Medical Progress and Creative Destruction

June 30th, 2015

“Creative destruction”, a sometimes throwaway phrase with deep implications, occurs when creativity in all its forms (novelty, invention, or imagination) lays waste to established forms of culture, belief,  politics, business (manufacturing and distribution,) even behavior. The results can be as profound as revolutionizing, annihilating or causing replacement of whatever existed before. Examples abound throughout history.  Consider: the railroad and the automobile vs. horse and carriage, radio vs. the telegraph, email vs. the post office, social networks and the Internet vs. the publishing industry, the smart phone vs. the recording business, photography, even TV. At times, the obverse, “destructive creation” can be inferred as a kind of feedback loop.  The crossover point is somewhere between progress and failure.

Examples of destructive creation come to mind, such as software upgrades killing off perfectly good software to force consumers and industry alike into upgrading.  Consider the cost we endure for the replacement rate resulting from new products.. By discarding our household goods, cars, old TV’s, computers, and mobile phones, we “destructively” increase toxic and other waste. “Progress” thus results inevitably in environmental degradation.

Destructive Creation and Medicine

Medical Progress in the form of immunization, antibiotics, cardiac surgery, revolutionary imaging, etc. has been a colossal success story over the past century, conferring on our age extravagant improvement in health and longevity. Yet from time to time, we suffer disillusion when we learn, often long after the fact, that some promising new drugs are so dangerous they’ve been taken off the market, that uncountable cardiac procedures, such as catheterization, stent placement, implantable pacemakers were not indicated, that tens of thousands of joint replacement need never have been performed.

Dr. Eric Topol, in his 2011 book, “The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care”, rhapsodizes over our smart phone detecting cancer cells, monitoring your brain waves, or warning you of an imminent heart attack. Could this be overshooting the runway? At the same time Topol was on the money when he predicted our vital signs could be monitored continuously, perhaps even our blood chemistries. After all, we now have the soaring stock price of the new IPO, Fitbit, “which tracks every part of your day—including activity, exercise, food, weight and sleep—to help you find your fit, stay motivated, and see how small steps make a big impact.

Does this mean we can now commodify the medical profession, as well as healthcare itself, by simply replacing them with digital technology and mobile devices?


Martin F. Sturman, MD, FACP

copyright 2015, Mathemedics, Inc.


Anti-Vaccination Madness

April 10th, 2015

Once any idea becomes accepted by the general public, it becomes frozen by habit and time; when it’s proven wrong the “falsehood index” hardly declines. New evidence is ignored in the zeitgeist of immutable belief. I am indebted to the comedian, Stephen Colbert, for introducing us to his term, truthiness-in the dictionary now-signifying imitation or ersatz truth, the appeal of raw feeling over proven reality.

Tragically, truthiness can get dangerous. Vaccine-preventable diseases, such as diphtheria, pertussis, tetanus, measles, mumps, and rubella are increasing.  The anti-vaccination hysteria which has resulted in measles (as well pertussis) coming back to haunt us after years of virtual disappearance.   By 2000 measles was virtually eliminated in this country.  But worldwide, there are still about 20 million cases a year; in 2013, 145,700 people died of measles. Last year several hundred new cases were reported in the U.S., the largest outbreak in almost 20 years.  Parents have elected not to vaccinate their children because they can; 19 states have philosophical exemptions to vaccination, and 47 have religious exemptions. Between October 1990 and June 1991, 1,400 people living in Philadelphia were infected with measles and nine children died.  The Centers for Disease Control (CDC) found that the deaths had nothing to do with a new strain, and “everything to do with the parents.” They have recently reported that one-third of all children between 1-3 years have not been immunized. The percentage of American who believe vaccines are safe or effective is only 53%.

One estimate (JAMA) suggests that from 1924 to 2012 childhood vaccinations prevented more than 100 million cases of serious disease. The fundamental question is: do parents’ right to raise their children justify their decisions to not to vaccinate, thus putting the entire community at risk for disease?

Stay tuned.

Martin F. Sturman, MD, FACP

copyright 2015, Mathemedics, Inc.

How and When Medicine Was Sold Out

February 12th, 2015


That’s the kind of ad I like, facts, facts, facts.

Samuel Goldwyn

What is a Profession?

