Confirmed Detecable at 10 weeks...now what?

Called the lab again with HR, we got a supervisor who confirmed the suspected >75,<200 PCR at 10 weeks. Meaning I need to treat to 72 weeks (according to newest studies), although different dr's have different opinions. SOC is still the 2 log drop at week 12 and anything else is NOT FDA approved. Nonsense, but that is how it is. So far I have Dr. # 2 saying 60 weeks, Dr. #1 saying it WAS UND at 10 weeks and he would not tx beyond week 48 even if it was, but it was. Dr. #3 saying that he agrees with Dr. #1 that it doesn't matter and agreed I was UND, but after in his face, "read this, read that", kind of thing he sort of agreed. So now I have to get the treating dr. to say I can't go beyond 48 in a letter to SEE if I can get C2C to pay for the drugs. All this in 5 weeks.... Possibly a plus is that Dr. #1 has no clue when I even started tx. My bottles and boxes of meds say I have 6 refills, that would put me through the 72 weeks, of course the ins. co could deny it....What a pain!

continued...

[sfbaygirl]

The lab is going to call #1 and tell him that it was detectable, but I said PLEASE put it in writing because he doesn't write things down and I would like a copy of this letter to get extention. They would not send it to me. They will only send it to Dr. #1. Hopefully, after my plea they will send it in writing to him and I can get a copy.

I am worried about the ins. co paying beyond the 48 weeks and I guess the nextstep is to call the pharm and the ins co to see what they will do. Thankfully I am not as sick as I was at week 10 or I couldn't deal with all of this. Any suggestions on how to help this process along will be appriecated! Thanks!

New People; Be really careful to get the lab reports and to understand them!

As I was talking to HR, he suggested that even if I was between 75 and 200 at week 10, it most likely wouldn't have gone down that much by week 12 and that nowadays, clearing at week 4 is the best thing.... Thanks!

[revenire_v6]

It will all work out. I realize the anxiety can be overwhelming but you will be fine.

[ladybug52]

Well, you followed this whole thing thru till you got to the truth. Good for you. If you can fight Dr's and ins, and labs like you have been, the virus doesn't stand a chance! Sorry the news wasn't better, but at least you know what you have to do and can move forward.
Are you still sneaking back into your house? Don't set off any alarms!
Big hug from Bug

[Forseegood]

agree with Ladybug, youre a fighter, a true Warrior Woman, you'll do what ever you have to do and you'll get your SVR...peace and blessings to you...

[jmjm530]

Sorry about the news. Your advice to newcombers is very good. Always get clarification right away regarding any uncertain labs even if this means talking to the head of the lab itself, which is not as difficult as it sounds, since others here have done it including myself. Unfortunately, with the large numbers of tests run, and the confusing way they are reported, it is unrealistic to expect first level customer service, or even your doctor to understand the results. Of course they should, but I'm talking reality.

Was week 10 your first test? What were the follow up tests and when did you become non-detectible? Also, what test caused all the confusion and what lab?

-- Jim

[sfbaygirl]

Just got a letter from my dr #2 about my 60 week tx decision. Thought I would share it, as we were all wondering why 60 weeks...

Hi Linda,
Sorry to hear about your house fire -- how unfortunate, especially with all the other stress you have.  I am very impressed with your knowledge of all the HCV studies, you have a very solid understanding of the state of the art in HCV therapy, more than most GI's and probably most hepatologists.
As for the 60 week recommendation, I am practicing with our group's standard of care which recommends 9 months of treatment beyond the first undetectable viral load, with a minimum of 48 weeks for GT 1/4.  Since your viral load was negative at week 20 (and likely well before that due to borderline at week 10), I suggested a total of 60 weeks to "hedge our bets" and hopefully reduce the risk of relapse.  I agree there is no support for this exact practice in the literature to date but it is based on experience and common sense.  If you feel strongly that you want to continue to week 72 I would be willing to prescribe meds and follow, but I do believe week 60 should be sufficient.  Keep in mind that we will never be able to completely remove the risk of relapse and there will always be second guessing after you stop therapy.  We really don't have the ideal test for this.
Let me know if I can help,
TF

Thought this was interesting!

