Posted on 08/14/2002 1:42:48 PM PDT by krodriguesdc
Mumps and the MMR vaccine
Evening Standard editorial comment
Parents have good reason to be concerned about the possibility of a mumps outbreak in London. The epidemiological history of this infectious disease suggests that mumps is unpleasant but hardly ever fatal to children. In rare cases it causes meningitis or encephalitis; it can also cause infertility in boys. Before there was a vaccine for mumps, it tended to kill no more than five people a year.
Yet it is impossible to be certain that half a century of vaccination against the disease will not have weakened our natural immunity to the extent that a renewed outbreak would produce unusually severe symptoms.
This is why the near quadrupling of mumps cases in the capital to 112 in 2001, and the 30 per cent rise in the last quarter over the previous three months, is particularly worrying, given that clinics across the country have been without supplies of the mumps vaccine for up to six months and do not know when they can expect fresh supplies.
The Government will be blamed for creating this situation, and endangering childrens' lives, by insisting that the triple MMR vaccine be used to inoculate children against measles, mumps and rubella, but it is not directly the fault of the Department of Health. The reason why there is such a shortage of mumps vaccine is that not much of it is being manufactured (none to UK licence specifications) and the logical reason for this is that every country in the developed world except Britain has accepted the overwhelming scientific evidence that MMR does not trigger autism in young children. This is not to say that blame should rest with parents who refuse the triple vaccine.
Ever since Dr Andrew Wakefield produced his own variant findings, which suggested a possible link between MMR and autism and bowel disorders, enough anecdotal evidence has emerged that the MMR vaccination appears to coincide with the onset of autism in young children to convince many parents that they must be connected. Pressure is therefore growing to make it the responsibility of the Government to accelerate the production of mumps vaccine and then provide all three vaccinations separately on the NHS. This will be the first major challenge for the new public health minister David Lammy, and perhaps the toughest he will ever have to face.
I'll stick with the horses mouth, doc.
If you've got other "proof," cite it.
Beyond that, I've told you what I think would be good research into this question.
Later...
It revisits a similar controversy from the '70.
MMR vaccination and autism 1998
Déjà vu [---] pertussis and brain damage 1974?
Britain's vaccination programme has hugely reduced the incidence of diphtheria, haemophilus meningitis, measles, polio, pertussis, congenital rubella, and tetanus.4 As the incidence of these diseases has fallen vaccine safety has assumed greater importance, especially in parents' minds. Any safety issue requires cool scientific consideration.3 Here the hypothesis is that MMR leads to a non-specific gut condition permitting the absorption of non-permeable peptides, which in turn cause serious developmental disorders.1 Supportive evidence consists of cases referred to a gastroenterology group. The data published comprises 11 boys and one girl, each with bowel abnormalities and serious developmental regression (nine had autism). In eight children parents reported regression starting shortly after the children received MMR.1
An editorial accompanying the article and a recent review by the World Health Organisation list the considerable evidence against this and previous related theories from the same group. 3 5 Since each year over 600 000 British children receive MMR in their second year, an age when autism can typically manifest itself, chance alone dictates that some cases will appear shortly after vaccination.3 Cases will be selectively referred to a group known for its interest in MMR, inflammatory bowel disease, and autism, so the hypothesis rests on clinical anecdote rather than an epidemiologically sound base.
