That said, it is clear that vaccination against SARS CoV-2 also comes with risks. It is not completely benign. That is also indisputable. Specifically, vaccination against SARS CoV-2 has been associated with myocarditis/pericarditis, especially in adolescent and young adult males.

The mechanism of this very rare, albeit very real, complication (estimated to be between 0 to 35.9 cases per 100,000 across age groups and mRNA vaccine cohorts) has been thought to be either an allergic reaction, an autoimmune reaction from the vaccine, or a cross-reaction from the antibodies generated by the vaccine itself.

Researchers from Yale University have elucidated the actual cause of myocarditis. They studied 23 patients with vaccine-associated myocarditis and/or pericarditis. They did extensive and exquisite studies on these patients, and here their conclusions:

our results demonstrate up-regulation in inflammatory cytokines and corresponding lymphocytes with tissue-damaging capabilities, suggesting a cytokine-dependent pathology, which may further be accompanied by myeloid cell–associated cardiac fibrosis. These findings likely rule out some previously proposed mechanisms of mRNA vaccine–-associated myopericarditis and point to new ones with relevance to vaccine development and clinical care.

Thus, it is the actual immune system itself – revved up by the vaccine – that directly damage the heart muscle itself. Now, this raises a number of questions: why more often in young males? Why the heart and not other organs? If there could be scarring in the heart, then what are the long-term effects? What does this mean for future mRNA vaccines? Hopefully, these and even more questions will be answered with further research.

Yes, the cohort is quite small, and it may be difficult to extrapolate these findings to all patients with vaccine-induced myocarditis. Nonetheless, the findings are an important contributor to the literature. It emphasizes the great importance to follow these patients long-term to make sure they don’t have any long-term complications. In addition, it is quite important to highlight what the researchers themselves pointed out about their findings:

It is also critical to contextualize the rare risk of adverse events and potential clinical sequelae after SARS-CoV-2 vaccination in comparison with the greater risks of sequelae (including myocarditis), hospitalization, and/or death resulting from infection with SARS-CoV-2.

Indeed, according to the CDC, the risk of cardiac complications of the infection itself far far outweighs the risk of myocarditis from the vaccine:

Hopefully, further research will add to this study’s important body of knowledge and help us develop even safer vaccines for the next pandemic.

Study Reference: Anis Barmada, et al. Cytokinopathy with aberrant cytotoxic lymphocytes and profibrotic myeloid response in SARS-CoV-2 mRNA vaccine–associated myocarditis. Sci.Immunol.8,eadh3455(2023). DOI:10.1126/sciimmunol.adh3455

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Before these things happened, most of the country – if not the world – seem to have moved on from COVID-19. Barely anyone masks in the airport (though I still do). Barely anyone masks on the plane (though I still do). Still, having the national public health emergency officially end is a major turning point. It seems that the COVID-19 nightmare is finally over.

At the same time, the nightmare for the families and loved-ones of the more than 1,100,000 Americans who were killed by COVID-19 has hardly ended. The nightmare of the approximately 245,000 children in the US and 10.5 million children globally – who have lost one or both parents to COVID-19 – has hardly ended. Yes, we are celebrating – rightly so – not having to wear masks everywhere in the hospital all the time. And for so many, the pain and horror of loss continues day by day.

We are celebrating the end of the pandemic, and so many others have to celebrate birthdays without their loved ones there any longer. We are celebrating no longer being overwhelmed by patient after patient with a strange and novel deadly disease, and so many others just celebrated Easter without their loved ones there any longer. We get the mark the anniversary of the first patient with COVID-19 to hit our ICU with gratitude that we survived the pandemic. So many others must endure anniversary after anniversary of the death of their loved ones to COVID-19 (including my own uncle, who died from COVID-19 several years ago).

I am not trying take away from the happiness of this moment. We on the front lines of the COVID-19 pandemic have endured so much pain, so much anguish, and so much difficulty. At the same time, I would be remiss if I did not pause and think about all the people who are suffering from the terrible loss inflicted by COVID-19.

May the Precious Beloved comfort all those who have suffered loss from this terrible pandemic. The pain may get better, but it never goes away. Having lost a child myself, I know all too well about this pain.

The post Reflecting on the End of the COVID Public Health Emergency appeared first on Medika Life.