[jmjm530]

I thought Dr. 2's letter was excellent and on point. It's always a **** shoot and adding 36 weeks is as good a guestimate as anyhing else, especially since there was a reasonable chance you were non-detectible by week 12. Keep in mind you were under 200 IU/ml at week 10 and non-detectible at week 20.

All the best in your decision.

-- Jim

[orphanedhawk]

Doesn't Dr.2's opinion with his connection to such a reputable institution convince your insurance company that you need longer care?

[Myown]

Sorry to hear of this added stress, but you have a great head on your shoulders and I know things will work out for you.

[sfbaygirl]

Hi Dr.

I had a fire at my house and it has been a nightmare. I am in a hotel, still doing tx and trying to get my ducks in a row for an extention. The ins. co denied me seeing you and sent me to another dr. in my group. I did my due diligence and went to see him. He was a clone of the first doc and agrees that SOC is 48 weeks and no more, but possibly will talk to you about the extention etc., but said I should start writing my appeal letter to the ins. co now.  Even if I have to pay for appts with you I will, the drugs are an issue though, so I am working on a denial letter from dr.#1 and ins co. To see if I can get C2C to pay for the drugs. What a struggle they make you go through to be taken care of correctly!!

I know we talked about me treating with you after the 48 weeks is up and your recommendation was 60 weeks. I was surprised by the report and how awful it made me sound

[jmjm530]

Your doctor probably was basing his 36 week extension on Drusano, as many good clinicians do. The 72 week studies you refer used FIXED DOSE ribavirin, so it's not apples and apples, meaning there are no 72 weeks studies I know of that used weight-based ribavirin as I assume you did.  I pretty much agree with the letter your doctor posted. 60 weeks is no guarantee, nor is 72 weeks. Based on the way you are presenting things, you may indeed be able to convince your doctor to extend to 72 weeks. Like his, your arguments are also sound, and after all it is your liver. Just remind yourself of the wise saying -- be careful what you wish for because you might just get it. Take your time, think about this carefully and I'm sure you'll come to the right decision.

Be well,

-- Jim

[sfbaygirl]

I am not sure how much weight it will hold re; the report from #2 to get ins to pay for meds. Perhaps it will convince the ins. co to pay for the meds, maybe not. I think since they want me to be with there GROUP, they may listen to THEIR docs, not one that is in their network though. The lab DID pay for the labs #2 gave me. Although they don't HAVE a sensitive PCR at my lab, only down to <50. No Fibrosure either, even in their 3 inch thick book of lab tests. Believe me people, I have sat at the computer at the lab and made them SHOW me what tests they would provide and how sensitive. They even printed Lapcorps site, to see if I can get the ins. to approve it. If I want another test that is not in their book or computer, I have to get a waiver and go through hoops.

From what I have heard here, many have trouble getting the meds paid for beyond the FDA approved SOC, therefore, nothing after 48 weeks. If you get someone to write a report that is compelling it is possible, possibly why #2 wrote the report he did, to help me get approval for the tx he wants me to have. Healthnet does pay for him, just not in my group. If I had a PCP that was in his group, I could get Healthnet to pay for him and most likely what he prescribes. This is why I am working on gathering the data I need to prove to ins. that I need him.

Last time I asked Healthnet about going to him, they said , "she we pay for USF, Standford etc. But when I asked the ins. said no. IF they don't approve of the dr. I want, why would they pay for the meds? Kinda like talking to the labs, you get one opinion from someone and another from someone else, so not sure I trust their word on the phone. I will call though, again, about the meds. Just want to make sure I have the meds in place, therefore the C2C. I have my tax forms, now I need my letter...

[sfbaygirl]

I keep saying Durso, instead of Drusano. But, yes I believe that is their basis of care. The Perlman study, although small, is weight based Riba, unlike Berg, Tapias -Sanchez. I also am considering the Halt C, that shows SVR to be so much higher in the tx the first time round, rather than re-treating, which I didn't mention to him.

I am really tempted to just do 60 weeks, as I feel that all these studies use set numbers not set in stone, by any means. Perhaps if they had set their parameters at 60 weeks the results would be close enough to the 72 to not require such a long bout of tx.