The IRS defines a trade or business as “…generally including any activity carried on for the production of income from selling goods or performing services… ” But if traders are performing services, what separates this from a profession where services are also performed? Let me explain.  Professionals, such as lawyers, and especially physicians, enjoy an unusual magnitude of trust by serving society and represent  a safe haven of respect, unlimited privacy, and intimacy. Equally important, doctors were not expected to sell anything.

Historical Background

To distinguish themselves from the archipelago of fraudulent health care providers, 19thCentury physicians not only instituted higher educational standards and licensure but also demanded that their members refrain from advertising to the public. Not unexpectedly, members of the medical profession framed their rejection of advertising as an ethical objection.According to the first AMA code of Ethics (1847), it was “derogatory to the dignity of the profession to resort of public advertisements.”

When Medicine Became a Business

For over a century following the AMA Code of Ethics, up to the early 1970’s physicians and lawyers exercised rights to establish their own professional boundaries, especially prohibitions of advertisements or promotions in any venue. These prohibitions included promising cures, publishing testimonials, pushing pills, and selling medical services or devices by any means. To violate these rules resulted in censure and ostracism. An unforgettable example was related to me a few years before I opened my own practice. It involved a physician whose announcement of arrival and a brief biography in a local newspaper resulted in his ultimate excommunication from the local medical society!

The rules about professionals advertising suddenly changed when the legal profession first got the axe in 1975. The Federal Appeals Court had held that publication of a fee schedule by the Fairfax County Bar Association was immune from liability for price fixing because the practice of law was a learned profession, not trade or commerce under the Sherman Antitrust Act. “Not so,” said the (Burger) Supreme Court, (8 to 0), stating that the Virginia State Bar enforcement mechanism …through the prospect of professional discipline, “constituted price-fixing” and indeed was a violation of the Sherman Act. See  Goldfarb v Virginia State Bar. Two years after the successful suit the Federal Trade Commission (FTC)  confirmed the commission’s perception of health care as a “commercial marketplace in which goods and services are bought and sold,” and accused the profession of “restraint of trade.” At that point the AMA in a final “phase transition” removed all prohibitions to advertising, retaining only a weak restriction against false or misleading advertising. (Opinion 5.02, issued in 1975 amending the 1847 Code of Ethics almost completely.)

Some Unanticipated Results of Medical Advertising

Advertising is the foundation of commerce in capitalistic economies; it is widely acknowledged as a crucial investment in maintaining trade, employment, and profitability. It is crucial to the survival of business and trade by enabling consumers to make informed, or at least, reasonable judgments, about purchasing most of the goods and services they require.

Then what could possibly be wrong with conflating commerce and its undeniable need for advertising, with medicine and health care? The profound implications of this marriage becomes obvious since physicians, like any people in business, are in constant search of new customers, they are free to market their services as goods in order to sell health and longevity.

The public, obviously, has no choice in the matter but is compelled to seek medical care when ill or for preserving life, by preventing and alleviating sickness. What is true for health (read “disease”) does not hold for bananas, smart phones, and deodorants, the purchase of which is optional. It is the very genius of promotion and marketing of health care that ignores these questions by turning them on their head. In this manner, advertising health in America becomes a powerful cultural influence, by creating a public preoccupation with health and longevity. Privatization of healthcare has always been part of the American Experience, but commercialization is only forty years old. Promotional exuberance encouraged by competing health care entities soon edged into a financial arms race to the bottom line. We now enjoy lives crammed full of advertising doctors, hospitals, ER’s, nursing homes, insurers, other health businesses  such as “alternative” medicine, exercise centers, health food stores, etc. all competing for business, making such goods and services into some of our most impressive growth industries. Increasingly, the entire health care universe begins to mirror Big Pharma, as it floods TV with drug ads.  Solicitation in effect becomes compensation.

Increasing demand for health care services fueled by advertising is responsible in large part for making U.S. health care, according to the 2014 Commonwealth Fund report, the most expensive in the world. yet (it) “…consistently underperforms other countries in most dimensions of performance.” Currently, according to the report, the U.S. ranks last among 11 major industrialized nations in efficiency, equity, and health outcomes attributable to medical care.

To paraphrase Napoleon, it’s worse than a tragedy, it’s a mistake.

Martin F. Sturman, MD, FACP

Copyright 2015, Mathemedics, Inc.