When I was a teenager, I became horribly sick after sleeping in front of a fan for hours on end (it was summertime and very hot). I also remember reading – way back in medical school – that respiratory viruses are able to attach better to the nasal mucosa in cold air. New research has elucidated the possible mechanism behind this. It turns out that our nasal mucosa has inherent, innate anti-viral properties.

There are things called “nasal epithelium-derived extracellular vesicles in innate Toll-like receptors” that line our nasal epithelium, or the lining of our noses. According to this research, these extracellular vesicles induce “a swarm-like increase in the secretion of nasal epithelial EVs via the TLR3 signaling,” and this helps prevent viral infections from happening.

Cold air, it turns out, seems to disrupt this process:

And so this may help explain why colds are more common in the winter months.

Now, it is true that there is also increased influenza in the winter months, even in warmer climates such as the Southern part of the U.S. And COVID did not stop during the summer, although it was definitely less prevalent than in the winter. Still, this may help explain part of the reason why respiratory viral infections are more common during the cold winter months.

Therefore…there seems to be a scientific case for a scarf: the scarf can help keep the upper airway nice and warm, so this innate antiviral defense system can stay as intact as possible. The same is true with a…dare I say it…mask (or balaclava) in the cold as well. It should be able to do the same thing: keep the ambient air in the upper airway warm.

Is this fool-proof? Of course not. But it is one possible extra arrow in the quiver to fight against respiratory viral infections in the winter. It is relatively inexpensive, does not involve drugs or medicines, and can be fashionable as well! And, with how annoying – and potentially deadly – some of these respiratory viruses can be, we need all the defenses we can muster.

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Yet, living and let living should not prevent us from asking the question, “Does vaccination against SARS CoV-2 work? Does vaccination against SARS CoV-2 save lives?” Researchers set out to answer this question.

Dr. Alyssa Bilinski and others from Brown University and the University of Pennsylvania analyzed COVID-19 and all-cause excess mortality between June 2021 and March 2022. They compared overall US mortality with that of multiple countries and, interestingly, also compared mortality from the top ten most-vaccinated states (73% vaccination rate) to the ten least-vaccinated states (52% vaccination rate). They found that COVID-19 deaths per capita in the US overall and in both state subgroups was higher – much higher – than all the peer countries during the study period (figure below).

In fact, the per capita COVID-19 mortality in the ten least-vaccinated states was almost double that of the ten most-vaccinated states, and the overall COVID-19 mortality was the most of all the countries and the US overall, by quite a margin. These are pretty striking data.

The researchers also looked at excess mortality from all causes during the same time period, and the same result was found: US excess all-cause mortality also exceeded mortality of peer countries in all periods, as did excess all-cause mortality in the least-vaccinated states. But, this time, the all-cause excess mortality of the ten most-vaccinated states was comparable to that of several countries (Denmark, Germany, the Netherlands, Austria, Italy, Finland).

Now, the overall vaccination rate in the US was 63%. If the overall US vaccination rate was similar to many of the peer countries, the US would have averted hundreds of thousands of deaths according to their mortality models.

The study did have limitations: some of the mortality estimates were provisional, and the mortality was not adjusted by age and comorbid conditions. Yet, the researchers made a good point about this last point: “unadjusted estimates remain important, because a country’s response to COVID-19 should reflect risks in its population rather than a hypothetical standardized population.”

So, in short, did COVID-19 vaccination save lives? Yes, it did. In those countries and states in the US that had higher vaccination rates, the per capita COVID-19 mortality rates were lower. If someone does not want to be vaccinated, that’s fine. That same person, however, should not say, “the vaccines don’t work.” Clearly, the data show that they do.

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In 2020, research was published analyzing the voting patterns of physicians in Texas, California, and New York. The research found that physicians in those states did not vote as often as the general population. In fact, this study indicated that only half of eligible physicians were even registered to vote. This was very disappointing to me.

The fight for the right to vote in this country has been waged for over a century. When our nation was first established, women did not have the right to vote, and Blacks were not even considered fully human. A lot, thank God, has changed for the better since that time. And, since that time, there have been scores upon scores of Americans who have shed their blood and given their lives to give me the right to vote and have my voice heard.

I cannot let that fight, I cannot let the lives of those brave Americans be lost in vain by neglecting to do my duty as a citizen and registering to vote and then voting in every election.

