Tag Archives: american

Hysterectomy not tied to heart risk factors, study shows

Despite evidence suggesting that women whose uterus has been removed may be more likely to experience heart troubles, a new study finds that the usual signs of heart disease risk are not more severe in middle-aged women after hysterectomy. After following more than 3,000 women for about 11 years, researchers found that heart risk factors like cholesterol, markers of inflammation and blood pressure were not significantly worse in women in the years following an elective hysterectomy, compared to women who did not have the procedure. “I think it's encouraging to women and clinicians that this is not something they have to worry about if they're considering hysterectomy (in) midlife,” said Karen Matthews, the study's lead author from the University of Pittsburgh. Hysterectomy, the surgical removal of the uterus, is the second most common surgery among U.S. women, after cesarean-section deliveries. Often the procedure is used to remove or prevent cancer, especially among younger women. But many women may elect to have the surgery for other reasons, including to treat painful benign growths in the uterine wall known as fibroids or to staunch heavy bleeding. Hysterectomies can involve removal of the uterus only, or the ovaries as well. Ovary removal in particular has been linked to increased cardiovascular risk because it takes away the main source of estrogen in a woman's body and plunges her abruptly into menopause. Even the gradual decline of estrogen following natural menopause has been linked to women's increased heart risks, so researchers have investigated whether hysterectomy raises those risks. But studies of the connection have produced mixed results. For the new study, Matthews and her colleagues used data from the Study of Women's Health Across the Nation, which followed a large, multiethnic group for more than a decade to understand the experience of American women during and after menopause. The 1,952 women included in the study were between 42 and 52 years old and not yet in menopause when tracking began. They were followed from 1996 through 2008, receiving annual checkups that recorded information about their health, surgeries and whether or not they had started menopause. Specifically, the researchers looked at physical measurements that are markers for heart and cardiovascular disease. They included various components of cholesterol, blood pressure, blood clotting factors and molecules that are signals of inflammation. Overall, the researchers report in the Journal of the American College of Cardiology that none of those measurements in the 183 women who chose to have their uterus removed - with or without their ovaries - were significantly worse, compared to the 1,769 women who went through menopause naturally. Matthews said their findings apply to women who are finished having children, in their forties and are considering a hysterectomy to help with excessive bleeding or other factors that cause a quality of life problem. She said they couldn't make a conclusion for women who need to have their uterus and ovaries removed because of cancer. “Our study really couldn't examine that question because we had too few women who had gynecological cancers, and the equation changes when you have gynecological cancer,” said Matthews. But Dr. JoAnn Manson, who has researched women's health after hysterectomy but was not involved in the new study, suggested the results don't mean that women who have hysterectomies are in the clear, because past studies only saw a difference in heart risks after 10 to 15 years. Manson, who is chief of preventive medicine at Brigham and Women's Hospital in Boston, told Reuters Health that the abrupt transition to menopause after a hysterectomy may only reverberate years later because “atherosclerosis takes a while to develop… That seems to take up to 10 and 15 years for clear differences to emerge.” For that reason, “This isn't totally surprising that there wasn't a difference in risk factors during the follow up period,” Manson said. Matthews said that's one potential explanation for why their results differ from previous studies, but she said there could be other reasons, including that modern women are somehow different from women included in past research. “It may be that it's emerging much later, but I would be surprised,” Matthews said.source : http://www.foxnews.com/health/2013/05/15/hysterectomy-not-tied-to-heart-risk-factors-study-shows/