Proved serious vaccine reactions are characterised by specific clinical or laboratory findings, but the non-specific nature of the developmental and gut abnormalities in these cases is striking, and no precise case definition is offered.1 No vaccine viruses were reported in the children's biological specimens, though the researchers have previously reported viruses in bowel tissues of children with inflammatory bowel disease, findings which others have been unable to confirm.3
Epidemiological evidence is unsupportive: the WHO found no links between measles, MMR, and inflammatory bowel disease5; and a survey of conditions associated with autism did not mention inflammatory bowel disease.6 National data seem to indicate a rise in the incidence of autism, but it started over a decade before MMR's introduction in 1988 and showed no change at that time (M Bax, D Lawton, Family Fund Trust, unpublished data). This evidence suggests either no causative association or one that is exceedingly rare. These and many other data relating to MMR safety have been reviewed by the Joint Committee on Vaccination and Immunisation, which found no case for changing vaccination policy. Unproved theories are no basis for dropping a vaccine of proved global safety and effectiveness. 3 5
Despite the lack of evidence of a causal relation, and the experience of other hypotheses from the same group (linking first wild measles, then measles vaccine, and latterly MMR with bowel disease) not standing up to independent scrutiny 5 7 much parental anxiety has resulted. MMR immunisation rates have begun to decline and those at the "sharp end" of immunisation [---] general practitioners, health visitors, and community paediatricians [---] are experiencing parental inquiries.8 Any decline in immunisation, or the giving of MMR as three injections at annual intervals (as suggested by one of the report's authors), will undo the recent near elimination of measles and rubella in the UK.8
The experience with pertussis in the 1970s was also based on anecdotal case reports linking pertussis vaccination with infant brain damage.9 Again a temporal link between a vaccine and a devastating childhood condition whose natural peak onset was at the very time when most children received that vaccine was misinterpreted as a causal relation. A national study eventually showed that, while there was a temporal association with encephalopathy, any risk of lasting damage was so rare as to be unquantifiable.10 But the initial report, then as now, attracted media attention; parental and professional anxiety soared; and national immunisation rates fell from 80% to 30%. The number of susceptible children rose, and in the 12 years after 1976 three major pertussis epidemics accounted nationally for over 300 000 notifications and at least 70 deaths. The suffering of families experiencing long miserable illnesses was considerable, and in some cases long term damage ensued. Some parents came to believe that an immunisation they had approved had damaged their child.
There are differences between then and now. The connection of encephalopathy with pertussis vaccine was biologically more plausible than the link proposed for MMR and autism. The original national study10 has already shown no link between measles vaccine and long term developmental disorders.11 Detection of vaccine reactions is more efficient, with international data sharing and a careful eye on safety by independent scientific experts on the Joint Committee on Vaccination and Immunisation and committees of the Medicines Control Agency. Surveillance results in product withdrawal when there is clear evidence of a safety issue.
In the 1970s immunisation had a low priority, and evidence based information for those doing the immunising was minimal. District immunisation coordinators did not exist, and vaccination rates slumped partially because it was unclear whose responsibility it was to do anything about them.12 The pertussis experience must not be repeated with MMR vaccine. While vaccine can be guaranteed to be without any risk, this has to be weighed against the huge advantages of protection against disease. Seeds of concern have been sown among parents and no doubt will continue to be spread. Those advising families must make sure parents can base their decisions on hard science and evidence.
1. Wakefield AJ, Murch SH, Linnell AAJ, Casson DM, Malik M, Berelowitz M, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis and pervasive developmental disorder in children. Lancet 1998; 351: 637-641[Medline].
2. Gangarosa EJ, Galazka AM, Wolfe CR, Phillips LM, Gangarosa RE, Miller E, et al. Impact of the anti-vaccine movements on pertussis control: the untold story. Lancet 1998; 351: 356-361[Medline].
3. Chen RT, Destefano F. Vaccine adverse events: causal or coincidental? Lancet 1998; 351: 611-612[Medline].
4. In: Salisbury DM, Begg NT, eds. Immunisation against infectious disease. London: HMSO , 1996.
5. World Health Organisation. Expanded programme on immunization (EPI) [---] association between measles infection and the occurrence of chronic inflammatory bowel disease. Wkly Epidemiol Rec 1998; 73: 33-40[Medline].
6. Fombomme E, Du Mazaubrun C, Cans C, Grandjean H. Autism and associated medical disorders in a French epidemiological survey. Am Acad Child Adolesc Psychiatry 1997;36:1561-9.
7. Metcalfe J. Is measles infection associated with Crohn's disease? BMJ 1998; 316: 166[Full Text].
8. Begg N, Ramsay M, White J, Bozoky Z. Media dents confidence in MMR vaccine. BMJ 1998; 316: 561[Abstract/Full Text].
9. Kulenkampff M, Schwartzman JS, Wilson J. Neurological complications of pertussis inoculation. Arch Dis Child 1974; 49: 46-49[Medline].
10. Miller D, Madge N, Diamond J, Wadsworth J, Ross E. Pertussis immunisation and serious acute neurological illnesses in children. BMJ 1993; 307: 1171-1176[Medline].
