This Week in Virology
Hosts: Vincent Racaniello, Dickson Despommier, Alan Dove, Rich Condit,
and Brianne Barker
Guests: Daniel Griffin and Chuck Knirsch
Aired 4 July 2020
Vincent Racaniello: This Week in Virology, the podcast about viruses, the kind that make you sick. [music] From MicrobeTV, this is TWiV, This Week in Virology, Episode 635, recorded on July 3rd, 2020. I’m Vincent Racaniello and you’re listening to the podcast all about viruses. Joining me today from New York State, Daniel Griffin.
Daniel Griffin: Hello, everyone.
VR: Also from New York State, Chuck Knirsch.
Chuck Knirsch: Hi, everyone.
VR: From Fort Lee, New Jersey, Dickson Despommier.
Dickson Despommier: Hello there, Vincent. Hello there, everyone.
VR: It is time for our weekly COVID-19 update. Daniel, I have a couple of questions, maybe do you want to give your update first, and then we’ll do them?
DG: Yes, let me do that. I’ll hit everyone with the update and then we’ll hit the questions.
VR: Very good.
DG: First I’m going to start off with a quotation– I think I get feedback, people seem to like these, so I’ll continue. This was actually suggested by a patient. It’s another Winston Churchill quote, and it was, “If you are going through hell, keep going.”
CK: I never heard that one.
DD: I like that one. I like that, actually.
DG: This is one of those gentlemen who’s a long-hauler who’s still suffering with COVID. I don’t know if he was speaking about himself, our world situation, but it seemed appropriate. As of today, as we’re recording this podcast, early July 2020, Plainview Hospital reached a couple of milestones. One is in this hospital, over 2,200 individuals with COVID-19 were taken care of.
The census peaked at a hundred and sixty-five patients in the hospital at one time. Though although there were a few other ID docs who saw a handful each, it was really one of my partners in Anuja Lee and myself, that saw almost all these patients. A tremendous amount of COVID-19 experience.
Anuja Lee and I also saw people at a few of the other hospitals in the area, also, I was out at urgent care centers, and as I think, I do a bit of outpatient work as well so seeing patients in person in the outpatient setting, as well as telehealth. The milestone though is today when I went to work, at least this morning as of 9:00 AM, this may have changed a few hours later, there were zero patients in the entire hospital that were active PCR-positive COVID patients. That is the first time since February.
VR: Well, if you were in California, it would be different, wouldn’t it?
DD: Or in Texas or [crosstalk]–
DG: Yes, I think that’s important. The rest of the world, the rest of our country, things are not so great. The other milestone, we’re now past 50,000 cases in a single day, so things are not going so great.
DD: There are more states though that are going down than are going up. There are. [crosstalk]
DG: The ones that are the ones that are going up, they’re making up for the rest.
DD: Arizona, Texas, California, and Florida. People are just not listening. They’re just doing what they want to do, I think.
DG: Let’s hit testing. I talking to Vincent a little bit as we’re waiting for Dickson to address technical difficulties. I’m not sure if they were addressed [laughs].
DD: That’s fine.
DG: Actually, every Wednesday there has been since this began, I don’t know if it was late March or– I think it was late March when this started. Columbia University does a COVID-19 symposium. This is the second time I spoke, and this time I was speaking about testing. It was a lot about, “How often do you actually have to test? How quick do those results have to come back? What’s the sensitivity to really getting a handle on a virus with the transmissibility of this?” It’s a little frustrating.
One of the big things we’re running into is that there are delays. You get a test, there’s a delay so as you’re waiting for that test to come back, that person is potentially infectious. There also is an issue with how often people are being tested, but, unfortunately, when we talk about titer as in the whole concept of testing people, determining who has it, we don’t have the frequency of tests that we would think would really make that work.
Even when people say, “Oh, a certain number of the states have adequate testing,” it’s really not adequate in the modeling that we did, which will hopefully come out as soon as it gets through peer review. I’m still sort of anti-preprint. I still try to actually get things peer-reviewed before our stuff gets out there. Also, while testing, I wanted to make a point of repeating concerns about serology. What happens when someone has a positive serology test, what do we tell people?
I think this has become even more concerning with, actually, some information. I was talking about on Fox News, for our listeners that listen to Fox News, and this was the whole issue about the durability. A couple of things that we now have seen is that when patients have PCR-positive COVID-19, so really solid, “This is COVID-19,” not everyone produces a measurable antibody response.