Today, reading a post from someone who had heart problems from interferon and not getting rescue drugs, although indicated, helped me rethink my decisions about 72 weeks, that and your posts about how harmful these drugs are long term. Right now, I think I could be okay after tx. My brain seems to have recovered, Brian doesn't visit too often anymore...and my horrible sx I had at first have subsided, so it is easier for me to think about extention. Who knows how I will be in another few months? I still have no energy or desire to do much of anything. Still have those shot days and horrible GERD. I am thinking that I will do the 60 weeks and see how I am doing. Have my heart checked, my thyroid..all that stuff. Let's see how it goes. As we know, tx is like Jumanji, we never know how the dice will roll week to week. All I know is my life is on hold, I am pretty much a couch potatoe and can hardly remember life before tx anymore. I want to get back to normal after tx, I dont' want lasting effects forever. How do we know when to stop? Question of the century, huh? Goof did well, got out on the advise of my doc, without going months and months longer. As you say, it is a cr@pshoot and who knows? I could be clear by stopping at 48, but given what I know from the studies, I need to go longer. I would rather not repeat this for another 72 weeks, because I chose to only go 48 or 60...then again I have less than the 50% now, since I was not clear at 12. But could up my chances to 75% by going to 72? What a choice!! Sometimes it feels like a no brainer and at others it feels like, hey why not throw those dice?

[jmjm530]

I posted something on "doing all you can do" the other day but couldn't find it to re-post. So I'll try again.

The often posted thought (and this is not directed to NYGirl because many have used it) that if you somehow don't "do all you can do"  you won't be able to sleep right or look at yourself in the mirror if you relapse -- this thought has always irked me. Maybe it's a good pep talk for someone who SHOULD go "X" weeks, but IMO not a good reason to make that decision.

First, of all, no one "does all they can do". Why stop at 72 weeks? Why not go 2,3, or 5 years? Maybe if everyone treated five years we could get the relapse rate down to under ten or even five per cent, even for slow responders.

Point being not to go five years, but that all of us have to make a stop decision at some point and it's never "all you can do", it's always what someone determines is a reasonable length of treatment weighing the relative risks against the rewards.

If someone weighs those risks against the rewards and comes out with 72 weeks fine. But if someone else comes out at 48 or 60 weeks, that's also fine, and these folks should not be pegged as not having done "all they can do". It's just that they and their doctors made a different choice looking at the same data.

That said, if we do want to get into the "look yourself into the mirror" thing if you relapse, what about those who end up with permament side effects from treating too long? How are they supposed to look themselves in the mirror. So that kind of logic -- which I don't subscribe to -- obviously cuts both ways.

I hope everyone makes all their treatment, including extension decisions, based on as much logic as possible after consulting with their doctors as well as doing independent research if that's in their nature.

Just let's not tell people that if they don't do this or that, they won't ever be able to forgive themself. You make your best decision, and then you don't look back. IMO.

All the best,

-- Jim

[sfbaygirl]

The test I took was Hep C RNA Quant using the Roche Cobas TaqMan Analye Specific Regent (ASR) are used in my labrotory tests... This test is VL less than < 75IU/ml.

This was my first PCR and I did it at 10 weeks, because I was going on vacation at week 12. Thought if it was UND, I could go on my merry way, if not, I would have another at week 12. DR. #1 said I was UND, so I went on my merry way....if I had known, I would have done another PCR at week 12.

NEW PEOPLE! These PCR's, TMA's, bDNA tests are so important early on in tx, I can not emphasize this enough. I could be on my merry way, if had gotten tested earlier, a few weeks later. I just went along with what my GI said. I didnt' know any better. I sure do now, but I can't go back and redu my labs now. At least get those first 4 and 12 week PCR's and get them sensitive down to <10. If you can afford it, and your ins. won't pay for them, pay for them yourselves. It could mean extending or not at the end. Besides the fact that this test by some unknown lab in Utah, could have problems with how accurate their tests are. HR has told us how some labs accuracy is so much better than others. Don't waste your first weeks of tx and sx's with cheap testing and inferior care. Check it out! Ask here if you need help.

[ladybug52]

Well thanks for finding out about all this before I started tx! Really, it stinks that you had to go through so much but you have helped so many others to not make the same mistakes. Who could have known that the lab would be incompetent or the dr's for that matter? Nice compliment the dr gave you!
Good Luck!
Hugs from Bug

[sfbaygirl]

Thanks! Yeah the compliment from the big liverhead made my day, for sure. But it's true, those of us that just follow the pied piper ignorant GI down the path to tx, may be doomed to repeat it. That's why this board is so valuable for all of us. We learn so much about the disease and tx that we can become more knowledgeable than our own dr's sometimes. Wish I had learned pre tx, instead of during tx. Glad I just learned, mostly thanks to everyone here.