In so many countries in our world, sham elections are held where the dictator receives “99.9%” of the vote tally. In so many countries in our world, people’s lives and livelihoods are placed in danger for daring to have their voices be heard. In so many countries in our world, people yearn for the privileges that we here take for granted. This fact motivates me to get out the vote and let my voice be heard.

Those of us in healthcare – physicians especially – should be at the vanguard of those who consistently cast their ballots in every election, large or small. So much of our profession is regulated by policymakers and legislators who are not in healthcare. So much of what we do is, many times, subject to the whims of politicians and the machinations of electoral and partisan politics. We deserve a say in this process, and as the saying goes, “if you are not at the table, then you are on the menu.” The very first thing we need to do to be at the table is vote and have our voices heard.

In January of this year, another paper was published showing an increasing trend of physician turnout in elections:

This is encouraging to see, and we need to continue this trend.

We all have very busy professional and personal lives. It can be hard, sometimes, to take the time and cast a ballot, especially since election day is usually during the workweek. Take that time, however, we must. It is not only our duty as citizens of this country, but – as this year’s study authors noted: “physicians’ engagement with the political process, particularly through voting, plays an important role in shaping public policy, affecting patient health and clinical practice.”

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Veda Rolle, a Bahamian native and woman of faith, has lived in The Bahamas her entire life and thrived on the sun, sand, and sea in her home, an island paradise. Although the vaccine has been shown to assist in recuperation and weaken the pandemic strain impact, she is adamant in her choice to remain unvaccinated. The Bahamas experienced 37,453 COVID cases throughout the pandemic, with 833 deaths.  

With the vaccine, just like the rest of the world, the country began opening up under a new way of living while coping with the pandemic. On the bright side, The Bahamas has recently been cleared with level 1 status by the Center for Disease Control (CDC). The Minister of Health and Wellness, the Honorable Dr. Michael R. Darville, commented on the cause of this shift in status by saying,

“The Level 1 CDC rating reflected the sustained downward trend in COVID-19 infection rates in the country, which is due in no small part to how Bahamians and residents have adhered to COVID-19 protocols and bode well for our tourism industry and our economy.”

The Minister of Health and Wellness, the Honorable Dr. Michael R. Darville, The Bahamas

Fear of the vaccine has been a topic of interest since its release. For Veda, she feels at ease remaining in a “wait-and-see situation.” She explained her concern for the long-term effects of the vaccine and not knowing the health impacts of what is being placed inside the shots. When commenting on her personal choice to remain unvaccinated, she expressed her resistance to the vaccine by saying:

“I don’t trust the Big Pharma, and I don’t admire the government’s position of coercing folks to get the jab; then, just calling it a “jab” is not attractive.”

Veda Rolle, a Bahamian native

When asked if she thinks the vaccine does more harm than good and, if so, why Veda replied:

“One can only reach a conclusion based on the information disseminated through the various media and mediums. If the media, scientists, governments, and physicians can’t be trusted (as they may be partly due to self-interest), our conclusions will be tainted. Therefore, how much harm or good depends on disseminating truthful information. Therefore, I don’t know, as there are so many diseases that are man-made, and who can tell if these result from the side effects of other medications and vaccines? Nevertheless, I don’t live in unnecessary fear because I serve a GREAT GOD.”

Veda trusts in her faith, and millions worldwide have resorted to their means of preventative measures. Some people still choose to wear masks and sanitize in public, limit the time spent outdoors, and make homemade remedies. Veda, trusting in God to continue being her protective shield, has continued to be cautious and follow strict guidelines to limit her COVID exposure.

The development of the COVID vaccine has resulted in a rigorous debate about the legitimacy of technology and medicine, leaving some questioning the safety of healthcare writ large. Indeed, we’ve seen a transformation in healthcare and technology; however, who’s to say this is positive for society?

Veda shared her thoughts on the evolution of society by saying,

“The Triune God will give man the wisdom, knowledge, and understanding to continue to use technology to revolutionize medicine. The Word of God says they will be wiser but weaker. I pray that the knowledge is used for good and not evil.”

In addition to her faith, Veda believes in natural remedies such as nasal sprays, salt water, nasal steaming, and other medications like Hydroxychloroquine as a means of prevention. Although Veda is anti-vaccine because she does not trust the government, Pharma, etc., she believes Hydroxychloroquine is a valuable solution to COVID.