11. Miller D, Wadsworth J, Diamond J, Ross E. Measles vaccination and neurological events. Lancet 1997; 349: 730-731.
12. Nicoll A, Elliman D, Begg NT. Immunisation: causes of failure and strategies and tactics for success. BMJ 1989; 299: 808-812[Medline].
"I had discovered a new explanation for our deadliest disease," he said, "I thought I would get a big-shot professorship out of it."
The rest, considering what he said in the quote I posted, is probably embellishment.
TomB - please tell me what's wrong with tihs account of Dr. Kilmer...Pulse — Editor's Note
Vol. 278, pp. 1114, Oct. 1, 1997
Learning From the Past
Li-Yu Huang, MHS, Texas A&M University College of Medicine
But what the present age now scorns and hates, a grateful posterity may perhaps find a worthy work. —Hieremias Martius[1]
Despite Martius' astute 16th-century observation, innovations in the biomedical sciences continue to meet a lukewarm and sometimes hostile reception. The rigorous peer review process used to evaluate grant proposals and scientific publications is often so restrictive that investigators with fresh ideas are stymied because their research does not fit the prevailing theories of the time.[2]
The experience of Dr Kilmer McCully, now recognized as a pioneer for his research on homocysteine's link to heart disease, illustrates this point. McCully's greatest obstacle was not poor research or questionable data; it was inopportune timing. McCully attempted to investigate the effects of homocysteine levels on cardiovascular disease at a time when cholesterol's effects on heart disease were in vogue. After years of ridicule from colleagues and struggles for funding, McCully's ideas are finally being appreciated. For example, the National Institutes of Health recently requested applications for research on homocysteine (New York Times Magazine. August 10, 1997:25).
McCully's story is not unique. Researchers Barry Marshall and Robin Warren met similar opposition in the 1980s when they championed the link between Helicobacter pylori and peptic ulcer disease.[3] The accepted etiology for ulcer disease at the time was an overproduction of acid. The hypothesis advanced by Marshall, a young intern, was a difficult one for ulcer disease experts to embrace. Marshall's new hypothesis also came at a time when a new weapon to combat stomach acid—histamine2 receptor blockade—was being introduced. The excitement over this new class of drugs further hindered the acceptance of an infectious etiology for ulcers (Fortune. June 9, 1997:102). However, after a decade of continued research by Marshall, including an experiment in which he tested the causative bacteria on himself, H pylori is now recognized as the etiologic agent of ulcers.
There is great value in studying the history of important discoveries, for it is from the past that we gain insight into how to shape the future of medicine. With this in mind, this issue of Pulse explores an eclectic collection of topics in the history of medicine.
Medical student Michael Hutchens chronicles the past practice of grave-robbing in medical education, questioning if expedience should ever supersede doing what is ethically correct in medicine. Expedience can create all sorts of demands, including those for physicians' rapidly scribbled handwritten notes and prescriptions, the consequences of which are explored by resident physician John Cabral, MD, MPH. In a third article, medical students Salomeh Kejhani and Julie Boyer examine the history of the often stark differences in philosophy between medical students and the medical establishment. Finally, Sean Savitz discusses the important role Harvey Cushing played in shaping the field of neurosurgery.
References
1. Strauss MB, ed. Familiar Medical Quotation. Little Brown & Company; 1968:461.
2. Horrobin DF. The philosophical basis of peer review and the suppression of innovation. JAMA. 1990;263:1438-1441.
3. Marshall BJ. Heliobacter pylori: the etiologic agent for peptic ulcer. JAMA. 1995;274:1064-1065.
(JAMA. 1997;278:1114)
And of course the Wakefield study isn't "fundamentally flawed" despite there were only twelve children included in the study.
If you've got other "proof," cite it.
* Chen RT, DeStefano F. Vaccine adverse events: causal or coincidental? Lancet 1998; 351:611 - 612.
* Dales L, Hammer SJ, Smith, NJ. Time Trends in Autism and in MMR Immunization Coverage in California, JAMA 2001; 285:1183-1185
* DeStefano F, Chen RT. Negative association between MMR and autism. Lancet 1999;353:1987-8.
* Fombonne E, FRCPsych, Chakrabarti S, FRCPCH, MRCP. No evidence for a new variant of measles-mumps-rubella-induced autism. Pediatrics 2001; 108:e58.