Ultra-low salt intake may not boost health, U.S. panel says

Americans at high risk for heart problems who have been told for years to sharply cut salt from their diet may not actually benefit from ultra-low sodium diets and could even face some harm, an independent panel of health experts said on Tuesday. The influential Institute of Medicine, in a report to U.S. health officials, reviewed the latest data on the link between salt intake and health. While blacks, diabetics and others more likely to have heart problems are urged to slash their salt intake, the IOM review showed there was limited evidence such a diet helped, and that too little salt might increase the risk of heart trouble. “The evidence on both the benefit and harm is not strong enough to indicate that these subgroups should be treated differently from the general U.S. population,” the panel wrote. That suggests higher-risk populations may not need such a drastic reduction of salt in their diets and that other steps to curb heart disease risk may be needed. Americans are still consuming far too much salt, the IOM experts said. On average, U.S. adults eat about 1.5 teaspoons of salt over the course of the day, or about 3,400 milligrams. Federal guidelines recommend that healthy people consume no more than 2,300 milligrams daily. But the latest data calls into question whether individuals with higher risk factors for heart disease or stroke should limit their daily intake to 1,500 milligrams, as the government recommends. Brian Strom, the panel's chairman and a public health professor at the University of Pennsylvania, said the newest studies back the known benefits of “reducing sodium from very high intake levels to moderate levels.” “But they also suggest that lowering sodium intake too much may actually increase a person's risk of some health problems,” he said, including heart ailments. Still, the studies are limited and in some cases flawed, so more research is needed, the IOM panel told the Centers for Disease Control and Prevention, which requested the report. Health advocates including the American Heart Association were quick to dismiss the findings, saying the recent studies reviewed by IOM focused on sick patients and not the majority of Americans, most of whom eat too much salt. “The bottom line for consumers is still: cut back on sodium,” said the Center for Science in the Public Interest's (CSPI) Bonnie Liebman. 'IT'S PRETTY TOUGH' The problem is not just food loaded with salt. It's also that Americans eat a lot of food that contains lower amounts of salt, such as bread and pasta, without realizing their sodium content. Health officials have called for Americans to take various steps to cut back, such as asking for no-salt dishes in restaurants and eating more naturally low-salt foods like fruits and vegetables. Health advocates said the IOM's review was beside the point given the high levels of sodium that still plague U.S. foods. It's almost impossible to ingest just 1,500 milligrams a day, said Liebman, director of nutrition for CSPI. “Virtually any meal at any restaurant would give you at least half-a-day's worth of sodium, maybe a whole day's worth, maybe more,” Liebman said. “You'd have to make everything from scratch. ... It's pretty tough.” Consumer groups and some lawmakers have for years called on the U.S. Food and Drug Administration to set federal salt levels for food, a recommendation that the IOM backed in 2010. In New York City, health officials have been working with restaurants and food companies to voluntarily remove salt from everyday foods. A trio of studies published on Monday found that smaller restaurants still load their food with salt even as national chains and food manufacturers have cut back.  The FDA, in a statement, said it was reviewing the IOM's report, calling it consistent with its “efforts to work toward achievable and reasonable voluntary reductions in the sodium content of the U.S. food supply.” IOM was not asked to review current federal salt intake guidelines, which were issued in 2010. U.S. health officials are expected to revise the guidelines on salt and other nutrients in 2015.source : http://www.foxnews.com/health/2013/05/15/ultra-low-salt-intake-may-not-boost-health-us-panel-says/

Study IDs key protein for cell death

When cells suffer too much DNA damage, they are usually forced to undergo programmed cell death, or apoptosis. However, cancer cells often ignore these signals, flourishing even after chemotherapy drugs have ravaged their DNA. A new finding from MIT researchers may offer a way to overcome that resistance: The team has identified a key protein involved in an alternative death pathway known as programmed necrosis. …

