A Tamiflu Rx question for my prescribing colleagues

[Dymanic]

And how to perform that trick early enough for the stuff to do any good.

 

[fls]

I'm not quite clear which side you are referring to by "they".

The medical professionals you are chastizing for failing to fall prey to the availability bias.

www.en.wikipedia.org/wiki/availability_bias

Linda

 

[Skeptic Ginger]

The medical professionals you are chastizing for failing to fall prey to the availability bias.

www.en.wikipedia.org/wiki/availability_bias

Linda

Are you suggesting because I saw one reported death of a child with swine flu who went untreated that this is the only data from which I am drawing my conclusion this might be a recurring theme?

While I may be using 30 years of anecdotes and my personal bias that influenza is a dangerous virus, I am not merely using the single incident in forming my reaction.

I'll await your clarification before going further with this since I am not certain that is what you were getting at.

 

[Skeptic Ginger]

And for further reference, As kids' swine flu deaths spike, vaccine reaches public:

... the Centers for Disease Control and Prevention (CDC) announced that child deaths from swine flu were 'shooting up" in the United States, with 19 deaths from influenza reported in recent days.

"We're now up to 76 children having died from the 2009 H1N1 virus," said Anne Schuchat, a senior official at the CDC.

"To put that in context, in the past three years, the total pediatric influenza deaths ranged from 46 - 88. We've already had 76 children dying from the H1N1 virus and it's only the beginning of October," Schuchat said.

Now of these fatalities, how many were seen by providers who delayed or outright missed the opportunity to provide Tamiflu? I don't know yet but CDC will likely publish the details soon.

 

[fls]

Are you suggesting because I saw one reported death of a child with swine flu who went untreated that this is the only data from which I am drawing my conclusion this might be a recurring theme?

While I may be using 30 years of anecdotes and my personal bias that influenza is a dangerous virus, I am not merely using the single incident in forming my reaction.

I'll await your clarification before going further with this since I am not certain that is what you were getting at.

You pressured Paximperium on the basis of this example, as though the answers to these questions would be relevant to decision-making.

And if the 14 yr old in Texas who died was your patient, would you reassess that position?

Just out of curiosity, do you have kids and what age group(s) are they in?

You state that you have generalized what is available to you - your own experience - such that those who hold a different perspective are disparaged.

And the benefit the researchers used to weigh the risks against was shortening the symptoms by a day. How about the benefit of preventing death?

It amazes me how much bias there is in the medical community that influenza is a benign disease. I have a much different bias.

(I'm guessing you didn't read the actual study on that one.)

Leaving that up to provider judgment is fine in most cases. What I am thinking, however, is there is so much bias in the medical community about influenza that it is biasing that usually more neutral judgment.

And how did you tell us that the guidelines were inadequate? By referring to a recent example.

It suggests that the example that most easily comes to your mind is used to estimate the prevalence of bias in the medical community.

Linda

 

[Skeptic Ginger]

You pressured Paximperium on the basis of this example, as though the answers to these questions would be relevant to decision-making.

You state that you have generalized what is available to you - your own experience - such that those who hold a different perspective are disparaged.

This is not how I perceive the discussion in this thread. First, challenging a person to elaborate on their thinking is not "pressuring". If you think that is what I was doing you couldn't be more wrong.

(I'm guessing you didn't read the actual study on that one.)

And how did you tell us that the guidelines were inadequate? By referring to a recent example.

It suggests that the example that most easily comes to your mind is used to estimate the prevalence of bias in the medical community.

Linda

There is a CDC guideline which states we should prescribe Tamiflu to certain at risk groups with probable influenza, and, to those people with severe cases.

My neighbor's pediatrician judged their son not to have a serious case of 2009H1N1. I felt it was serious enough to warrant Tamiflu. The CDC guideline does not define "a serious case". I am specifically asking for other provider's opinions in this matter. I want to be making the best decisions for my patients. One cannot do that if one doesn't seek out other views on a controversial matter. While I have strong feelings in the matter of pediatric and young adult fatalities that might have been preventable, I respect the opinions of most other medical providers whether they resemble mine or not.

The 14 yr old who died in Texas was also judged by her pediatrician to not have a serious case. Clearly that was an erroneous judgment as evidenced by the fact she died only 3 days later. And while we don't know how the child presented to the pediatrician, the report does say the family called back and reported the child had a fever of 104F. They were again told this was not serious. (If the story is correct.) We don't know if that was a staff member's opinion and/or if the pediatrician was consulted before the answer was given to the family.