We’ve estimated about 80%, which means one in five go through the course of the disease and never produce what we recognize as a positive serology. The other, and this was the concern, was if you then look at people two months out, everybody’s antibody levels are trending downward, and if you look at people with more milder disease, maybe 40% are now serology positive. People who were sick enough to have high antibody titer, you start to see them turn serology negative.
Maybe people have heard about these, they now have COVID parties in certain parts of our country where young people all go together, there’s a cash pool, and the first person who can get a positive COVID-19 test gets all the money in the pool. I’m looking at Vincent’s face to see if he’s disturbed by that.
VR: I didn’t hear that. That’s ridiculous.
DD: That’s absurd.
DG: Yes. It is absurd and part of the thing I want to point out here is we do not know, there’s this whole concept of reaching herd immunity, we don’t know if there’s durable immunity after being sick with COVID. That’s an issue. The whole idea, and I think a lot of people want to think about the idea, “I’m going to go out, I’m going to get it, I’m going to get it over with, I’ll no longer have this Damocles hanging over my head. Now I’ll have this protection”.
I’m not sure that there’s any guarantee that that occurs. I’m not sure there’s any guarantee that whatever immunity you have is durable, so this raises a lot of concerns with what to do with the serology. I’m going to actively discourage people from going to these parties and getting COVID. Think about the issue, we don’t even know, as it is with other viral illnesses that have a significant inflammatory component, if a second bout of COVID is worse than the first.
Try to avoid getting COVID until we have a better understanding of what to do. Hopefully, avoid getting COVID until we have the ability to make you immune. I don’t know whether or not that’s going to be generating protective antibodies or whether it’s going to be T cell base. I’m on-board with some of the other discussions about we put a lot of eggs in the spike basket. I don’t know if we should be doing that, but I think that’s a little bit of cause for caution. I want to talk about the long-haulers.
Vincent asked a few times and I’m always curious about how many people end up getting COVID and never really getting better. I can’t say never because it’s only been so many months, but months later, two, three months still feeling sick. There are now support groups, these numbers getting into the thousands. One support group alone is approaching 4,000. There are thousands of these people in the U.S. alone who got sick and still don’t feel well.
I feel bad because I see some of these people and they go to providers who discount it like, “Hey, back up. Time to get over that, you were sick in March.” There was an article that came out in Respiratory Research where they looked, basically, they said, “Okay, 30 days after discharge, let’s do some objective measurement on pulmonary function.”
Basically, you were seeing objective evidence of impaired diffusing capacity, lower respiratory basal strength, lung imaging abnormalities in the majority of COVID-19 patients even a month after discharge. We have objective evidence that something is not all better, and it’s very consistent. I’ll say the clinical presentation that I hear from different patients, this description of a chest heaviness.
What I’m beginning to really say is almost like a histamine-like experience where they say, “Do you know what? Sometimes at the end of the day, I feel like, ‘Oh, my gosh, I just got too much sun, my skin’, but I didn’t actually go outside because I’m staying in my room.” That’s a very interesting, maybe there’ll be some clues to the pathology or the pathophysiology there. There’s persistent fatigue, I was taking care of a nurse just this week who was like, “I pride myself on being there.”
There’s persistent fatigue. I was taking care of a nurse just this week who was like, “I pride myself on being a hard worker and I just have this fatigue.” I feel, I think, particularly bad because here’s someone who was in the front lines with us and she’s just like, “I want to get back to work.” The brain fog is described, this weakness which we have objective measurement that they have trouble with doing these six-minute walk tests, the weakness exercise tolerance.
There also seems to be, in addition to these things, some say, mental health impact, depression, anxiousness and there’s actually a discussion, maybe a lot of people who are sick enough to be in the hospital, but maybe we should extend this need to talk to someone not that I was discount this as a psychiatric in any way, but I think there are psychiatric impacts to COVID. Neurological impacts is probably better to say. Most people describe that I talked to as having symptoms particularly to chest heaviness that are worse in the morning, get a little better throughout the day, but a lot of people have a one, two in the afternoon, “I’m just done.”