Marijuana-like compound could lead to first-ever medication for PTSD

The life of an individual suffering from post-traumatic stress disorder (PTSD) is often a debilitating one, as patients are frequently plagued by intense nightmares, flashbacks and emotional instability.    There are a number of psychotherapeutic treatments and cognitive behavioral therapy options to aid sufferers of PTSD, but these interventions are not always available to patients.  And while medications tend to be the first line of defense for these individuals, no pharmaceutical treatments have been developed yet to specifically target PTSD. But now, new research may help dramatically change the course of treatment for PTSD patients.  In the first study of its kind, researchers at New York University Langone Medical Center have utilized brain imaging technology to highlight a connection between the number of cannabinoid receptors in the brain and PTSD.  Cannabinoid receptors, known as CB1 receptors, are activated in the brain when a person uses cannabis, which can lead to impaired memory and reduced anxiety. The researchers’ findings pave the way for the development of the first every medication designed explicitly to treat trauma – something, they say, is desperately needed. “The first line of treatment (for PTSD patients) is selective serotonin reuptake inhibitors, which is a class of medication generally used with good effects in people with depression,” lead author Dr. Alexander Neumeister, director of the molecular imaging program in the departments of psychiatry and radiology at NYU School of Medicine, told FoxNews.com.   “These medications do not really do the job for people with PTSD, so clinicians use anything else that is legally available on the market.  They often use different classes of medications developed for things like depression, schizophrenia, or bipolar disorder, and overall there’s consensus that these do not work.” Affecting nearly 8 million Americans each year, PTSD is an anxiety disorder that is developed after an individual experiences a dangerous or painful life event – such as a sexual assault, a tragic accident, surviving an act of extreme violence or the experience of fighting in a war.  Of the 1.7 million American men and women in the military who have served in Iraq and Afghanistan, approximately 20 percent have been diagnosed with PTSD. During the past decade, Neumeister and his team have studied the impact PTSD has on the brain’s physiology and have found that exposure to severe trauma can considerably alter how the brain functions.  With this knowledge in mind, the researchers decided to examine CB1 receptors in the brain due to a common trend observed among PTSD patients: Marijuana use.  In an attempt to cope with their symptoms, many PTSD patients end up using and abusing cannabis, which helps to temporarily relieve them of their incapacitating episodes. According to Neumeister, PTSD patients often report that smoking marijuana works better for them than any other legal medication, leading the researchers to believe that the manipulation of CB1 receptors in the brain may have a beneficial impact on trauma symptoms. “About 8 years ago, the first animal study was published showing that everybody has endogenous cannabinoids, or endocannabinoids, in the brain – meaning this substance is in the brain of every person,” Neumeister said, noting that endocannabinoids act like cannabis, binding to CB1 receptors to help extinguish traumatic memories. “Animal studies have suggested that increasing cannabinoids in the brain helps them to forget painful events and form new memories, so they start to learn to digest what they went through and get over it.  We thought this may be relevant to PTSD.” To test this idea, the researchers performed positron emission tomography (PET) imaging on the brains of 60 participants who had been divided into three groups – those with PTSD, those with a history of trauma, but no PTSD, and those with no history of trauma or PTSD.  Each participant was injected with a harmless radioactive tracer, which was designed to travel to the CB1 receptors in the brain and illuminate them under the PET scan. The images revealed what the researchers had expected.  The individuals with PTSD had higher levels of CB1 receptors in areas of the brain associated with fear and anxiety than the volunteers without PTSD.  Those with PTSD also had lower levels of the neurotransmitter anandamide, an endocannabinoid that binds to CB1.  Neumeister explained that lower levels of anandamide prompts the brain to compensate by increasing the number of CB1 receptors, resulting in an imbalanced endocannibinoid system. Because CB1 receptors help regulate mood and anxiety, the scientists advised against creating medications to destroy them in the brain, as that would lead to depression.  Instead, Neumeister said their PTSD medication would rely on promoting CB1 equilibrium. “We want to increase the concentration of these endocannabinoids,” Neumeister said.  “So we are currently working on the methods to do this, and we have developed a compound that is able to increase the concentration of endocannabioniods without attacking the receptors. It helps restore a normal balance of this chemical in the brains of those with PTSD.” Neumeister claims the compound is very safe and does not come with the added health problems caused by chronic marijuana use. “Very soon, we will be able to start clinical trial of this medication in people,” Neumeister said.  “It’s the first medication developed for people with PTSD, so I hope that it will open up a new generation of treatment for people.” The study, funded by the National Institutes of Health, was published in the journal Molecular Psychiatry.source : http://www.foxnews.com/health/2013/05/14/marijuana-like-compound-could-lead-to-first-ever-medication-for-ptsd/