Sugar Highs and Sweet Buzzes

September 25th, 2014

Among American moms it is a truth widely acknowledged that ingestion of sweets and high sugar foods makes kids crazy. Mothers and otherwise sensible people, mouthing dietary political correctness  will tell you a sugar “high,” can result from eating sweets, like ice cream, cakes, soda, and candy. If a child becomes jumpy, irritable, unmanageable or otherwise acts strangely after eating candy, it’s obviously not the kid, it’s the candy. This nasty syndrome supposedly is not limited to youngsters, but may also be manifested in adults by loopy behavior often with nervousness and the shakes.

Do sweet foods really pack a high or even a buzz? Sorry to inform you, this is a magisterial myth. If high blood sugar really pushed people “off the mainland”, what of those millions of diabetics who generally behave normally even when they occasionally suffer with wildly fluctuating blood sugars in the 150-350 (mg/dl) range? How about patients receiving glucose infusions, most of whom run sky high blood sugars for hours? I’ve never seen such patients jumping off a hospital bed. Studies conducted at Vanderbilt University and the University of Iowa found no evidence that sugar has any adverse effects on children’s behavior.

Richard S. Surwit, a medical researcher at Duke University, years ago studied sugar’s effects on volunteers in a weight-loss program. Not only did subjects lose equal weight on calorie-controlled high-sugar and no-sugar diets, he found no negative side effects. “Nobody reported any behavioral problems, any mood swings, any anxiety, any hyper-kinetic kind of behavior,” He adds, “Sugar has gotten a really bad rap…Most simple carbohydrates, like potatoes and rice, have the same metabolic effect as granulated sugar.” Yet who ever heard of a potato buzz? A rice high?

Surwit thinks the myth about sugar might have originated during World War II when, in an effort to ease the burden of sugar shortages, health officials spread a rumor that sweets promoted hyperactivity. My own theory is that the effects of low blood sugar, which can indeed cause nervousness, shakiness, and even mental changes, has been the source of confusion in the public mind. Recurrent diagnostic infatuations with “low blood sugar” as a widespread cause of depression, fatigue, and a host of other symptoms – not hyperactivity – has been a hot medical fad on and off for 60 years. (More about low blood sugar in a future newsletter.)

Despite studies to the contrary, misinformation about sugar effects persists. Candy, cookies and cakes fill the menus of birthday parties and social occasions, where people, and especially children and parents are keyed up to begin with. Is this guilt by association? “There are things in sweets that might give you a buzz, but it isn’t sugar,” Surwit said.



Copyright 2014 by Mathemedics. Inc.

Are You a Gluten for Punishment?

March 21st, 2014

Over 840 million people in the world are hungry. Yet for millions of Americans obsessed with food phobias, gluten – if you’ll pardon the expression – takes the cake. Time magazine, in its survey of Americans’ food eating habits, labeled the gluten-free movement number 2 out of its top 10 list of food trends in 2012. A recent market research report by the NPD Group states that of 1000 respondents one third are cutting back on dietary gluten big time.

Gluten (from Latin gluten or glue) is a composite protein in wheat, barley, and rye and thus found in foods processed from these grains, such as bread, cakes and other baked goods, as well as breakfast cereal and pasta. Rice, including “sticky rice” and corn are gluten-free.

What’s so Frightful about Gluten?

Celiac disease is an uncommon autoimmune disorder of the small intestine which occurs in genetically predisposed people.  Symptoms, most classically appear in children, include abdominal pain, chronic constipation, diarrhea, vomiting, weight loss, growth failure, and anemia due to malabsorption. In adults some of these complaints may be absent, and symptoms in other organ systems have been described. Increasingly, diagnoses are being made in asymptomatic persons as a result of various, if controversial screening tests for certain antibodies.True celiac disease, according to The University of Chicago’s Celiac Disease Center affects about 0.75% of Americans, about 1 in 133, but some figures quoted in Wikipedia suggest a much lower prevalence. Yet, despite these statistics, gluten fright has captured the public mind, becoming a “dietarily” correct food phobia on a level with the usual suspects: sugar, salt, saturated and trans fats, carbs, and cholesterol.