There is some suggestion in some of these early reports that this is more often seen in younger individuals, that this has a female preponderance. I say the older men die, the younger women suffer. As I mentioned, there are now thousands of these individuals and support groups, but I’m seeing women, I’m seeing men, I’m seeing people of all ages. One of the interesting things several of my patients have stumbled across on their own, and one was actually recommended by a pulmonologist I work with at NYU, was the use of something called NAC, or N-acetylcysteine, or Mucomyst.
I think the pulmonologist was trying it as a mucolytic, but some of these patients are actually saying that it seems to have some impact. Maybe there’s some antioxidant or anti-inflammatory impact. We’re learning. I don’t want to be endorsing that, but just commenting on that. Non-steroidal anti-inflammatory drugs and I’m going to– Well, I’ll just say it right here. Early on, that was another one of the dogma, like, “Don’t use non-steroidal anti-inflammatories.” It was a letter by a French pediatrician and the WHO has now looked at over 70 studies.
I’m going to quote them when they say, “At present, there’s no evidence of severe adverse events, acute healthcare utilization, long-term survival or quality of life in patients with COVID-19 as a result of the use of NSAIDs.” These patients actually, and this is also an issue in people early on, they actually respond quite well to ibuprofen, Aleve, aspirin. Just another thing that is pulled out of our arsenal that actually doesn’t look like there was any evidence to support pulling that out.
Outpatients, most of the focus has been on the patients in the hospital, but as we’ve always pointed out, the majority of patients never end up hospitalized and there’s now some concrete data addressing this population. There was an early release that came out, MMWR, looking at the characteristics of the outpatients versus the inpatients. Some of this, we’ll say, is intuitive. The outpatients tend to be younger. We knew the inpatients were older. The outpatients have fewer comorbidities. The opposite, we knew the inpatients had more. The outpatients were more likely to be of lower socioeconomic status. Interesting.
By two to three weeks after the onset of symptoms, they did a survey. Basically, a third of patients were saying, “I’m still sick.” The idea that this is only a two-week syndrome, that’s not true for a third of people. A third of people by two to three weeks, they’re still having this. The other, I want to make a point, and sometimes people say, “Oh, I haven’t heard about something in a little while. It must have gone away.” I want to make a point of just re-emphasize thromboembolic complications. This is a disease that involves a thromboembolic phenomenon, and there’s some interesting things coming out now about platelets and megakaryocytes playing a role.
Actually, very quickly. Our first two publications on this were on thromboembolic complications out of our group and first, it was pulmonary emboli, but then a week later, we were actually publishing on arterial clots. One individual actually had the arterial clot removed, and it basically was shiny white platelet-rich. Some of the autopsy stuff we’re seeing, where they’re looking at this, is consistent with what we described early on in the epidemic.
Summary of current therapeutics. I’m going to try to keep this short today. Things were not doing, we’re not using much in the way of hydroxychloroquine, we’re not using much in the way of famotidine, we’re not using much in the way of azithromycin. I keep trying to point out, it’s a virus, it’s not malaria, it’s not an ulcer, it’s not a bacteria. Remdesivir, we now have a price. You can get a five-day treatment of remdesivir for $3,120. Interesting.
Their argument on pricing was, “This is going to save the hospitals a lot of money.” And my point was, “Oh, I’m glad the hospital’s going to jump in and pay for that because it’s going to save them money.” Just, by the way, if I’m unable to make a decision, I don’t want to spend the $3,000 on remdesivir. I’ll save that for something else.
Steroids. That’s now gaining traction. It’s interesting, even though we’ve been talking about it for a little while, the history of that, the data, it’s going to take people a little while to break from the dogma to, as we said it, business school pivot they’re thinking. Or what was the rhetoric we used at business school? You probably are familiar with that. It’s when you change what you have to say by a hundred and eighty degrees, right? You do it in– Our thinking will evolve.
Anticoagulation, this is interesting because now there’s more discussion about maybe in addition to blocking the clotting cascade, maybe we need to be thinking more about anti-platelet agents. On one of the anticoagulation panels that I’m working on, this is actually, hopefully, going to be addressed.
CK: Especially for outpatients because you worry they’re not being closely monitored and I don’t know how many cases you’re seeing, Daniel, of outpatients that are on the verge of needing to come in the hospital because that might be a good group that you would look at an anti-platelet therapy, I think, right?