[GoofyDad]

There was some serious handwringing going on here when I stopped. I had my studies laid out and was emailing the publishing doc of one study in Denmark if I recall. Being included in the decision making cuts both ways. It came down to the Doc's reasoning that we couldn't really predict with a reasonable assurance that the extra time bought me appreciably better odds. But we knew it carried risk. Sound familiar?

As it turned out, I think I remember Kalio (also GT 3) posting her relapse early the morning I was headed in to finalize go-stop decision that I had pushed until the very last moment.

Then you stop and the real second guessing begins.

[aquarius64]

i am so sorry to hear about this. this much add alot of stress and worry. hopefully things will turn out alright. i don't know much about tx except the whole 24wks-48wks thing. i am a little retarded and i didn't get to read all of the posts here(the kids keep coming in and needing me), but what genotype are you? i will say prayers for you and hope it all gets better for you!

[wyntre9]

I can't believe how complicated your situation is, with meds, and TX and SX and doctors and insurance, not to mention all the personal and domicile issues in your life.

I honestly don't know how you keep it together.

The inspiring thing is that you do.

Get MAD and keep fighting!

Hugs to you.

[nygirl7]

I went through a LOT of agonizing thinking when it was me. I understand how you feel, exactly.

I finally decided I would let the world's bestest doctor tell me what he thought. Since he was the lead investigator on most of the studies....nobody in the world would know better WHAT was the best thing to do.

He told me "if you want to know at the end of the day when you go to bed that you did everything right and everything you could - do the 72 weeks".

I SIMPLY CANNOT TELL YOU HOW MUCH THIS HAS PAID OFF FOR ME!  Now that I am done - I KNOW in my heart that I DID in fact do everything and the RELIEF that I have...well I just can't tell you.

Whatever will be - will be. I can't stress it because I DID everything I should have. There is nothing more I could have done.

And at the end of the day, I take SO much comfort in the fact that I don't say "wow I wish I had done the 72 and not just 60 - maybe it would have WORKED then".

There is no remorse.  THAT for me was worth the extra time - without any doubt.

I hope you will think of it that way. Believe me, the extra 12 weeks FLY BY like nothing. AT that point you are so used to doing the meds that now I feel sort of lost not taking them. After 60 weeks...it's just too hard to take the chance and then have to beat yourself up if it goes wrong.

Just do the extra 12 and KNOW that you did EVERYTHING right that you too could do.

[compulsive]

Wow - you've really got a plate full !!
  Dealing with your house, fighting the insurance company, trying to get the Doctors to help...  and treating!

  I hope this all sorts itself out soon - but - I know, things rarely sort THEMSELVES out, - your gonna have to help it all along.

  I wish you some great good luck with all this, and that small efforts in the proper direction will be all that is required to get good results for you.  

[jmjm530]

SF: What a choice!!
------------------
Yeah, coming down the stretch, when to stop is one of the hard decisions. The right answer will eventually come to you.

Still curious what test you took at 10 weeks and with what lab. Might help some others to decipher (or avoid) what appeared to be some confusing lab reporting.

-- Jim

[nygirl7]

I would have bet 10,000 dollars Jim that you would have answered something contrary to what I posted just because you always do.

Like Rev said above - 72 weeks is as far out as the studies go right now so that is why we go to 72. We have data to back up the fact that it CAN be of quite a great help to our "odds".

Not everyone of course will CARE either way if they've DONE ALL THEY CAN or not but it sounds to ME like she is giving it great and heavy thought and THAT is the thought that makes me realize she wants to do ALL THAT SHE CAN to know she did the best and right thing.

Since there iis NOTHING to support that just doing a few extra weeks adds ANY benefit AT ALL (and I was told it was a complete waste of time) and that at first they saw 60 (adding 36) had benefit but THEN they studied 72 and found it DID increase the chances of SVR....so now they agree that 72 weeks is OPTIMUM if you have not had EVR success.


Of course in the FUTURE they could do studies to find out that 90 is the best or 120 is even better - but for now it is the definitive version of "all we can do".