[Author’s Note: The Food and Drug Administration has not approved Hydroxychloroquine as prevention or treatment for SAR-Cov-1 COVID. A study in the Lancet reviewing 247 clinical trials reaffirmed that there is no benefit of Hydroxychloroquine in treatment or symptom reduction.]

Understanding Veda’s point of view and hearing her reasoning for being hesitant, I can appreciate her choice to refrain from receiving the vaccination. While it may be a scary decision, the pandemic has driven us all to make choices we never thought of making. Veda’s strength, faith, and determination have shined like no other. She has remained strong, steady, and steadfast – not only in her choice but with her faith. We all choose to confront the pandemic the way we feel best. Veda’s choice to remain unvaccinated and her steadfast faith is her personal protection.

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October 11, 2022 (New York, NY)—COVID-19 and recent outbreaks of monkeypox and polio have highlighted how vulnerable the world is to infectious diseases. But every day, public health workers stop epidemics before they start. Just last month, Ghana contained its first outbreak of Marburg virus—which is highly contagious and has a fatality rate as high as 88%. This story, like many other prevented epidemics, didn’t make the headlines.

Today, Resolve to Save Lives releases a new “Epidemics that Didn’t Happen” report that shows that investment in preparedness, combined with swift, strategic responses by public health authorities, can stop disease outbreaks, saving lives and preventing suffering. These are the everyday successes that are rarely reported. The latest “Epidemics that Didn’t Happen” celebrates successful outbreak responses around the world and demonstrates the returns—in lives saved—of investing in health systems.

“Successes of front-line public health workers around the world prove that public health works when we invest in and prioritize strengthening health systems—especially at the national and subnational levels,” said Dr. Tom Frieden, President and CEO of Resolve to Save Lives and former Director of the US Centers for Disease Control and Prevention. “Our report demonstrates that responses don’t have to be perfect to be effective, but sustained investment in preparedness can mean the difference between an outbreak that’s contained and one that devastates a community, a country, or the world. Epidemic preparedness must not stop when an outbreak does.”

When outbreaks aren’t contained, the results can be economically catastrophic as well as deadly: estimates place the global cost of COVID-19 as high as $20 trillion, with approximately 20 million lives lost. However, research from Resolve to Save Lives found that it would cost approximately $124 billion over five years to make the world much better prepared for disease threats—a bargain that could save countless lives and preserve economies.

The real-life examples presented in the latest report highlight different aspects of effective public health programs, including how:

• Improved systems and skills following deadly epidemics contained Ebola outbreaks in Guinea and DRC
• Learning from experience helped health care workers in India contain a Nipah outbreak to a single case
• Advanced planning, regional awareness and rapid action stopped cholera in Burkina Faso
• A diverse team mobilized and successfully contained a rabies outbreak in Tanzania
• Well-coordinated health offices in Brazil swiftly contained a flu outbreak on a cruise ship
• Community trust enabled early detection of and response to a dengue case in Indonesia

“Outbreaks begin and end locally, so community action is crucial to preventing epidemics. Public health officials’ engagement with communities pays off because it builds trust in the health system,” said Amanda McClelland, Senior Vice President of Resolve to Save Lives. “Another key component is protecting health care workers, who are the frontline of defense against outbreaks. When primary health care centers are safe work environments, patients and health care workers are protected and are better able to detect and respond to health threats before they spiral out of control.”

The case studies were developed with support from health ministries and global health organizations including, Indonesian Red Cross Society, International Federation of Red Cross and Red Crescent Societies, Vital Strategies and FAME Hospital.

To read the report, visithttps://preventepidemics.org/epidemics-that-didnt-happen/

A complete recording of the Preparedness in Action: Transforming Global Health Security event featuring the report can be found here.

Read recently published JAMA Viewpoint by Dr. Tom Frieden and Amanda McClelland: “Preparing for Pandemics and Other Health Threats: Societal Approaches to Protect and Improve Health”

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About Resolve to Save Lives

Resolve to Save Lives is a not-for-profit organization partnering with countries, communities and organizations to prevent 100 million deaths from cardiovascular disease and make the world safer from epidemics. To find out more, visit: resolvetosavelives.org or Twitter@ResolveTSL

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The blood counts never came back to normal, even though they were supposed to. The toxic effects of the chemotherapy never went away, even though they were supposed to. The hospital stay was not short, even though it was supposed to be. Everything that could go wrong went so terribly wrong.