Why celiac disease symptoms, especially in adults, are so varied and why gluten may not be the culprit in non-celiac gluten sensitivity are discussed in this important article in the journal Gastorenterology. The authors reported results of various gluten challenge diets and compared them with reversion to a normal diet in 37 patients. Only 6 patients responded to pure gluten challenge. Although the study was limited, it raises vital questions about the oft-reported improvement on gluten free diets by the public. The researchers concluded that the large majority of people with self-reported gluten sensitivity didn’t experience symptoms after a gluten challenge when they had eliminated foods high in certain carbohydrates from their diets. *

Shopping for Gluten-Free and Your Grocery Bill

Another excellent article by Martha C. White, declaresl: “Why We’re Wasting Billions on Gluten-Free Food”. Ms. White points out that, as food fads go, we’re paying an enormous premium to avoid gluten without any legitimate medical reason. In effect, we are hypnotized by urban myths, advertising, and the profusion of gluten-free grocery shelves. The “99%” imagine they’ll feel better, attain good health, and who knows, longevity-by shelling out huge bucks for gluten free-food they probably don’t need.

Foody nonsense and fad diets along with their accompanying phobias masquerading as dietary theology, go back to the 70s, when sugar became the bête noir of foods. Then, as mentioned above, it was fat, salt, carbs, cholesterol-and finally the latest pariah ingredient, gluten. People who have bad reactions to common gluten-containing foods – pasta, breads, baked goods and breakfast cereal – may actually be sensitive to something else. It’s also probable that some people develop gastrointestinal or other symptoms simply because they believe they’re food-sensitive.

Researchers from Dalhousie Medical School at Dalhousie University in Canada compared the prices of 56 ordinary grocery items that contain gluten with their gluten-free counterparts. All of the gluten-free ones were more expensive, and some were much more expensive. The average unit cost of the gluten-free product was $1.71 while the average unit cost of the regular gluten-containing product was $ 0.61. This translates to gluten free products costing 242% more than the “real thing.”

The challenge has been met by an increasing number of food manufacturers who have happily entered this highly profitable growth industry. The market research company Packaged Facts said in a report last fall the gluten-free market in the United States was $4.2 billion last year. It predicts that the category will grow to $6.6 billion by 2017.

See my recent newsletter for a more complete discussion

Martin F. Sturman, MD, FACP

Copyright 2014, Mathemedics, Inc.

Dangers of Robotic Surgery

October 11th, 2013

An unnerving study by researchers at Johns Hopkins found multiple examples of botched operations that were not reported to the FDA.  The investigators, headed by Dr. Martin A. Makary  an associated professor of surgery at Johns Hopkins , accomplished this  by combining news reports and court records, and concluded that such cases were vastly underreported. The reporting mandate that requires medical device manufacturers and hospitals to report every device-related death and serious injury to the FDA within 30 days simply is dysfuntional or worse.  It is well-known, for example, that reports made to the FDA represent only a tip of the iceberg-this includes events related to drug reactions, drug deaths, device failures, and  other significant, serious or catastrophic results of medical treatment. The “true” reporting rate for drug reactions and misadvnetures has been rated at 10%, but this is clearly a wild understatement considering that drug deaths alone, not counting suicides, exceeded auto accidents, at 40,000 a year.

Robotic-assisted surgery has taken off, increasing more than 400%  in the U.S. between 2007-2011. A leading company, Intuitive Surgical Inc. the manufacturer of  da Vinci systems sold over 1,400 such systems costing between $1.5million-$2.5 million to scores of hospitals according to Intuitive’s Investor Reports. Between January 2000 and 2012 thousands of mishaps were reported to the FDA.  Among reports were 174 injuries and 71 deaths related to the da Vinci surgery system.

Reported in the New York Times, Sept. 10, the expansion of robotic surgery “has occurred without proper evaluation and monitoring of results,”said Dr. Makary, and senior author of the above study, who added,  “We adopt expensive new technologies, but we don’t even know what we’re getting …if it’s for good value or harmful…Because the reporting mandate has no teeth, he said, we have this haphazard smattering of reports that relies on voluntary self-reporting with no oversight, no enforcement, and no consequences.”

This is unfortunately true for other implanted devices, in particular cardiac stents and pacemakers. See my previous blog 11/6/2009. “Medical Devices: Disturbing News” (blog page 4).  As for medical devices in general and their poor oversight by the FDA because of failures of reporting, how about reducing the excise taxes on them to satisfy anti-Obamacare politicos?