Personally I am quite glad that I got up the cojones and just did it. I find it QUITE wonderful to know that I don't have to second guess myself and my decision.

Doctor Jacobson was 100% right in my case.

If I could ever sleep at night - I'd be able to having made that decision.

It gives MEE tremendous peace - SVR or not. No second guessing. That is WONDERFUL.

[nygirl7]

The "all you can do" comment came directly from Dr. Jacobson. That was his definition - not mine.

And he is the top doc when it comes to understanding data from studies.

[jmjm530]

NY: I would have bet 10,000 dollars Jim that you would have answered something contrary to what I posted just because you always do.
------------------------------------------------------
Give me your email and I'll tell you where to send the check.

Actually, I would have answered something contrary to the statement you made (as I did a few days ago to someone else) regardless who posted the thought. I also made that quite clear in the post.

No need to personalize this NYGirl. You post a lot. I post a lot. You have strong opinions and often post in a very black and white manner. I also have strong opinions. Therefore it's easy to understand your perception that I'm somehow calling you out. But you're wrong.  It's what you're saying I disagree with -- has nothing to do with you.  Certified check only please.

Be well,

-- Jim

[jmjm530]

I'll also add that my doc used some similar words to me in terms of extending and I also told him exactly what I told you. Another doc -- same data -- told me in so many words that I was nuts to extend beyond 48 weeks. It's not always black and white.

[jmjm530]

I was trying to make two points. One, the point you just made that treatment is very individual, but the other being that even with the same stats, good doctors (and good MH members) can reasonably disagree. In my particular case, the doctor who wanted me to go longer based it on my stage and age plus his instincts. The doctors who wanted me to stop at 48, simply saw no reason to continue on and dismissed age and liver state because of both the fact that I was RVR and that I wasn't cirrhotic. I ended up extending less (54 weeks) than my doctor probably wanted but more than the 48 weeks. Looking back (I know you're not supposed to do that) I think 48 weeks was the right call but it's such an emotional/stressful time when you make these decisions, and being on the drugs and all -- so you do the best you can and lean heavily on doctors you respect.

-- Jim

[jmjm530]

If I may be presumptuous, I think "version 6" is one of the better versions.

[HCA]

My personal opinion on treatment duration is that generally speaking the battle for SVR is won or lost in the first couple of weeks.
There is no doubt that for slow responders (detectable at 12 weeks to any degree whatsoever)that the geno 1's should not cease at 48 weeks if they want the best chance.
The virus does not recognise incremental increases of 24 weeks,and has formed no contract to the effect that it will expire at any given point.
72 weeks,like 48 weeks is an arbitary duration where researchers have elected to quantify results.
It could be 69 and 52,you name it.
For the sake of meaningful reasearch we need reference points,and these rather bizzare 12 week tranches are what the profession has chosen to work in.
In that case is 60 weeks a valid period?Insofar as it may be better than 48 weeks -yes!
The problem here is that the debate has become,as evidenced in earler posts,philosophical.
At this point in time we have to factor in an instinctive ingredient.72 weeks seems to combine a punishing regime for both the virus and the patient and seems to be generally at the threshold of endurance,and does give the patient the knowledge that they could not reasonably been expected to endure more suffering.
Let us hope that the inhibitor era ,if it finally arrives,will make all else redundant.

[sfbaygirl]

I think the arbitary numbers that the researchers pick is what is so crazymaking.  I do think that the recent studies of going 72 weeks when not clear at 12 weeks, is the way most see this. Obviously, my doc doesn't. Lot's of them dont'. I know this group of dr.'s do research most of the time, so why shouldn't I believe them, that 60 weeks is fine. All reason tells me otherwise, but it's a hard decision. I agree with you that it could be 59 or 63, who really knows? Going through all this awful tx, wondering about how these powerful drugs will effect us in the long run, comes into play. While I don't want to do this again, especially given the HALT C studies, it's hard to know when to stop. I don't think that the PI's are going to make a difference, perhaps in time, but the interferon and riba are needed to make them work.

[GoofyDad]

In my case stopping was probably harder than continuing. I wanted to go go on because I was afraid to stop. I researched. I pondered. I tossed and I turned. At stage 4 is was critcal that I did 'all that I could do'.

I posted here, and predictably the overwhelming response was that I should continue. That I should do 'all that I could do'. Hardest were the 'more and more GT 3's are relapsing these days' annecdotal comments.