DG: Yes. I do the telehealth, Chuck. I was taking care of a patient on Tuesday who’s in Houston. I’ve been remotely caring for people in California and Texas, other parts of the country. This was a physician. It’s, actually, a friend of his is a TWiV listener. He was like, “I got to talk to Dan because you’ve got COVID.” As we had our discussion, he had done a few things that I wasn’t happy about. There was azithromycin and unnecessary steroids, and the person who didn’t need these things.
Then we talked about the fact that he had previously been on chronic aspirin and he wasn’t handling it well with his stomach. I was like, “This might be a time for you to start taking the aspirin and stop taking all that other stuff.” Yes, in the outpatient setting, physicians have certainly on a case-by-case basis made recommendations about platelets.
We know that about anti-platelet agents such as aspirin, and we know that certain groups are at increased risk of strokes. If you’re in that setting, it makes a lot of sense, but again, we’re waiting for data to help us, but yet most patients will not end up in the hospital. We need guidance on what to recommend for those people.
DD: There’s an interesting movement afoot among professional athletes, particularly male professional athletes, particularly football players. A lot of them expressed great concern about restarting the season because of the close contact and the lack of proper knowledge as to whether the person opposite you on the line is infected or not because he’s asymptomatic.
The other thing if they were too bad, I’ve heard them express this on ESPN, is that what if they do get it and then they have all these later-onset sequelae? Muscle weakness, fatigue. That’s not so good for professional athletes supposed to perform at the peak of their abilities. I think this is got huge ramifications to have a COVID party among young people of presumably very bright futures ahead of them and various walks of life, to have that threatened by such trivial thinking. That’s just absolutely antediluvian. It’s just–
DG: I see Chuck also not approving of this. One of my other hats is I’m the infectious disease expert for the Long Islander hockey team, which I played hockey growing up as a kid. I still have all my teeth, so I must have been really bad. But no, this is a big issue for a lot of the sports teams. How do you play your sport, how do you practice, how do you do a lot of the things you do, and stay safe because you think, “Oh, I’m young,” but what we’re concerned about is if you end up as an athlete with– you’ve lost 10% of your pulmonary capacity because of– That’s a problem. That might be what prevents you from having that career you were interested in.
This is a huge issue and think about what the young people like, “Oh, I got my COVID. Now, I don’t have to worry about it. Why don’t you go for a run?” Then you realize, “I don’t run quite as well.” We don’t know the long-term impacts yet. There’s a lot of issues here.
CK: Daniel, you and I have children that are college students and I’m particularly concerned about them not being able to get back to their usual– not usual, their unusual routine come this fall. CDC just put out their guidelines for school reopening and they do address the university setting. I was impressed by the lack of recommendations around routine testing, and maybe it was done for pragmatic reasons that there aren’t enough tests, but I do know already that universities are planning, I’ve seen some– and I won’t name them by name yet because I think it’s still draft, but weekly testing.
Vincent, I’ve heard you say that in TWiV a couple times, that wouldn’t it be great to be able to test on a weekly basis?
VR: Cornell just had an editorial in The Wall Street Journal saying that they didn’t have the capacity to test everyone on a weekly basis. They’re going to try pooled testing.
DG: I’ll weigh on this because, yes, this is not good and there’s several issues here. The first I want to point out is that the people, and someone asked me about this recently, “Oh, what about that thing in kids?” I will say the multi-system inflammatory syndrome in U.S. children and adolescents, it didn’t go away. And there are actually are two publications in The New England Journal of Medicine, their focus was to make a strong connection to say, “No, this is related, this is a COVID-19 connection here. This is not just random.”
In New York State, the New York State Department of Health has had almost 200 cases reported to them and 96% were classified as confirmed. If anything, we think this is underreported. We do think that there is an issue with COVID-19 causing harm, pretty significant harm, in a certain percent of children.
A couple of things I want to say here because this is important too, you want to put this in context of the age-dependent effects of COVID-19. The CDC published, really it was April 2nd, so really early on when they started noticing that there was less than 2% of the cases were being seen in people under 18, where people under 18 make up over 20% of the population. There was a much lower incidence of cases.
We could talk about why there might be underreporting and undertesting in that population, but the American Academy of Pediatrics came out recently with a strong recommendation where they say, “The AAP strongly advocates that all policy considerations for the coming school year should start with a goal of having students physically present in school,” and there’s a big debate about this. I’m going to come out and just say, I’m actually on the side of opening the schools.