Then, on Saturday morning, something changed. Her breathing got worse. She was less responsive. She was immediately transferred to the ICU to get closer monitoring. All throughout the day and night, her organ systems began to fail – one by one. By the end of the night, she was on a ventilator and had to be transferred to another hospital to get dialysis.

Everything continued to deteriorate, and by the following morning, my daughter was dead. She succumbed to gram negative septic shock that caused multiorgan failure. All I could do was watch in horror and grieve over the death of my firstborn, a death I could do nothing to prevent.

This is the ruthless monster that is sepsis. This is the horror that I witnessed firsthand as a father and witness countless times as a physician in the ICU caring for sepsis patients.

Sepsis is defined as organ failure as a result of an abnormal response of the body to an infection. It can be devastating. In a matter of hours, it can take someone from awake, alert, and talking to fighting for his or her very life in shock on a ventilator and dialysis machine. It is the number one diagnosis we see in the ICU, and it has exacted a terrible toll on so many people and their family and loved ones.

We try to always be vigilant against this disease, because it can sneak up on our patients with very little warning. Decades of research have been conducted to try and fight this disease, and there have been many drugs and therapies that have been tried and tried without success. I “grew up” in the era of those drugs and therapies, and I have seen one after the other fail to prevent death and destruction from this disease.

At the same time, it is not hopeless: I have been blessed to help heal countless patients from certain death from sepsis, and seeing them survive this terrible illness brings a feeling of joy that is beyond words to describe. Sepsis can be treated successfully, as long as one is always thinking about it, is aggressive with resuscitation early on, and administers appropriate antibiotic therapy as soon as it is suspected.

September is Sepsis Awareness Month. It is of the utmost importance that we, as ICU clinicians, are ever vigilant against this ruthless monster that ravaged my poor daughter and sent her back to our Precious Beloved. And we should also take some time to remember and pray for all those who have lost their battles with sepsis, as well as their families and loved ones having to move on with the grief of horrible loss. May our Lord ever comfort them in this life and the next. Amen.

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Perhaps the cloak of invisibility these disabilities provide may furnish a greater ability to navigate our society as they wish. Those who are dependent on wheeled or motorized rides or braces are hard to ignore, but ignore them we do.

Think about it for a moment. If you had to ring a bell each time you wanted to have someone come to open the door to a local community center, how would you feel? Oh, you’d be OK with it? Suppose no one came? How would you feel if it were the dead of winter or raining hard or the wind was blowing your coat open as you waited in vain?

What if, when you had to use the lavatory at that same center, you encountered a “courtesy” or “modesty” panel once you managed to get the first door open? Or what if you went into the handicapped stall and found yourself trapped, yelling for help, and no one came? How helpless and maybe even embarrassed would you be? You’d be OK with that, too?

Both of these situations happened to a person who serves on a local committee to respond to the needs of the town’s disabled citizens. What was the response to this individual’s situation? The group dismissed it because someone would come to open the outside door—no need for one of those expensive automatic doors where you push a large plate to open it.

And surely, the lavatory needed that modesty panel, and someone did come to help the person in need after they yelled. But help didn’t come immediately, and there was no way other than yelling to signal a need for help. They failed to see how either situation could be demeaning to someone’s self-esteem. And this is a committee that was formed to advocate for the disabled.

Non-disabled persons fail to understand the many impediments between a physically disabled person and any pursuit, be it a restaurant, a bus, a theatre, or an athletic competition. The disabled are often not considered in too many designs for buildings or transportation.

Sure, my town has installed dimples on the sloped areas at corner crossings so those with sight impairment know where to cross the street. But one local disabled woman, who used a wheelchair, was hit and killed by a car when she tried to enter a local supermarket parking lot — there was no sidewalk leading into the lot. The national supermarket chain assumed everyone on foot would enter the lot almost two blocks away, where there is a sidewalk. The disabled were never considered in the parking lot design.

Even if you had to use a walker, do you know where you’d be put in too many theatres? Yes, off to the side or in the back in a “handicapped” section. Can you say you’d be “sent to Coventry?” Go on a bus with a walker or wheelchair? It’s another time you must opt for a cab or an Uber. Buses don’t have spaces for walkers, and not many have lifts that work for wheelchairs.