A problem arises for all of us, in making this assessment about what is a serious case, and that is, Tamiflu works best if started within 48 hours of symptom onset. So we need criteria to determine what constitutes a serious case early on in the infection. I don't find waiting until the patient is in trouble is an adequate definition of a serious case because not all serious cases are going to appear to be in trouble in the first 48 hours.

As far as I know, this is where Paxi and I differ here. I have no doubt he would recognize a serious case once it became severe. And a serious case would likely be detected sooner rather than later if they were plugged into the system Paxi works in. But I didn't get the impression that expanding the assessment of what was and wasn't a serious case so that Tamiflu could be started within the first 48 hours was something Paxi was concerned about doing.

He is welcome to correct me if I misunderstood his comments.


As for reviewing those missed opportunities to start the patient on Tamiflu or Relenza, a thorough review has not come out yet. I have read ongoing reports. There was a new study published in the current issue of the NEJM. The data was published earlier in a PPT presentation, Influenza Surveillance.

Hospitalized Patients with 2009 H1N1 Influenza in the United States, April–June 2009


Of the children admitted to the hospital, 40% had NO underlying health problem. For adults the percentage was smaller.

The median # of days from illness onset to admission in children under 18 was 3 with a range of 0-17. (n=116) That suggests these kids were fairly promptly identified as having a serious case, however, not receiving Tamiflu within 48 hours of symptom onset was significantly associated with a negative outcome. And day three is past the 48 hours. Only 9% had the antiviral started before admission (of the whole group). We don't know here how many if any of the children with negative outcomes had missed opportunities to have Tamiflu prescribed.

39% of patients received antiviral therapy within 48 hours after the onset of symptoms. Among 195 patients for whom the date of the initiation of antiviral therapy was available, such therapy was started before admission in 18 patients (9%), on admission in 86 patients (44%), within 48 hours after admission in 61 patients (31%), and more than 48 hours after admission in 30 patients (15%)....

Of the 19 patients who died, 90% received antiviral drugs, and all received antibiotics. The median time from the onset of illness to the initiation of antiviral therapy was 8 days (range, 3 to 20); none of the patients who died received antiviral therapy within 48 hours after the onset of symptoms.

Patients who were admitted to an ICU and those who died were more likely than patients who were not admitted to an ICU to have shortness of breath, a neurologic disorder, radiographically confirmed pneumonia, ARDS, or sepsis; they were also more likely to have received antimicrobial agents or corticosteroids (Table 4, and Table 2 in the Supplementary Appendix). In addition, patients who were admitted to an ICU and those who died were older, were less likely to have been vaccinated for influenza during the 2008–2009 season, and had a longer time between the onset of illness and the initiation of antiviral therapy, as compared with patients who were not admitted to an ICU. In a multivariable model that included age, admission within 2 days or more than 2 days after the onset of illness, initiation of antiviral therapy within 2 days or more than 2 days after the onset of illness, and influenza-vaccination status, the only variable that was significantly associated with a positive outcome was the receipt of antiviral drugs within 2 days after the onset of illness.

 

[GreNME]

This is not how I perceive the discussion in this thread.

Your perception does not define the reality for everyone else on the planet. This is the single greatest flaw of your entire line of arguments in this thread.

 

[Skeptic Ginger]

Your perception does not define the reality for everyone else on the planet. This is the single greatest flaw of your entire line of arguments in this thread.

This comment is not relevant to this discussion.

 

[fls]

This is not how I perceive the discussion in this thread. First, challenging a person to elaborate on their thinking is not "pressuring". If you think that is what I was doing you couldn't be more wrong.

Then why bring up the case of the 14-year-old girl or bring up Pax's existent or non-existent children, at all?

Linda

 

[GreNME]

This comment is not relevant to this discussion.

You don't get to choose relevance. This flaw in your argument (or argument style) is precisely what fls is criticising.

 

[Skeptic Ginger]

Then why bring up the case of the 14-year-old girl or bring up Pax's existent or non-existent children, at all?

Linda

The case of the 14 yr old greatly increased my concern about the problem of having no criteria which would clearly indicate a 'serious' case of influenza in a healthy child within the critical first 48 hours.

