the answer was no, because there was no evidence these measures would make a significant difference.

“Experience has shown,” Henderson’s team concluded, “that communities faced with epidemics or other adverse events respond best and with the least anxiety when the normal social functioning of the community is least disrupted.” The researchers specifically advised leaders not to be guided by computer models, because no model could reliably predict the effects of the measures or take into account the “devastating” collateral damage. If leaders overreacted and panicked the public, “a manageable epidemic could move toward catastrophe.”

This advice was subsequently heeded in the pre-Covid pandemic plans prepared by the CDC and other public-health agencies. The WHO’s review of the scientific literature concluded that there was “no evidence” that universal masking “is effective in reducing transmission.” The CDC’s pre-2020 planning scenarios didn’t recommend universal masking or extended school and business closures even during a pandemic as severe as the 1918 Spanish flu.

For the full commentary see:

John Tierney. “Fauci and Walensky Double Down on Failure.” The Wall Street Journal (Friday, Aug. 19, 2022): A15.

(Note: ellipses added.)

(Note: the online version of the commentary has the date August 18, 2022, and has the title “Fauci and Walensky Double Down on Failed Covid Response.”)

Human Challenge Trial Sped Phase 3 of Typhoid Vaccine Clinical Trial

Observers Give Thumbs-Up to Matthew Speight as He Prepared to Drink Typhoid Bacteria as Part of a Human Challenge Trial.
Source of Image: NYT commentary cited below.

(p. D3) “I was curious.” That’s how James M. Duggan, an Oxford University medical student, explains why he agreed to swallow a big dose of live typhoid bacteria.

. . .

Mr. Duggan, 33, was not on a self-destructive sympathy bender. Like more than 100 other residents of Oxford, England, he was taking part in a trial of a new typhoid vaccine.

Typhoid fever, caused by the bacteria Salmonella typhi and spread in food and water, kills almost 200,000 victims a year — many of them young children — in Africa, Asia and Latin America. Survivors may suffer perforated intestines, heart problems and other complications.

The experimental vaccine was a big success. The trial’s results were published in The Lancet on Thursday [Sept. 28, 2017]: the vaccine turned out to be 87 percent effective.

. . .

“These are great results,” said Dr. Anita Zaidi, the foundation’s director of diarrheal diseases. “And challenge tests are a great way to short-circuit the process of proving it works.

“If we’d done this in the field, we would have had to follow children for three or four years.”

So-called challenge tests involve giving subjects an experimental vaccine and then deliberately infecting them with the disease to see if it protects them.

These tests can only be done with illnesses — like cholera or malaria — that can be rapidly and completely cured, or with diseases — like seasonal flu — that normally do not damage healthy adults.

. . .

So what would motivate dozens of well-educated Britons to swallow a vial full of the germs that made Typhoid Mary famous? In interviews, they gave various reasons.

Some, like Mr. Duggan, were curious. Some wanted to help poor people. And some mostly wanted the cash.

Participants who followed all the steps, which included recording their temperatures online, making daily clinic visits and providing regular blood and stool samples, received about $4,000.

They all said they understood the risks.

For the full commentary see:

Donald G. McNeil Jr. “Curiosity, and Cash, Fight a Fever.” The New York Times (Tuesday, October 3, 2017): D3.

(Note: ellipses, and bracketed date, added.)

(Note: the online version of the commentary has the date Sept. 28, 2017, and has the title “They Swallowed Live Typhoid Bacteria — On Purpose.”)

The print version of The Lancet article mentioned above is:

Jin, Celina, Malick M. Gibani, Maria Moore, Helene B. Juel, Elizabeth Jones, James Meiring, Victoria Harris, Jonathan Gardner, Anna Nebykova, Simon A. Kerridge, Jennifer Hill, Helena Thomaides-Brears, Christoph J. Blohmke, Ly-Mee Yu, Brian Angus, and Andrew J. Pollard. “Efficacy and Immunogenicity of a Vi-Tetanus Toxoid Conjugate Vaccine in the Prevention of Typhoid Fever Using a Controlled Human Infection Model of Salmonella Typhi: A Randomised Controlled, Phase 2b Trial.” The Lancet 390, no. 10111 (Dec. 2, 2017): 2472-80.

Jellyfish Genome Suggests Multiple Pathways Can Synergize to Extend Healthy Lifespans

(p. A3) A team of scientists in Spain has succeeded in mapping the genome of a jellyfish known for its ability to cheat death by rebirthing itself.

. . .

In a study published Monday [Aug. 29, 2022] in the Proceedings of the National Academy of Sciences, the authors said they hoped their genome mapping might lead to discoveries relevant to human aging and efforts to improve the human healthspan.

. . .

Three types can rejuvenate after adulthood and of those three, only one, the Turritopsis dohrnii, keeps its capacity at 100%, according to the study.

. . .

The scientists compared their genome mapping of T. dohrnii to that of a closely related species that isn’t known to have post-reproductive rejuvenation.

. . .

Dr. Jan Karlseder, a molecular biologist and director of the Glenn Center for Biology of Aging Research at the Salk Institute, said the study contained an important message about extending the healthspan, or healthy years, of an organism.

“The most interesting thing is that it’s not a single molecular pathway . . . It is a combination of many of them,” he said. “If we want to look for an extension of healthspan, we cannot just focus on one pathway. That will not be sufficient. We need to look at many of them and how they synergize.”

For the full story see:

Ginger Adams Otis and Alyssa Lukpat. “Scientists Map the Genome of an ‘Immortal Jellyfish’.” The Wall Street Journal (Tuesday, Aug. 30, 2022): A3.

(Note: ellipses between paragraphs, added; ellipsis within paragraph, in original. Bracketed date added.)

(Note: the online version of the story has the date August 29, 2022, and has the title “Scientists Move Closer to Unlocking the Secrets of the Immortal Jellyfish, and Possibly Human Aging.”)

To Avoid Death, Northwestern U.S. Finally Embraces Air-Conditioning

(p. A15) SEATTLE — Road crews sprayed water on century-old bridges in Seattle on Thursday to keep the steel from expanding in the sizzling heat. In Portland, Ore., where heat has already killed dozens of people this summer, volunteers delivered water door to door. Restaurants and even some ice cream shops decided it was too hot to open.

For the second time this summer, a part of the country known for its snow-capped mountains and fleece-clad inhabitants was enduring a heat wave so intense that it threatened lives and critical infrastructure.

. . .

It is not just a matter of comfort. The region is still tallying a death toll from the June heat wave, and mortality data analyzed by The New York Times shows that about 600 more people died in Washington and Oregon during that week than would have been typical.

Officials in Portland’s Multnomah County pointed to a lack of air conditioning in homes as a key factor in deaths. Unlike large swaths of the country where air conditioning is now standard, many in the Pacific Northwest live without such relief. Just 44 percent of residents in Seattle reported having some sort of air conditioning in 2019, although those numbers have been on the rise, with installers struggling to keep up with demand.

. . .

The warming particularly threatens residents of low-income neighborhoods. During the last heat wave, Vivek Shandas, a professor of climate adaptation at Portland State University, went to the poorest parts of the city with a calibrated thermometer and got a reading of 121 degrees, five degrees higher than the official high for the day, recorded at the airport.

For the full story see:

Mike Baker and Sergio Olmos. “Broiling Today, Northwest Knows It Must Adapt for a Hotter Tomorrow.” The New York Times (Saturday, August 14, 2021): A15.

(Note: ellipses added.)

(Note: the online version of the article has the date Aug. 13, 2021, and has the title “The Pacific Northwest, Built for Mild Summers, Is Scorching Yet Again.”