In the end, analysing the logic on the table, every available study, and talking at length with my doctor (who knows a study or two himself), I realized that continuing would have been an emotional commitment - one not supported by the data. He looked me in the eye and said I think you're good. I deferred to his judgement.

The day I skipped the shot it was far harder to skip than it would be to inject what I had in the fridge. When it's not a clear decision point, stopping takes heart and courage. It's not simnly a matter of raw bravado gets the prize. That would be too easy.

Good luck you guys.      

[sfbaygirl]

I know what you mean, it would be hard to stop before what all the studies we read are. But we have an excellent hepatologist who knows his stuff. Yeah, lots of dr.'s disagree. Like Jim said he went to 3 hep docs and they all said different things. In the end, I think we do have to put our tx into the hands of the Dr. we choose to do our tx and listen to what they have to say. We have read the studies, so has he and if he says, "your'e good!" He has to have a reason for it. I guess if we had medical degrees perhaps we could be a better postition to make this kind of decision. There are a lot more factors than just these studies.

Goof, I thought you were stage 3? Are you going for the scan?

[FlGuy]

'I guess if we had medical degrees perhaps we could be a better postition to make this kind of decision'
Not necessarily...

[willows]

If you are just being contrary in your posts, then I guess I am a contrary person too.  I read this whole thread very carefully and then tried to apply the logic on both sides of the idea of 72 vs 48.  Your comments about why not just 2 years then, or three, on and on, was a vibe I could not help but feel.

No black and white, you are right.  Cheerlead for 72 weeks, cheerlead for 48, either way, there really isn't an answer from one of us here that applies generically.  This virus, really leaves me hanging out here and I miss a solid, yellow-brick road to follow.  Terribly.

Willows and Toto

[Pdilly]

You stated you were a stage 1 and then went to a 4.  What made you decide to get retested?   I had red palms that went away immediatly after starting tx.  I don't think I had any other stage 4 symptoms.

[sfbaygirl]

No, I have not had a test that says I am stage 4. I had a Fibroscan in NOV that shows stage 1-2, I had a bx 6 years ago that shows stage 1 grade 4. I think what you were looking at is the 1/4? That meant Genotype 1 and 4.

Willows, I hear you! I sure wish there were a yellow brick road. I'd be there with you and toto as the Lion looking for his heart.

[FlGuy]

I wonder if red palms can be red herrings on tx.  Just a couple of days ago I noticed mine are a little redder these days (week 16).  Just so Goof has something to swipe at, not doing antything differ with my hands these days either.

[jmjm530]

Well, well said! Which everyone could be as logical and smart as you and I :) Stopping takes a tremendous amount of courage often putting reason before emotion. BTW I think I might have been one of the ones that told you to continue, but never said "do all you can". LOL.

-- Jim

[mblessed]

Jim - you seem knowledgeable in lab results I cant figure what they mean if you are still here can you help me? Or anyone out there who can help me get my brain wrapped around this
- evy

[jmjm530]

I posted to you in the other thread, above.

[ladybug52]

A lot of good input from a lot of knowledgeable people. You just have to wade thru and follow your gut instinct on what's best for YOU. No one else can decide for you, but we'll all support your decision.
As far as following the yellow brick road with Willows...the lion wanted courage! Scarecrow (me) wanted  a brain, and the tinman wanted a heart.
Hopes this resolves Dorothy issues if nothing else!
Bug

[sfbaygirl]

I am rolling on the floor, you are too funny girl! I thought the Lion had the heart, but it fits a bit better that I need the courage. LOL Although, I could be the tinman, my skin sure feels like it!

[GoofyDad]

SFbay: I think this is the quote that has us confused:

I was surprised by the report and how awful it made me sound….early cirrhosis, when I have tested at stage 1? If so why, given Berg, Tapias-Sanchez and Perlman (weight based Riba to 72 weeks) would you suggest 60 weeks instead of 72?



FLguy - Whaen you can take a break for a moment, sniff your fingers. If they happen to smell like fish, then that ain't no red herring. I'm surprised I said it first - thought someone might beat me to it.

[sfbaygirl]

What part are you confused about? I thought I posted the report here...maybe not. I can! Yes, he says he suspects early cirrhosis, given the palms, stiff liver, and US...