My neighbor told me her physician had told her he could not give her son Tamiflu because there was a shortage of the drug. My neighbor believed the doctor was saying that even if he wrote the script, there was no pharmacy that could fill it. Somewhere this communication was wrong (either how she heard it or how it was stated to her) because there were plenty of pharmacists in our area who could fill the Rx. She was concerned because her one son had had a mild illness but the one I wrote the script for was much sicker.

The next time I saw her she thanked me for writing her son a script for Tamiflu and said she had seen the news about a 14 year old with no pre-existing health problems who died from H1N1. My neighbor's son is 14.

I have a 20 yr old son. If he gets influenza, I will give him Tamiflu. I do not want to take any chances.


So the problem I had here was, how could I, in good conscience, tell a mother she could not have Tamiflu for her son when I know full well I will be giving it to my son if he gets flu? I cannot reconcile that. I have a duty to prescribe correctly. At the same time I think the current flu strain is risky enough I wouldn't let my own son go past the 48 hours without starting Tamiflu because after 48 hours should the illness take a turn for the worse, Tamiflu would be significantly less effective.


That is part of the discussion here. Is it right to error on the side of caution for your own child while using the decision criteria of conserving Tamiflu susceptibility but in exchange for greater risk for someone else's child? This thought process went into my decision to write the script another provider had opted not to write. And that's why I brought it up.


I really think you are confusing my passion regarding this issue with criticism of other providers. While I would certainly criticize the provider who didn't initiate Tamiflu for a pregnant woman with influenza (as this is clear in the medical standard), I would not criticize a provider who was following CDC guidelines and had a different assessment from me about what constituted CDC's ill defined 'serious' case.

 

[Dymanic]

While I would certainly criticize the provider who didn't initiate Tamiflu for a pregnant woman with influenza (as this is clear in the medical standard), I would not criticize a provider who was following CDC guidelines and had a different assessment from me about what constituted CDC's ill defined 'serious' case.

For what it's worth, I think you are absolutely spot on with all of this. I would add this:

Conserving Tamiflu as a strategy for preventing the development of resistance is a good idea. But there's no guarantee that it will work. Even if a total moratorium on the use of oseltamivir were implemented today, it's entirely possible that this virus could aquire resistance anyway -- just as 100% of the isolates tested (along with 100% of the seasonal H3N2 isolates and, in some countries, the seasonal H1N1 as well) already show resistance to the M2 inhibitors amantadine and rimantadine -- despite the use of those drugs having been virtually negligible during the couple of years following the 2006 CDC interim recommendation that they not be prescribed.

Conserving Tamiflu in order to insure adequate supplies later in the season is also a good idea, but it's worth keeping in mind that resistance, if should develop, may develop quickly. We could end up with a whole lot of doses of a drug that is no longer very effective even if it IS administered within 48 hours (or, even better, on first onset of symptoms).

 

[Skeptic Ginger]

For what it's worth, I think you are absolutely spot on with all of this.

Thank you. I appreciate hearing that and I'm saddened Linda has taken my posts in the way she has.

I would add this:

Conserving Tamiflu as a strategy for preventing the development of resistance is a good idea. But there's no guarantee that it will work. Even if a total moratorium on the use of oseltamivir were implemented today, it's entirely possible that this virus could aquire resistance anyway -- just as 100% of the isolates tested (along with 100% of the seasonal H3N2 isolates and, in some countries, the seasonal H1N1 as well) already show resistance to the M2 inhibitors amantadine and rimantadine -- despite the use of those drugs having been virtually negligible during the couple of years following the 2006 CDC interim recommendation that they not be prescribed.

Conserving Tamiflu in order to insure adequate supplies later in the season is also a good idea, but it's worth keeping in mind that resistance, if should develop, may develop quickly. We could end up with a whole lot of doses of a drug that is no longer very effective even if it IS administered within 48 hours (or, even better, on first onset of symptoms).

Interesting point. A couple cases of Tamiflu resistance in Japan have turned up in people who've never been treated with Tamiflu. The assumption is the resistance must have been transmitted. Japan used lots of Tamiflu early on in the H5N1 outbreak as they had a few cases there. And Tamiflu resistance is almost 100% in the seasonal H1N1. It is bound to occur and it will certainly be selected for eventually in the 2009 strain.