Copyright 2013   Mathemedics, Inc.

Truth, Belief, and Human Survival

September 24th, 2013

Not a day passes when we don’t hear about the perils of HRT, antidepressants, “carbs”, cholesterol, sodium excess, gluten, and the importance of proper diet to protect us against obesity and diabetes, cancer, heart attacks, and death itself. Modern life as mirrored in the media, via our “devices”, hand-held and otherwise, offers 24/7 stimulation. This arrives in the form of entertainment, news, and advertising. Sadly, we are all drowning in “information,” whether it is advertising or government edict disguised as medical truth, or opinion parading as received wisdom. Public confusion reigns. The City of New York and other cities, decides to mandate the amount of trans fat allowed to be served in restaurants, the medical sovereigns or the Government tells us we will die of high blood pressure if we don’t restrict salt intake-the list goes on. In my opinion and that of others,  most of these decisions have been verified by a plethora of Junk Science. Many such beliefs edge into a form of snobbery when skeptics are ridiculed. We all want to be “right” and politically correct, even if, for example, Federal dietary guidelines change every few years or spectacular new medical treatments, such as anticoagulants and robotic surgery are proven to be dangerous.

Once we begin to acknowledge that life is all about uncertainty, we are still left with that slippery word, “truth”, and its fashionable costumes of faith and belief. Ultimately, we are left to deal with faith, reason, and the actual basis of knowledge. According to Gallup, 40% or 125 million of Americans take a literalist view of creation, believing that God created the universe, (either in millions of years or in 6 days), but place the big bang “2,500 years after the Babylonians and Sumerians learned to brew beer.” Only 17% of us doubt that a personal God has authored the Bible, let alone created the earth and its 900,000 species of insects. As Sam Harris in The End of Faith also observes, “A survey of Hindus, Muslims, and Jews around the world would surely yield similar results revealing that we, as a species, have grown almost perfectly intoxicated by our myths.” Can the human race, its very existence now imperiled by the clash of beliefs and civilizations, afford to drift entirely free of reason and evidence?

Perils of Prescription Drugs

July 1st, 2012

The Institute for Safe Medical Practices, ISMP or  Quarterwatch  , is an invaluable independent non-profit organization monitoring domestic events of all serious drug reactions reported to the FDA.  The Institute has issued a chilling summary for the calendar year of 2011 based on their analysis of  reports to the U.S. Food and Drug Administration: An estimated 2 to 4 million persons suffered serious, disabling, or fatal injury associated with prescription drug therapy. This figure is arrived at by the FDA’s own estimate-proven in previous studies over the past decades- that less than 1% of all serious adverse events are reported directly to it. Among the almost 180,000 reported cases in 2011, 88% were collected, written, and submitted by drug manufacturers, and only 12% were submitted directly to the FDA by health professionals and patients. “Many factors influence manufacturer reporting of adverse events. A company actively marketing a brand name drug may learn of adverse events when its sales force calls on physicians, and through consumer hotlines and assistance programs. On the other hand, the multiple manufacturers of a generic drug have little contact with physicians and patients and seldom learn of events to report. This and other variability is avoided with direct reports to the FDA because all events can be reported to a single FDA web site or 800 number, 1-800-332-1088 for OTC drugs.  See

Using 2011 report totals suggests that there would have been an estimated 2 million or more cases of serious injury, including 128,000 patient deaths. The most frequently identified drugs in direct reports to the FDA were the anticoagulants dabigatran (PRADAXA) and Warfarin (COUMADIN), showing that inhibiting clotting ranks among the highest risk of all drug treatments. In addition, they “identified nine other drugs associated most frequently with five clinically relevant, drug-related injuries, and show the drugs most frequently the target of lawsuits.”  Additional “top” drugs include LEVOFLOXACIN (LEVAQUIN), CARBOPLATIN, LISINOPRIL, ZESTRIL, Reglan (Metoclopramide) and 350 other drugs.

FDA is looking at whether bleeding is happening more frequently than should be expected with Pradaxa which is in the newer  medication class of thrombin inhibitors. There is no rapid current method of stopping bleeding caused by this drug.  Thus, one of the major Pradaxa side effects is serious bleeding which cannot be stopped.