Want to go birding on the weekend at a considerable nature center on the East Coast of the US? Well, don’t plan on any help from employees because the governor cut the budget to the bone, which meant no employees on weekends.

Yes, there are boardwalks for those with mobility disabilities, but if there’s a problem or a safety issue, you’d better have helpers with you. Theft may be the least of your troubles.

What about going away to a quaint bed-and-breakfast for a vacation? Everywhere you go, there must be an elevator.

I recall going to California on a vacation years ago, and we went to a Seaworld site. As we entered the walkway leading to the tanks with the orcas, a young family was walking there, too. The couple had two children, a boy, and a girl. I will never forget the young, attractive, possibly, 10-year-old girl who was wrapped in the most elaborate body brace I’d ever seen.

The couple laughed and joked with the kids, and I had to admire the strength it must have taken to get to that place in their minds, never mind to take their kids to a park like this. Sometimes, I wonder what became of her or the young girl I saw standing on a table in a rehab shop where they fitted her with Plaster of Paris and cloth for a body brace.

My visit to the shop was minor. I had to have metal shanks sewn into my shoes’ soles to help my feet heal. As I marveled at the girl’s patience and the size of the brace grow, I said a silent prayer of thanks to myself.

Once outside the shop, wearing my newly rehabbed shoes, a young boy with his mother cried out, “Look, ma, she’s crippled,” as I tried to walk down the street. His mother quickly leaned over and admonished him. The shanks broke within a week, and I had to return for a more substantial pair. The moment and the images have stayed with me still.

Yes, we live in a society that prides itself in its inclusiveness of those who have been pariahs in the past. Don’t be too proud because there’s still much work to be done.

The post When Do the Disabled Get the Respect and Services They Deserve? appeared first on Medika Life.

Full disclosure: back when Covid was rampant, and our hospital was busting at the seams with Covid patients, I was in full support of everyone having to wear a mask. I believe it definitely helped reduce transmission of the virus, and this saved lives, especially when we did not have a vaccine, and most of our population was still susceptible to the virus.

We are in a different situation now. Vaccines are widely available, and many people have already been vaccinated and boosted (myself included). Most of the adult population has either been vaccinated or have had Covid or both. While cases are rising – and hence my donning a mask every time I go inside – hospitalizations are not rising to the same degree. Things are different now.

What I like most about our current situation is the “live and let live” approach. I recently went shopping, and I was probably one of a small minority who wore a mask. Yet, no one gave me a hard time. No one yelled at me for wearing a mask. No one gave me a dirty look. Those who had masks went on their merry ways, and those without masks did the same.

The same went with me: I did not take anyone who did not wear a mask to task. I didn’t look at them with disdain or think they were “ignorant.” Every person can gauge their own personal risk tolerance, and every person was tolerant of another’s choice with respect to masking in public.

For me, with cases rising in the community, I wear a mask because I don’t want to get sick – with Covid or anything else. If I get sick and can’t work, it puts strain on my colleagues who have to cover my shifts while I’m out. It causes a huge disruption to many people’s lives, and so to protect myself and others, I endure the inconvenience – especially in the hot weather – of wearing a mask.

Others do not have the same worries and constraints as I do, and that’s fine. We are all living and let living, and this is very refreshing. Perhaps the lack of contention over masks is a result of the fact that indoor mask mandates are now a thing of the past. Perhaps the mask mandate – of which I was indeed very supportive – did more harm than good from an overall societal perspective.

I am willing to concede that I may have been wrong about the importance of mask mandates, not from a viral transmission perspective, but from a social cohesion perspective. As we study the aftermath of this pandemic, hopefully we will learn important lessons on how we can do better the next time a global pandemic reaches our shores.

It is sad that our country has been so divided over the issue of whether to wear a mask in public. Indeed, back in 2018 when I was in Paris on vacation, I would look at people wearing a mask in large crowds with derision. Fast forward to today, if I ever go back to Paris on vacation, I will be one of those people wearing a mask, too. My how times have changed.

The most important thing is that we tolerate each other’s decisions. Whether it is on a plane (where I also still wear a mask), in the mall, in the park, or anywhere else, we should respect each other’s choice to mask or not wear a mask. The “peace of the mask” has been most refreshing.

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