While I don't want to waste Tamiflu as a drug, the fact we are seeing deaths that were probably preventable tells me we need to define 'serious' cases more liberally, especially in younger adults and older children.

And the serious under vaccinating of health care workers because of their own failure to take influenza seriously suggests underestimation of the seriousness of flu by health care workers themselves is widespread.

 

[fls]

I really think you are confusing my passion regarding this issue with criticism of other providers.

No. I'm really just looking for an answer to the question that I asked. You are under no obligation to actually answer it.

You appeared to ask Paximperium, on two occasions, specifically whether the presence of an available example (that he had a recent experience of a 14-year-old patient dying from influenza or that he has a personal experience of a parent's concern for their child) would lead him to alter his decision-making process, which would presumably include estimates of the severity of disease in general (else why would you refer several times to the general inability of the medical community to accurately estimate the severity of disease compared to your skillz). When he pointed out that the use of available examples is considered irrelevant to clinical decision-making, you didn't leave it at that. You came back to him with the statement that it is relevant. Now, if you're wondering why clinical decisions are being made that are different from yours, I have to wonder whether part of that might be due to your use of an availability bias vs. Paximperium's attempt not to use this bias. It only appears that that was what you were doing, and I don't know if that's what you do in real life. We can easily get carried away with our rhetoric here. But I am curious as to whether you really think that Paximperium should be changing his decision-making process to take into account available examples. And if not, why did you you question him on the basis of those examples if you didn't think that they would possibly alter his decisions?

Linda

 

[fls]

For what it's worth, I think you are absolutely spot on with all of this.

Thank you. I appreciate hearing that and I'm saddened Linda has taken my posts in the way she has.

WTF?

Unless you intended the last half of your sentence to be a total non sequitor from the first half of your sentence, are you actually under the impression that you have any idea whatsoever whether or not I think you are spot on with your concerns? Because I haven't said anything at all about that particular issue. It looks like you are presuming that I disagree with you simply because I questioned you on a different issue.

Linda

 

[Skeptic Ginger]

WTF?

Unless you intended the last half of your sentence to be a total non sequitor from the first half of your sentence, are you actually under the impression that you have any idea whatsoever whether or not I think you are spot on with your concerns? Because I haven't said anything at all about that particular issue. It looks like you are presuming that I disagree with you simply because I questioned you on a different issue.

Linda

Linda, what I don't know is why are you responding with such hostility? I have tried repeatedly to state and restate what I've posted. You've completely misconstrued what I've said into some attack on Paxi. I cannot for the life of me figure out why.

However, I will try one more time to correct your misconception by answering your above post. Give me a few minutes if you are reading this before I have done so.

 

[fls]

Linda, what I don't know is why are you responding with such hostility?

Where do you get hostility from? I'm just confused.

I have tried repeatedly to state and restate what I've posted. You've completely misconstrued what I've said into some attack on Paxi. I cannot for the life of me figure out why.

Where do you get attack from? You seemed to be having a reasonable discussion with him.

However, I will try one more time to correct your misconception by answering your above post. Give me a few minutes if you are reading this before I have done so.

You don't need to go through the bother if you're going to re-explain your OP again, or if you're going to defend yourself against the idea that you are attacking Paximperium. I got those already.

Linda

 

[Skeptic Ginger]

No. I'm really just looking for an answer to the question that I asked. You are under no obligation to actually answer it.

You appeared to ask Paximperium, on two occasions, specifically whether the presence of an available example (that he had a recent experience of a 14-year-old patient dying from influenza or that he has a personal experience of a parent's concern for their child) would lead him to alter his decision-making process,

That is correct.

...which would presumably include estimates of the severity of disease in general (else why would you refer several times to the general inability of the medical community to accurately estimate the severity of disease compared to your skillz).

I can cite a number of evidences SOME in the medical community underestimate the risk of influenza in an otherwise healthy child. I do believe this bias affects assessment of the need for Tamiflu in an otherwise healthy child with confirmed case of flu. (see the last 2 paragraphs)

When he pointed out that the use of available examples is considered irrelevant to clinical decision-making, you didn't leave it at that. You came back to him with the statement that it is relevant.

Is there any reason I should not express my opinion on the matter? This really sounds like you object to the fact I expressed a disagreement with Paxi's opinion.

