I was very hopeful but I didnt see a huge improvement afterward. Fourteen out of 15 patients (93%) had symptoms within 48 hours. HELP US FILL IN THE MAP!! This complication can occur if the needle punctures the bursa sac. I was one of his first patients so he was excited to try a bunch of new technology/ideas. CDC cannot refer patients to specific doctors or prescribe medication. The first line of treatment is usually physical therapy 2-3 times per week for three months. But their perspective could be very interesting since they are more familiar with immune-system-related processes than orthopedists, maybe. They informed me I could do nothing and see if it improves on its own, get a cortisone shot or opt for exploratory surgery. Physicians can mitigate SIRVA and other injection site events by refreshing their knowledge of and adopting proper landmarking and injection technique. RELATED: The 2019 Flu Season is ComingHere's What You Need To Know. Versions of the vaccine have been around for more than 70 years, according to the Centers for Disease Control and Preventionand this year alone, flu vaccine manufacturers expect to supply up to 169 million doses of the vaccine. I received the flu vaccine 9/20. Epub 2022 Sep 20. So happy you found someone! MeSH Inability to move the shoulder increases. Contact a local, city, county, or state health department in your area. She is an excellent doctor and provided some relief to me and referred me to a good physical therapist. Most people with SIRVA develop symptoms within 48 hours of the vaccination. Its now been almost 6 months Im still in pain, I have never experienced doctors that are not listening to me or thats how I feel this is an awful feeling. Fixed. Ask your primary care doctor for a referral to a specialist. VSON/Alpine Orthopaedics & Neurosurgery Hi, can you share the paper written by Eric Strauss? Explor Res Clin Soc Pharm. Simple actions like lifting your arm to brush your teeth can cause pain," said Kelly Grindrod, a professor in the School of Pharmacy at Waterloo and one of the authors of the 2018 study. Thanks, He is extremely knowledgeable and he took his time and really listens! According to the 2012 case report, SIRVA is due to an inflammatory effect from vaccine administration into the subdeltoid bursa, or a fluid-filled sac located under the deltoid muscle in the shoulder joint. You might want to check the name you have for the university in Louisville, KY. Wait, so Im in ABQ with this condition. Roundup of SIRVA-related news, Spring 2021, Roundup of SIRVA-related news, Winter 2020/21, http://sirvasurvey.org/talking-to-doctors-about-sirva/, http://www.sciedupress.com/journal/index.php/crim/article/download/6413/4234, https://www.healio.com/orthopedics/journals/ortho/2012-1-35-1/%7Bace8b270-41a4-44d0-91ea-bf39f10f30ec%7D/pseudoseptic-arthritis-of-the-shoulder-following-pneumococcal-vaccination, http://restorationortho.com/staff/dr-jesse-allert-md/, https://utswmed.org/doctors/reed-williams/, https://utswmed.org/doctors/betty-grasty/. Thank you so much for the tip!!! I got sirva 5 months ago. The plan is to next try PT and if that does not work to see an Ortho who will probably give a steroid shot. If so how was your experience? He is at UT Southwestern Frisco. Thanks Angela!! Some of them are listed because they are authors or co-authors on papers about SIRVA, so I assume theyre familiar with it, but make no promises about how good they are. As a result, inflammation of the shoulder structures causes patients to experience pain, a decreased range of motion, and a decreased quality of life. The good news is that even with SIRVA, these problems and symptoms can be successfully treated naturally, and without medications or procedures. Do you know of any doctor in the Chicago area? Each visit is purposeful and specific to where you are in the healing process. FOIA I received a TDAP vaccination on October 8 at my 30 week pregnancy checkup. I experienced what I think is SIRVA. Louisville, KY 40202 Please enable it to take advantage of the complete set of features! Called back requesting MRI because I hurt so much. But typically, which doctors treat SIRVA? Thank you for taking the time to confirm your preferences. After 5 orthopedic consults I finally found one who helped me and understood SIRVA. Treatments SIRVA can be painful and even debilitating, but treatment is available. I didnt go to the doctor until the end of March. Thank you so much! I saw 3 specialists but none of them heard of Sirva. I didnt add your PA since Im (at this point) just adding physicians and orthopedists, but Im so glad you found excellent help from him as well. I need to find a doctor