I think it’s really important and I sort of the slogan of, “Open the schools not the bars.” I think physicians get asked about what do we think about opening the schools. I think it’s great to have opinions, but they should be based on facts. We do know that when we don’t have schools, not every child has a great home environment, and I’ve already talked about this a few times.
We’re seeing an increase in drug abuse, in alcohol, and domestic violence. Without schools, we don’t have access to the kids, we can’t find out that there’s a bad home situation that we might want to be able to help with. I think that there are a lot of bad home situations. I was in the hospital today and one of the hospitalists was like, “How come we’re seeing so many alcoholic withdrawals and GI bleeds?” I was like, “Yes, because–” You know what I’m saying. But as if liquor stores were considered an essential service.
We are seeing– There is clear harm to keeping the kids out of the schools and that has to be balanced, but how do you balance it? You open the schools in the right way and testing is critical. The testing has to be frequent, it has to be accurate, it has to have rapid turnaround. We just dumped trillions of dollars into the stock market to do whatever to the Dow Jones. We need to put billions of dollars into testing so we can keep our kids safe. This is a political will, it’s an economic will. It’s a question of priorities and I think our kids, schools, and education, they’re priorities. We need to make this happen in a safe way.
VR: I so agree. I think we can afford this. We could have– We’ve been working in these three months on rapid affordable testing and there’s just no will, as you say, to do that. It’s very disheartening. You asked me before we came on, how do I feel? I’m very depressed about this because we could be doing this, and you’ve shown you can do lots of testing rapidly.
DG: We had a couple of summer programs in the area. One was an outdoor summer camp with over a thousand kids, and then all the counselors and staff. Another, it’s a sailing program with a hundred and fifty kids plus all the staff. We talked to them, we went through programs with them. We said, “Okay, you need these people all tested, we will test everyone before the program starts and we’ll even set up periodic testing through the program.”
We set up drive-throughs, we did all the registration over the phone, and basically, we were testing hundreds of kids every day. This can be done. It just takes the will. You’ll just have to decide it’s a priority.
VR: Daniel, Rich asked me to ask you if there is any information yet on convalescent serum?
DG: There was the first randomized control trial on convalescent serum and it did not show benefit.
DG: Yes, I should probably share that with you guys. I would get that up on the PWB website for people to take a look at. What we saw in our experience was if it was given late, we actually saw people not do well because it is, it’s FFP and it has clotting factors. If you gave it to people, we had a number of people in the intensive care unit who got this as part of this Mayo Clinical trial. During the second week, all their D-dimers tripled and we had a lot of complications.
Actually, most of them died, but my thought would be is if you got it earlier before that pro-thromboembolic period, that it might have some benefit. Again, it goes back to the issue is, “What is helping us clear this virus? Is it antibodies or is it an effective cellular response?” A lot of this goes back to stuff we just don’t know yet the science here.
VR: That’s right, but I think the RECOVERY Trial has one convalescence serum in progress, right, Chuck?
CK: Yes, it does. I think you need both. I don’t think it’s going to be only B cell responses or T cell responses, but in general, for viruses like this, you do need a B cell response. You need neutralizing antibodies. I wouldn’t rule that out and maybe it’s the– I think you’re right that if it would have an effect early, the steroids maybe later given that the benefit in the steroid seem to be most of the intubated patients were quite severe.
VR: Daniel, we have an email from an internist in Washington, D.C. who writes, “Keep up the amazing work. What a terrific asset to have such smart people focusing on understanding and communicating the latest science with all its imperfections and uncertainties.” He has a patient whose disease course scares me as the implications are potentially massive. “It would be great if you could pose this question to Daniel tomorrow.” He just sent this– on your show and he knows the timing, it’s great.
DG: [laughs] That’s great.
VR: “54-year-old male patient, mild COVID, cough and sore throat with positive PCR on April 4th, recovered quickly. Two negative PCRs in subsequent weeks, never got an antibody test. He presumed he was immune, however, when his son contracted COVID in mid-June, they did not distance. On June 22nd, my patient developed fever and cough in the next week, tested for COVID was positive. His symptoms have become increasingly severe including O2 sat of 88, fever 103, he’s on his way to the hospital now as I type this email.”