Now, if you're wondering why clinical decisions are being made that are different from yours, I have to wonder whether part of that might be due to your use of an availability bias vs. Paximperium's attempt not to use this bias.

Availability heuristic^WP

The availability heuristic is a phenomenon (which can result in a cognitive bias) in which people predict the frequency of an event, or a proportion within a population, based on how easily an example can be brought to mind.

Besides the fact the fatality I used as an example does represent all the aspects of the problem I am trying to discuss here, there is a reason I asked about the impact such a case would have if it were one's own patient.

What would I expect a provider to learn from having their own decision result in a fatality vs someone else's decision? That's not that hard to explain. When you are assessing a decision made by another, you have to imagine how the patient presented. If you have a particular bias flu is a benign infection in an otherwise healthy child you might imagine the child didn't look too bad when she presented in the physician's office. You imagine the child took a rapid turn for the worse.

If you were the provider who saw the child, you don't have to imagine. You know how the child presented. Whatever bias you had about the seriousness of influenza in an otherwise healthy child will now likely be reassessed.

I don't know Paxi's flu biases. They sound very reasonable. But I don't think the question was unreasonable.

It only appears that that was what you were doing, and I don't know if that's what you do in real life. We can easily get carried away with our rhetoric here. But I am curious as to whether you really think that Paximperium should be changing his decision-making process to take into account available examples. And if not, why did you you question him on the basis of those examples if you didn't think that they would possibly alter his decisions?

Linda

I think many in the medical community do need to reassess this particular medical decision.

The compliance with flu vaccine among health care workers in light of the infection control expertise encouraging vaccination of all health care workers, the number of health care providers, physicians and nurses alike, who tell their patients flu vaccine is not safer than flu, the number of people who should have gotten Tamiflu because they did meet the criteria yet were not prescribed it: all attest to the fact that many in the medical community have an under estimation of the actual risk influenza infection poses.

You are welcome to present the reasons why you think I am overestimating the hazard flu infection poses. I assume that is what you meant to suggest by "availability bias". I'll take your word for it I have overestimated your hostility in this thread.

 

[fls]

Is there any reason I should not express my opinion on the matter? This really sounds like you object to the fact I expressed a disagreement with Paxi's opinion.

Not at all. I just wanted it to be clear that this really was your opinion on the matter - you coming back to it seemed to indicate this and now you've confirmed it.

Availability heuristic^WP

Besides the fact the fatality I used as an example does represent all the aspects of the problem I am trying to discuss here, there is a reason I asked about the impact such a case would have if it were one's own patient.

What would I expect a provider to learn from having their own decision result in a fatality vs someone else's decision? That's not that hard to explain. When you are assessing a decision made by another, you have to imagine how the patient presented. If you have a particular bias flu is a benign infection in an otherwise healthy child you might imagine the child didn't look too bad when she presented in the physician's office. You imagine the child took a rapid turn for the worse.

If you were the provider who saw the child, you don't have to imagine. You know how the child presented. Whatever bias you had about the seriousness of influenza in an otherwise healthy child will now likely be reassessed.

I don't know Paxi's flu biases. They sound very reasonable. But I don't think the question was unreasonable.

So when this exchange took place:

I would prescribe tamiflu to any of the at risk groups. Younger children, chronic illness, elderly, pregnant and maybe their caretakers. I would not have prescribe tamiflu to a healthy 14year old.

And if the 14 yr old in Texas who died was your patient, would you reassess that position?

you didn't mean, "would you reassess the position that you would not prescribe tamiflu to a healthy 14year old", but rather, you meant, "would you reassess the position that you are able to identify severe disease in someone who is healthy?"

That you dropped your cross-examination of Paximperium after he explained how he goes about determining severity seems to confirm this.

I think many in the medical community do need to reassess this particular medical decision.

That they are able to identify whether someone has severe disease?

The compliance with flu vaccine among health care workers in light of the infection control expertise encouraging vaccination of all health care workers, the number of health care providers, physicians and nurses alike, who tell their patients flu vaccine is not safer than flu,

Can you provide a summary or a reference for this data?

the number of people who should have gotten Tamiflu because they did meet the criteria yet were not prescribed it:

Can you provide a summary or a reference for this data? It is interesting that they are collecting this data (I have ulterior motives - I am always looking for novel sources of systematic collections of data).

all attest to the fact that many in the medical community have an under estimation of the actual risk influenza infection poses.