* Fombonne E, du Mazaubrun C, Cans C, Grandjean H. Autism and associated medical disorders in a large French epidemiological sample. J Am Acad Adolesc Psychiatry 1997, 36:1561-69.
* Iizuka M, Itou h, Chiba M, Shirasaka T, Watanabe S. The MMR question. Lancet 2000;356:160.
* Kastner JL & Gellin BG. Measles-mumps-rubella vaccine and autism: The rise (and fall?) of a hypothesis. Ped Annals 2001;30:408-415.
* Kaye J, del Mar Melero-Montes M, Jick H. Mumps, measles, and rubella vaccine and the incidence of autism recorded by general practitioners: a time trend analysis. BMJ 2001; 322:460-463.
* Medicines Commission Agency/Committee on Safety of Medicines. The safety of MMR vaccine. Curr Probl Curr Pharmacovigilance 1999;25:9-10.
* Metcalf J. Is measles infection associated with Crohn's disease? British Medical Journal 1998;316:561.
try reading this one on how establishment practices stiffle good research...
MAGAZINE DESK | August 10, 1997, Sunday The Fall and Rise Of Kilmer McCully
By Michelle Stacey (NYT) 4182 words
Late Edition - Final, Section 6, Page 25, Column 1 ABSTRACT - Michelle Stacey article on Kilmer McCully, whose career-long study of homocysteine as trigger of heart disease is suddenly at forefront of cardiac research, after three decades in which he was virtual medical outcast; McCully, now 63, believes that homocysteine, an amino acid in blood, damages artery walls and causes heart attacks, but can in most cases be lowered to safe levels by certain common vitamins; he made initial observations while working in 1960's at Harvard, where he had graduated, but support for work flagged as medical community began to accept cholesterol as major element in heart disease; Robert T McCluskey, who headed research at Harvard and Mass General Hospital, blames lack of Federal funding; McCully himself recalls rumors of 'poison phone calls' that prevented him from getting new research job for two years, until he took post at Providence VA hospital; he comments on belated support for his theory; interview;
TomB what about this one?findings similar to Wakefield's...
is this one seriously flawed too?
Harvard Clinic Scientist Finds Gut/Autism Link, Similar to Wakefield Findings 12/7/01
Dr. Timothy Buie, a pediatric gastroenterologist from Harvard/Mass General Hospital has performed over 400 gastrointestinal endoscopies with biopsies, as well as evaluation of digestive enzyme function in children diagnosed with autism and finding a connection. The results of his testing are similar to the observations made by Dr. Andrew Wakefield regarding the presence of chronic inflammation of the intestinal tract, although the incidence was noted to be less frequent in his group.
Dr. Buie announced his findings last Saturday at the Oasis 2001 Conference for Autism in Portland, Oregon, the day before the announcement of Wakefield's forced departure from Royal Free in the UK. The biopsy results indicated the presence of chronic inflammation of the digestive tract including esophagitis, gastritis and enterocolitis along with the presence of Iymphoid nodular hyperplasia in 15 of 89 children.
Additionally the results of the enzyme testing of Dr. Buie's patients paralleled that of Dr. Karoly Horvath and colleagues at the University of Maryland School of Medicine. Dr. Buie found that the autistic children he examined showed disaccbaride/glucoamylase enzyme levels below normal. Some 55% of these children had lactase deficiencies (which breaks down lactose in milk) as well as deficiencies of the enzyme sucrase (responsible for digestion of table sugar). The findings also lend support to anecdotal reports of improvement of some autistic children on wheat and dairy (gluten, casein) free diets. Buie says that Harvard wants to do research into the use of protein enzyme supplements, which aid in the digestion of wheat and milk products for treatment. Buie echoed the opinion of other a growing number of clinical researchers and practitioners treating autistic patients, "these children are ill, in distress and pain, and not just mentally, neurologically dysfunctional."
See post 67
Right, it's not fundamentally flawed. And it's not proof, either.
At least Andrew Wakefield didn't try to explain away statistically significant results by post hoc calling them "artifacts" of parental recall bias. Nor did he omit certain little facts like catchup campaigns biasing his results. Those little omissions come from the howlers on your side of the debate.
I'll look at your citations. Frankly, I'm looking forward to your definition of "proof."