More on Direct to Consumer Drug Advertising

November 26th, 2011

Tremendous growth has occurred in direct-to-consumer pharmaceutical advertising  since 1998.  According to Pharma Marketing News (Pharmacy and Therapeutics, October 2011) spending in dollars rose from $1.2 billion in 1998 to $2.5 billion in 2000 and 4.5 billion in 2009, a 450% increase.

As I pointed out three years ago, prescription drug marketing directly to the consumer is routinely permitted under U.S. law. Notable, is the profoundly different regulatory environment in the European Union (EU), Australia, and Canada where pharmaceutical manufacturers are forbidden to advertise prescription drugs to the public.  Incredibly,  the U.S. and New Zealand are the only two countries in the world where it is legal for drug companies to advertise to the public.

Such “direct to consumer” or DTC advertising is meant, obviously, to create increased patient demand for specific drugs from their doctors. In this scenario, patients really become consumers, replacing the doctor as prescriber, if the physician is foolish enough to surrender his authority. Consumer Reports, in a 2006 survey found that 78 percent of doctors said that patients asked them at one time or another to prescribe drugs they had seen advertised on television.

While Congress recently gave the FDA more authority to regulate ads, it rejected a measure that would have allowed to agency to place a moratorium on ads for new drugs that raise safety concerns. The sad fact remains that Congress seems in no mood to address the main problem, the legality of advertising drugs to the public.

Don’t expect the ad barrage, TV or otherwise, to subside any time soon.  Evening and much of daytime TV is contaminated with advertising for various pharmaceutical products, including new antidepressants, new treatments for arthritis,  heart disease, diabetes, sexual malperformance-who can define “erectile dysfunction”?-a host of new anticoagulants-I could go on indefinitely. What I like best are the disclaimers:  Here’s an example from Chantix:

Some people have had changes in behavior, hostility, agitation, depressed mood, suicidal thoughts or actions while using CHANTIX to help them quit smoking. Some people had these symptoms when they began taking CHANTIX, and others developed them after several weeks of treatment or after stopping CHANTIX. If you, your family, or caregiver notice agitation, hostility, depression, or changes in behavior, thinking, or mood that are not typical for you, or you develop suicidal thoughts or actions, anxiety, panic, aggression, anger, mania, abnormal sensations, hallucinations, paranoia, or confusion, stop taking CHANTIX and call your doctor right away. Also tell your doctor about any history of depression or other mental health problems before taking CHANTIX, as these symptoms may worsen while taking CHANTIX.

Some people can have serious skin reactions while taking CHANTIX, some of which can become life-threatening. These can include rash, swelling, redness, and peeling of the skin. Some people can have allergic reactions to CHANTIX, some of which can be life-threatening and include: swelling of the face, mouth, and throat that can cause trouble breathing. If you have these symptoms or have a rash with peeling skin or blisters in your mouth, stop taking CHANTIX and get medical attention right away.

The real question is, why would anyone in his right mind take Chantix to stop smoking?  Or for that matter, a few hundred other drugs festooned with all those scary disclaimers.

U.S. Health Care Spending vs. Major Countries

August 12th, 2011

иконографияКартииHealth  care spending towers over other major industrial countries.  In 2008, hospital spending per discharge in the U.S. dwarfed all major industrial countries at $16,708.  This is nearly triple  the median of $5,949  according to the  Organization for Economic Cooperation and Development (OECD).  This analysis concentrated on 2010 OECD health data for Australia, Canada, Denmark, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. including the supply, utilization, and price of diagnostic imaging.  The country with the second-highest spending, Canada, spent only 75 percent as much per discharge ($12,669), and in both Germany and France, hospital stays were nearly one-quarter as expensive ($4,566 and $4,762, respectively.

This enormous difference in spending occurs despite the fact that the U.S. has fewer hospital beds and physicians, and sees fewer hospital and physician visits than in most other countries. Prescription drug utilization, prices, and spending all appear to be highest in the U.S.  OECD  tracks and reports on more than 1,200 health system measures across 34 industrialized countries. U.S. performance on other measures is variable. We ranking highly on five-year cancer survival, fair on in-hospital case-specific mortality, and poorly on hospital admissions for chronic conditions and amputations due to diabetes.

Shocking, isn’t it?  Stay tuned.