You are welcome to present the reasons why you think I am overestimating the hazard flu infection poses. I assume that is what you meant to suggest by "availability bias".

Well, if we follow your suggestion and any particular case is meant to lead us to reassess our clinical judgement, any particular practitioner will be more likely to encounter cases where tamiflu was unnecessary, rather than cases where tamiflu was necessary. If you want to suggest that the consideration of individual cases may lead to reassessment, then you shouldn't be surprised if most of that reassessment leads to concluding that the use of tamiflu is unnecessary.

I'll take your word for it I have overestimated your hostility in this thread.

Please don't. You addressed my question. And this is the third time this has happened this week (the other two situations were with my kids' teachers) - I didn't get a response until someone thought I was mad. This gives me the idea that I need to expand my repertoire.

Linda

 

[Skeptic Ginger]

You are really reading into this things that are not there.

...

So when this exchange took place: ...you didn't mean, "would you reassess the position that you would not prescribe tamiflu to a healthy 14year old", but rather, you meant, "would you reassess the position that you are able to identify severe disease in someone who is healthy?"

That you dropped your cross-examination of Paximperium after he explained how he goes about determining severity seems to confirm this.

Have you never bounced ideas and feelings about your practice off your colleagues? Does it always have to be a cross examination to re ask a question emphasizing a particular part of it?

Why did you choose to see this as a cross examination? That is the hostility I am talking about. You've made false assumptions. The thread title tells you what I wanted to discuss. There is a legit dilemma here. If I just wanted to rant about stupid providers who missed another chance to save a life with Tamiflu, that's what I would have made the thread about.

I'm trying to reconcile the CDC guideline with my practice. I've pointed out the shortcoming of not being very clear about what constitutes a serious case. I want to discuss it with other people and explore what they think about the situation.

...That they are able to identify whether someone has severe disease?

That's out of context.

Does everyone assess 'severe enough to prescribe Tamiflu' the same? Is assessing what constitutes severe disease within the first 48 hours the same as recognizing what more clearly might be severe disease in general?

...Can you provide a summary or a reference for this data?

I can't believe you are seriously asking for documentation that health care workers, like much of the rest of the population, believe in myths about influenza infection and vaccine.

Here are some very specific findings from a number of studies supporting the opinions I have expressed here.

Immunization policies in Canadian medical schools.

Only three schools (19%) required or recommended influenza vaccination,

Influenza vaccination in paediatric nurses: cross-sectional study of coverage, refusal, and factors in acceptance.

A lack of perceived personal need was the most common reason for vaccine refusal, given in 30% (77/258) of unvaccinated respondents.

Influenza vaccination among primary healthcare workers.

A media scare which occurred during the vaccination period was reported to have influenced the decision not to get immunized of 34.1% of HCW who had not been immunized.

Factors affecting influenza vaccine uptake among health care workers.

Almost 70% of those not immunized perceived themselves to be 'healthy' and gave this reason for declining immunization.

Can you provide a summary or a reference for this data? It is interesting that they are collecting this data (I have ulterior motives - I am always looking for novel sources of systematic collections of data).

I'll provide this in a follow up post. This assessment is more complex.

Well, if we follow your suggestion and any particular case is meant to lead us to reassess our clinical judgement, any particular practitioner will be more likely to encounter cases where tamiflu was unnecessary, rather than cases where tamiflu was necessary. If you want to suggest that the consideration of individual cases may lead to reassessment, then you shouldn't be surprised if most of that reassessment leads to concluding that the use of tamiflu is unnecessary.

In addition to what I addressed about this already, it is rather idealistic to think one's experiences with certain significant cases do not affect one's practice. Pediatric deaths have a huge impact on most providers.

Attitudes of health care workers to influenza vaccination: why are they not vaccinated?

"having cared for patients suffering from severe influenza" (P = .031) were significantly associated with compliance with influenza vaccination.

Please don't. You addressed my question. And this is the third time this has happened this week (the other two situations were with my kids' teachers) - I didn't get a response until someone thought I was mad. This gives me the idea that I need to expand my repertoire.

Linda

I'm sorry if you are having a bad week. I think you are one of the nicest posters on the forum and I love your sense of humor. But you do seem annoyed in this thread.