Doctors should ask patients about alcohol misuse, panel says

Primary care doctors should ask adults how much and how often they drink alcohol and counsel those with risky and dangerous drinking habits, a government-backed panel said today. Based on a review of studies conducted since 1985, the U.S. Preventive Services Task Force (USPSTF) determined there is good enough evidence both that screening can accurately detect alcohol misuse and that counseling can reduce heavy drinking in people age 18 and older. Screening “takes hardly any time at all, and it works pretty well,” said Dr. Michael LeFevre, co-vice chair of the Task Force and a family medicine doctor at the University of Missouri School of Medicine in Columbia. “From my point of view as a family physician, the shorter and easier the better,” he said. Risky drinking is defined by the National Institute on Alcohol Abuse and Alcoholism as more than four drinks in a single day or 14 drinks per week for men and more than three drinks in a day or seven in a week for women. Research suggests about one third of U.S. adults misuse alcohol. Asking men the last time they had five drinks in one sitting, and women the last time they had four, is a good start, according to LeFevre. “If they can name a time, that means we should be talking to them more about what their alcohol consumption looks like,” he said. If that time was for the patient's birthday, and the only time in years the patient had binge drank, it's probably not a big deal. But if that happens on a regular basis, he said, that would point toward alcohol misuse. The review behind the new recommendations included 23 trials that randomly assigned risky drinkers to behavioral counseling or normal care. Overall, counseling interventions led to a 12 percent absolute increase in the proportion of people who reported no heavy drinking episodes one year later, and an average reduction in weekly drinks from 23 to 19. Brief counseling sessions, the USPSTF noted, are more likely to help people who have a few too many drinks on occasion than those who abuse or are dependent on alcohol. People with a serious drinking problem may need more specialty treatment, according to the Task Force, which published its recommendations Monday in the Annals of Internal Medicine. “A brief intervention as applied by, say, a primary care physician in practice is probably not going to be adequate intervention for people on the alcohol dependence end of the spectrum,” LeFevre said. The USPSTF said there weren't enough data for it to weigh the possible benefits and harms of asking younger teenagers about their alcohol use. “The Task Force felt that it would be inappropriate to assume that what we have learned about the best ways to screen and manage adults (is) in fact applicable to adolescents,” LeFevre said. However, he added, that's not a recommendation against asking teens about their alcohol use - it's just a call for more studies to figure out the most effective way to do that. Dr. Sharon Levy said she hoped doctors didn't choose not to talk to teens about alcohol based on the new recommendations. “We recognize that there's not a lot of data, but we also recognize that alcohol use is one of the most significant contributors to (illness) and mortality in adolescents,” said Levy, director of the Adolescent Substance Abuse Program at Children's Hospital Boston. “There's no question that alcohol use is a serious problem for this age group,” she said. Levy, who wasn't involved in drafting the new guidelines, co-authored a statement from the American Academy of Pediatrics recommending that doctors screen adolescents for drug and alcohol use. She said the type of brief interventions recommended for adults who drink too much are also “developmentally appropriate” for teens. “They work with adults and they seem really adaptable,” Levy said.source : http://www.foxnews.com/health/2013/05/14/doctors-should-ask-patients-about-alcohol-misuse-panel-says/