Time to look beyond MMR in autism research
Is the measles, mumps, and rubella (MMR) vaccine safe? Yes, acceptably so, is the only conclusion possible to reach in the face of the totality of the epidemiological evidence. There are no substantiated data to suggest that the MMR vaccine causes autism, enterocolitis, or the syndrome first described by Andrew Wakefield and his colleagues in The Lancet in 1998. New research from some of the same authors as the 1998 Lancet report, in conjunction with a Dublin group led by Prof John O'Leary, has been published early online in Molecular Pathology . Fragments of the measles virus genome are reported in 75 of 91 children with ileal-lymphoid-nodular hyperplasia, enterocolitis, and developmental disorder, compared with five of 70 control children. But, crucially, these data do not support any link to the MMR vaccine, since no vaccine-specific strain data are presented for measles, mumps, or rubella. This latest twist has prompted Prof John Walker-Smith to end his silence since the publication of the first 1998 paper, of which he was the senior author. In this week's Correspondence columns (see page 705 ), Walker-Smith endorses the use of MMR, and calls for an independent research agenda into the causes of the bowel and behavioural disorders in this small and select group of children.
Sadly, a balanced scientific debate has given way to personal attacks and unreasoned demands for single vaccines. Public faith in the MMR vaccine has been eroded, leading to falls in its uptake and now outbreaks of measles in the UK. Unless public opinion swiftly changes, measles, mumps, and rubella cases will become commonplace, with their resultant deaths and sometimes serious morbidity, mirroring the pertussis vaccine scare in the 1970s. Doctors need to present all of the evidence to parents to allow them to make informed decisions, and that evidence comes down in favour of MMR.
But the debate also needs to move beyond the safety of MMR. What of autism and the burden it brings to children and parents? As Walker-Smith highlights, these children are ill-served by the current fear that MMR causes autism. The UK Department of Health announced last week that £2·5 million was to be given to the Medical Research Council to support autism research, following publication of the MRC's report on autism in December, 2001, which documents that six per 1000 children under 8 have an autism-spectrum disorder. Whether the actual number of cases is increasing or whether this high prevalence is due to increased awareness will be an important area for future research.
What is clear from the MRC report is just how much is unknown about the physical and psychological abnormalities that may underlie autism, let alone the possible causes. Functional brain-imaging studies have shown underactivation in areas associated with planning and control of complex actions, and in areas linked with processing socioemotional information. Brain neurotransmitter abnormalities have been reported. Psychological theories focus on social understanding, control of behaviour, and ability to focus on detail, but there are large gaps between theory and practice. A genetic component to autism-spectrum disorders is established, and the search for autism-susceptibility genes is underway. But the complexity of the autism-behavioural phenotype and the lack of knowledge about the developmental processes that are disrupted in autism are hampering molecular research. In addition to infections, prenatal exposure to drugs, perinatal complications, and diet have all been suggested as environmental triggers of autism, but independent replication will be critical in establishing whether any of these factors is relevant.
In 1998 in The Lancet, calling for an effective pharmacovigilance system for detecting vaccine-associated adverse events, Robert Chen and Frank DeStefano said "Without such a system, vaccine-safety concerns such as that reported by Wakefield and colleagues may snowball into societal tragedies when the media and the public confuse association with causality and shun immunisation". Unfortunately, this is exactly what has happened with MMR. In addition to such a system, a clear research agenda into the causes, developmental abnormalities, and treatments of the autism-spectrum disorders is needed.
The Lancet
Oh please. There are thousands of small-sample studies published in some of the best medical journals in the world. Some meaningful, some not. Notice I said meaningful, not conclusive.
Wakefield's study deserves follow up. That's the only point I've made. The fact that the vested interests have lined up to ruin the guy's life should be a concern to anyone interested in the truth. It certainly is to me.
Beyond that, I have no interest whatsoever in a debate on the general hazards of vaccines. I've vaccinated my own children. Enough said.
Go post your editorials and abstracts all you want. I've said my piece.
Yet the antivaccinationists are happy to use Wakefield's study as fact, without any support.
Go post your editorials and abstracts all you want.
OK. Here's Dr. Taylor's response to the criticism of his study.