“Here is my question and concern, if we believe the story, and I have no reason to believe the PCR test in April was a false positive, this appears to be a perhaps dengue-like worsening clinical syndrome upon reinfection. Are you seeing any cases like this in New York and if so, do you believe these are rare one-offs or could they have greater implications for the safety of vaccines or even the ability to develop natural herd immunity?”
DG: Clay, this is right in lines with some of the concerns that I’ve had when we talk about the serology testing. We saw several people in the New York area who got sick, COVID, they went home, we thought, “Oh, this is a win.” Then couple of weeks later, they’d come back and now they’re super sick and they would die. In the height of the pandemic, there was no way to know, was that a reinfection? Was that somehow some odd biphasic variant of this? I don’t know, and what you’re describing sounds to me like a potential reinfection, and it sounds like this reinfection was worse. Well, obviously, quite a bit worse. He initially had mild COVID with cough and sore throat. Now, the man is on his way to the hospital. These are the things I worry about, particularly people go to these parties, they’re going to become immune to COVID. Maybe they’re actually going to become hypersusceptible to a severe syndrome upon reinfection. This stuff, we don’t know and we’re learning about, but it’s why I think we need to be cautious. You don’t want to go get this and make certain assumptions that I think a lot of people make, they say, “Oh, it’s in general, you get something then you’re done, you’re not going to get it again.”
We don’t know because that’s certainly not the case with dengue. If you get one serotype of dengue, and then you get reinfected with the second. I’ll share this, I was in China in the ’80s, I don’t know if people know, but I used to speak Mandarin and do translations. I was hired to teach at Kunming at one point. In 1988, I don’t think there are a lot of Americans in China at that point, but I got quite ill, came back, and then several years later I was in Zimbabwe in Zambia, and I got sick again and it was felt to be a second infection with dengue where my platelets went down into the teens.
They called my parents and was like, “Well, if he’s here in the morning, we’ll let you know.” Some viral illnesses, the first time is not so bad, that second is when you get these really severe manifestations. We don’t know that– We’re still learning about COVID-19. Let’s not make any assumptions that end up with tragic consequences.
CK: If this is still within the realm, let’s also not assume this is reinfection, right? It’s eight weeks afterwards, and some of the progressors and literature have been positive much longer than eight weeks. The two negative tests in between, maybe the performance characteristics of the test as much as reinfection. Let’s not get all depressed about– Vaccine approaches right now because of this one case. I think we’re really going to need to know, you have to sequence virus before and afterwards to confirm something like this. We know how hard that will be with the absence of access to BSL-3 labs.
DG: It was interesting because I know early on there was this assumption and a lot of doctors wanted to get serology tests and say like, “Oh, if I’m serology positive then I’ll go volunteer at the Javits Center because I won’t have to worry.” I don’t know if we know. I think we have to be careful about making assumptions, but I would hope, I would suspect, that our vaccines are not going to cause this, but again it’s hope. I don’t know.
CK: It has to be studied. That’s why there will be mega-trials where safety can be really carefully studied.
VR: In fact, in the FDA guidance they issued this week, they say, “Look, please design your trial so you can look for vaccine-associated disease.” Specifically, for that, it’s important. Daniel, anything else before we say goodbye?
DG: I want to thank everyone who’s come to the Parasites Without Borders’ website and donated to help support the FIMRC site in Bududa, Uganda for the month of June with the Parasites Without Borders’ match. We raised $12,304 for FIMRC in Bududa, Uganda. I like to point out that this is a clinic that is fully-staffed by local Ugandans. This isn’t us coming in trying to save the day. These are people on the ground in Uganda who your generous donations really help because there’s food insecurity at the moment, there’s issues with transportation and access to medicines.
What we’re going to– We’ll announce today, I guess, is that we’re going to extend this fundraiser until the end of July. Thank you. Please go ahead, visit parasiteswithoutborders.com and we will continue to double everything that comes in to help support this clinic in Uganda.
VR: Daniel, thank you again. I really appreciate you coming.
DG: No, thank you. It’s a pleasure as always.
VR: Chuck, thank you as well.
CK: Good to see everyone on Zoom today.
VR: Dickson, thank you.
Dickson: Partially, you’re welcome.
VR: Partially? What does that mean, partially?
DD: Whatever you can hear, you’re welcome [laughs].
VR: All right. Okay.