New approaches give women more options for breast cancer surgery

CHICAGO – & Treating breast cancer almost always involves surgery, and for years the choice was just having the lump or the whole breast removed. Now, new approaches are dramatically changing the way these operations are done, giving women more options, faster treatment, smaller scars, fewer long-term side effects and better cosmetic results. It has led to a new specialty -- “oncoplastic” surgery -- combining oncology, which focuses on cancer treatment, and plastic surgery to restore appearance. “Cosmetics is very important” and can help a woman recover psychologically as well as physically, said Dr. Deanna Attai, a Burbank, Calif., surgeon who is on the board of directors of the American Society of Breast Surgeons. Its annual meeting in Chicago earlier this month featured many of these new approaches. More women are getting chemotherapy or hormone therapy before surgery to shrink large tumors enough to let them have a breast-conserving operation instead of a mastectomy. Fewer lymph nodes are being removed to check for cancer's spread, sparing women painful arm swelling for years afterward. Newer ways to rebuild breasts have made mastectomy a more appealing option for some women. More of them are getting immediate reconstruction with an implant at the same time the cancer is removed rather than several operations that have been standard for many years. Skin and nipples increasingly are being preserved for more natural results. Some doctors are experimenting with operating on breast tumors through incisions in the armpit to avoid breast scars. There's even a “Goldilocks” mastectomy for large-breasted women -- not too much or too little removed, and using excess skin to create a “just right” natural implant. Finally, doctors are testing a way to avoid surgery altogether, destroying small tumors by freezing them with a probe through the skin. “Breast surgery has become more minimalistic,” said Dr. Shawna Willey of Georgetown's Lombardi Comprehensive Cancer Center. “Women have more options. It's much more complex decision-making.” Breast cancer is the most common cancer in women around the world. In the U.S. alone, about 230,000 new cases are diagnosed each year. Most can be treated by just having the lump removed, but that requires radiation for weeks afterward to kill any stray cancer cells in the breast, plus frequent mammograms to watch for a recurrence. Many women don't want the worry or the radiation, and choose mastectomy even though they could have less drastic surgery. Mastectomy rates have been rising. Federal law requires insurers to cover reconstruction for mastectomy patients, and many of the improvements in surgery are aimed at making it less disfiguring. Here are some of the major trends: IMMEDIATE RECONSTRUCTION Doctors used to think it wasn't good to start reconstruction until cancer treatment had ended -- surgery, chemotherapy, radiation. Women would have a mastectomy, which usually involves taking the skin and the nipple along with all the breast tissue, followed by operations months later to rebuild the breast. Reconstruction can use tissue from the back or belly, or an implant. The first operation often is to place a tissue expander, a balloon-like device that's gradually inflated to stretch the remaining skin and make room for the implant. A few months later, a second surgery is done to remove the expander and place the implant. Once that heals, a third operation is done to make a new nipple, followed by tattooing to make an areola, the darkened ring around it. The new trend is immediate reconstruction, with the first steps started at the time of the mastectomy, either to place a tissue expander or an implant. In some cases, the whole thing can be done in one operation. Nationally, about 25 to 30 percent of women get immediate reconstruction. At the Mayo Clinic, about half do, and at Georgetown, it's about 80 percent. SPARING SKIN, NIPPLES Doctors usually take the skin when they do a mastectomy to make sure they leave no cancer behind. But in the last decade they increasingly have left the skin in certain women with favorable tumor characteristics. Attai compares it to removing the inside of an orange while leaving the peel intact. “We have learned over time that you can save skin” in many patients, Willey said. “Every single study has shown that it's safe.” Now they're going the next step: preserving the nipple, which is even more at risk of being involved in cancer than the skin is. Only about 5 percent of women get this now, but eligibility could be expanded if it proves safe. The breast surgery society has a registry on nipple-sparing mastectomies that will track such women for 10 years. “You really have to pick patients carefully,” because no one wants to compromise cancer control for cosmetic reasons, Attai said. “The preliminary data are that nipple-sparing is quite good,” but studies haven't been long enough to know for sure, Willey said. “It makes a huge difference in the cosmetic outcome. That makes the woman's breast recognizable to her.” Dr. Judy Boughey, a breast surgeon at the Mayo Clinic, said the new approach even has swayed patients' treatment choices. “We're seeing women choosing the more invasive surgery, choosing the mastectomy,” because of doctors' willingness to spare skin and nipples, she said. It helped persuade Rose Ragona, a 51-year-old operations supervisor at O'Hare Airport in Chicago. She had both breasts removed on April 19 with the most modern approach: Immediate reconstruction, with preservation of her skin and nipples. “To wake up and just see your breasts there helped me immensely,” she said. She chose to have both breasts removed to avoid radiation and future worry. “I felt it was a safer road to go,” she said. “I can't live the rest of my life in fear. Every time there's a lump I'm going to worry.” FREEZING TUMORS Attai, the California breast surgeon, is one of the researchers in a national study testing cryoablation. The technique uses a probe cooled with liquid nitrogen that turns tumors into ice balls of dead tissue that's gradually absorbed by the body. This has been done since 2004 for benign breast tumors and the clinical trial is aimed at seeing if it's safe for cancer treatment. “The technology is amazing. This is done in the office under local anesthesia, a little skin puncture,” Attai said. In the study, women still have surgery at some point after the freezing treatment to make sure all the cancer is destroyed. If it proves safe and effective, it could eliminate surgery for certain cancer patients. “I'd love to see the day when we can offer women with small breast tumors a completely non-operative approach, and I do think that's coming soon,” Attai said.source : http://www.foxnews.com/health/2013/05/14/new-approaches-give-women-more-options-for-breast-cancer-surgery/