Response to the MMR question
Raymond Gallup (July 8, p 161)2 dismisses our findings on the grounds that they are biased, since some of the authors are employed by a public-health authority. Such dismissal is absurd and insulting, especially in view of our record in identifying other adverse events attributable to MMR.4 His implication that we have something to hide by not immediately handing over our data to a US Congressional Committee is similarly ill informed. Ethical and legal issues surrounding patient confidentiality, data ownership, and data protection must be resolved before we could agree to such a request. Gallup asserts, without explanation, that our methods were flawed. We presume that he is quoting the false testimony that Andrew Wakefield gave to the US Congressonal Hearing on Autism and Immunisation on April 6, 2000, alleging that the Royal Statistical Society (RSS) had pronounced our methods to be wrong. This claim is totally unfounded, and Wakefield should withdraw it.
J H Roger (July 8, p 161)2 states that we used the wrong study design. This is a serious criticism, and we are surprised that he did not voice it at the RSS meeting he describes. We reject his allegation since he unreasonably criticises us for not setting out to test a hypothesis that had not been formulated. The data that generated the Wakefield hypothesis suggest an interval of 24 h to 2 months between MMR and first behavioural symptoms, typically regression.1 This finding is supported by parental reports as typified by that of David Thrower (July 8, p 161).2 It therefore seemed imperative to test the hypothesis that there was a close temporal association between MMR and regression and other markers of autism. Our methods were entirely appropriate for this purpose.
Roger implies that we should have used a case-control design. We compared first-dose MMR-vaccine coverage in autism cases born after 1987 and in the denominator population: this design is akin to an unmatched case-control study, with the entire population as controls. The groups did not differ. Moreover, coverage was constant when autism incidence was apparently rising. These findings provide further evidence that the very large reported increases in autism quoted by Thrower and Gallup cannot reasonably be attributed to MMR vaccine.
Roger states that the case-series method is unsuitable for investigating longer-term associations. In this instance, at least, it is not. In response to his reformulation of the Wakefield hypothesis to accommodate longer induction times, we did new analyses of our data. The results are negative, providing no support for the hypothesis that MMR increases the risk of autism at any time after vaccination.
Finally, Roger wrongly states that regression occurred typically 6 months after parental concern. Of the 93 cases with the two dates recorded, parental concern predated regression in only 21. The median intervals from concern to diagnosis we quoted4,5 are incorrect; the correct values are 19 months for core autism (n=198), 18·5 for atypical autism (n=100), and 48 for Asperger's syndrome (n=47).
At the RSS meeting, Roger began his talk by giving a moving personal account of what it is like to be a parent of a child with autism. We strongly endorse his and other parents' calls for more research into the cause of this disorder. However, those who, in the absence of any evidence of causality, condemn a vaccine that has saved countless children from premature death and disability, do no service to children, parents, or health professionals seeking to understand the causes of this distressing disorder.
*Brent Taylor, Elizabeth Miller, C Paddy Farrington
*Centre for Community Child Health, Royal Free Campus, Royal Free and University College Medical School, University College London, London NW3 2QG, UK; Immunisation Division, Public Health Laboratory Service Communicable Disease Surveillance Centre, London; and Department of Statistics, Open University, Walton Hall, Milton Keynes (e-mail:b.taylor@rfc.ucl.ac.uk)
1 Wakefield AJ, Murch SH, Anthony A, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 1998; 351: 637-41.
2 The MMR question. Lancet 2000; 356: 160-62.
3 Taylor B, Miller E, Farrington CP, et al. Autism and measles, mumps and rubella vaccine: no epidemiological evidence for a causal assocation. Lancet 1999; 353: 2026-29.
4 Miller E, Goldacre M, Pugh S, et al. Risk of aseptic meningitis after measles, mumps and rubella vaccine in UK children. Lancet 1993; 341: 979-82.
5 Farrington P, Pugh S, Colville A, et al. A new method for active surveillance of adverse events from diphtheria/tetanus/ pertussis and measles/mumps/rubella vaccines. Lancet 1995; 345: 567-69.
This one what?
I went to look up the study, since you didn't bother posting it, and there doesn't seem to be any.
He announced his findings 8 months ago, do you know of plans to publish them? (although 15 of 89 children leaves a lot of wiggle room).
LOL. Well, I'll wait patiently for you to post the CRITICISM of Taylor's study from multiple sources, including that of Dr. Wakefield which was published in Lancet. I'm sure that's coming shortly.
Why would I do that? Isn't that what you are doing?
You want me to do your job now?
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