Natural ways to relieve arthritis pain

As a doctor, I receive questions every day varying from heart health to infertility. Today, I received a question from a man who wanted to know what alternative therapies were out there for arthritis. Dr. Manny, I suffer from arthritis, and my symptoms get worse during the winter.  What can I do to manage the stiffness besides taking medication? - Marvin Many arthritis sufferers use what is known as complementary and alternative practices to manage their symptoms. Patients turn to these alternatives for many reasons. It may be because conventional medical treatment isn’t giving them the relief they need. Also, they may be concerned about the side effects associated with drug therapy, or they may feel that alternative therapies are safer because they are “natural.” Whatever the reason, many patients are finding additional relief by incorporating these five practices into their arthritis management regimen: Regular exercise The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) recommends that arthritis sufferers use these three types of exercise: 1. Range-of-motion exercises such as dancing to help maintain normal joint movement, relieve stiffness, and increase flexibility. 2. Strengthening exercises such as weight training to help keep or increase muscle strength. 3. Aerobic or endurance exercises such as bicycle riding to improve cardiovascular fitness, help control weight, and improve overall function. Weight control is important because extra weight puts extra pressure on many joints. A healthy diet Since there are over 100 known types of arthritis, there is no single diet that will help everyone. However, the Arthritis Foundation has established the following guidelines to assist patients in maintaining a diet that will help manage their symptoms: 1. Eat a variety of foods, and avoid those that can interact with your medications. 2. Use fat and cholesterol in moderation. 3. Eat plenty of vegetables, fruits and whole-grain products. 4. Use sugar and salt in moderation. 5. Drink alcohol in moderation. 6. Take in the daily requirements of vitamins and minerals, including calcium. Dietary supplements The American College of Rheumatology has noted that there is some evidence that ginger and willow bark extract may relieve pain. These remedies, however, may contain chemicals that are similar to those found in naproxen (Aleve) and ibuprofen (Advil), which can cause inflammation of the stomach and intestines. They also may interfere with blood clotting and cause fluid retention, which may be problematic for people with high blood pressure or cardiovascular disease. 1.) Chondroitin sulfate and glucosamine supplements are sold separately or in combination, and are recommended for pain relief when used in conjunction with other pain medication. Although their effectiveness is unproven, the college says they “appear to be relatively safe, and may be worth considering for people who have severe pain despite conventional treatments.” 2.) Fish oils that contain omega-3 fatty acids have been reported to relieve pain and joint tenderness. It may take several months before a patient sees results. Side effects include gastrointestinal distress and breath odor. Manage stress Stress is a normal part of life; but for arthritis sufferers, there are additional stress factors like increased dependence on family members and changes in appearance due to joint deformities or the side effects of drugs. The Arthritis Foundation says that controlling stress is imperative for arthritis patients because “when you feel stressed, your body’s muscles become tense. This muscle tension can increase your pain and fatigue and may limit your abilities, which can make you feel helpless.” Stress can lead to depression, which can touch off a cycle of stress, pain, fatigue, and limited/lost abilities. Managing stress can break that cycle. Hot and cold applications The Mayo Clinic makes the following recommendations: “Heat will help ease your pain, relax tense, painful muscles and increase the regional flow of blood. One of the easiest and most effective ways to apply heat is to take a hot shower or bath for 15 minutes. Other options include using a hot pack, an electric heat pad set on its lowest setting or a radiant heat lamp with a 250-watt reflector heat bulb to warm specific muscles and joints. If your skin has poor sensation or if you have poor circulation, don't use heat treatment. Cold may dull the sensation of pain. Cold also has a numbing effect and decreases muscle spasms. Don't use cold treatments if you have poor circulation or numbness. Techniques may include using cold packs, soaking the affected joints in cold water and ice massage.” Patients should always exercise caution when considering any other alternative therapies. Before beginning any alternative or complementary therapy, talk with your doctor to see if it is right for your particular situation, and ask about possible side effects and harmful interactions, especially if are taking any additional medications for other conditions.source : http://www.foxnews.com/health/2011/10/10/alternative-therapies-for-arthritis/

Patients should have right to control genomic health information, experts say

"A lot of people in this field would agree that no one has a right to withhold your health information from you," said Megan Allyse from the Stanford University Center for Biomedical Ethics. "But it’s problematic to suggest the inverse: that the medical system should give you information you didn’t ask for and don’t want. No one should be able to interfere with your ability to accept or decline access…

Epigenomics of stem cells that mimic early human development charted

Now, in the first comprehensive analysis of epigenetic changes that occur during development, a multi-institutional group of scientists, including several from the Salk Institute for Biological Studies, has discovered how modifications in key epigenetic markers influence human embryonic stem cells as they differentiate into specialized cells in the body. The findings were published May 9 in Cell…