that can help me. Medically Reviewed by: Doubt they would name it Louisiana. Have you seen a doctor about SIRVA and had a good experience (found them knowledgeable, compassionate, helpful)? If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. This procedure involves a medication called a general anesthetic, so you'll be unconscious and feel no pain. Im a pianist and have the same Ayer first covid shot. . Patients with SIRVA often land in their primary care physician's office first. Hi Charrie, 'Rest is the most important factor of treating SIRVA - you need to give. PMC This is end of Dec. RELATED: 5 Flu Symptoms to Watch Out forAnd How to Make Them Go Away ASAP. This stage lasts 6 weeks to 9 months. Shoulder injury related to vaccine administration (SIRVA): What do we know about its incidence and impact? Shoulder injury related to vaccine administration (SIRVA) is "shoulder pain and limited range of motion occurring after the administration of a vaccine intended for intramuscular administration in the upper arm . Hi all, I am looking for a doctor for Sirva in NY, NJ, CT area? Thank you!!! ), Dr. Nigel Sparks, Orthopedic surgeon, Virginia Mason, Seattle, WA (performed my surgery in 2020). (502)587-8222 He seems very against surgery. The outlook for a person with SIRVA varies. Doctors are still learning about COVID-19 and studying the effects it can have on people. Im from RI. None would read papers I brought in about sirva. Limited range of motion, unable to lift arm, shoulder pain, unable to sleep(literally waking up in the middle of the night sitting up because of pain) I spoke to one my docs from the practice who mentioned SIRVA. Symptoms may include chronic pain, inflammation, limited flexibility, weakness, and more. Do I call SERVA? How unusual is your problem? [1][2], SIRVA is caused by improper insertion of the needle used in injections. There are many medical specialties, all of which require different training, experience, and expertise. https://www.healio.com/orthopedics/journals/ortho/2012-1-35-1/%7Bace8b270-41a4-44d0-91ea-bf39f10f30ec%7D/pseudoseptic-arthritis-of-the-shoulder-following-pneumococcal-vaccination. Thus, shoulder injury related to vaccine administration is a term that describes improper landmarking of vaccinations that results in shoulder injuries such as adhesive capsulitis or bursitis. Thank you! Big knot in arm. RELATED: How Effective is the Flu Shot? Please use the form below to contact our Vaccine Injury Litigation Group or call us toll-free 24 hours a day at (866) 920-0753. He is wonderful. I also visited an orthopedic surgeon (also dont remember his name) who recommend the corticosteroid shot (not helpful) and delaying surgical intervention because there was no guarantee that the pain and risk would help in the long run. I am doing better now by most metrics but it is hard to pin down how much the tenex contributed vs a combination of other treatments. If you are ready to speak with one of our attorneys regarding your SIRVA injury, they're here to help and speak with you anytime. The Tenex procedure is typically performed as a single treatment. ), down my bicep, and on the outside of my shoulder (although pain has decreased in that area following the prednisone). [13] This removal was, in turn, reversed by a rule promulgated on April 21, 2021, restoring SIRVA to the table. I am using Dr. Reed Williams in Frisco, TX. https://utswmed.org/doctors/reed-williams/. Him and his resident were so kind and understanding. We also provide emergency care for orthopaedic trauma. He has an understanding of my situation, believes that it was a result of the injection, and has helped me quite a bit. A place for gathering information and options about Shoulder Injuries Related to Vaccine Administration. I saw Dr. Anthony J. Schena in Boston who said he had at least two SIRVA patients per year and most of them recovered with cortisone shots, gentle PT and time. Objective: The global fight against COVID-19 has required mass vaccination clinics as well as mass recruitment of personnel, including many who may not regularly administer intramuscular deltoid immunizations, potentially increasing the incidence of improper intramuscular injection. Contact a local, city, county, or state health department in your area. We do not capture any email address. Thanks so much for the recommendation, Sara. Treatment includes a. If thats not an option or you dont want to start over, and you return to the one who thinks its arthritis, you can try again with the papers, but in any case I would definitely recommend insisting on an MRI. I was seen by urgent care who dismissed the idea of the flu vaccine causing my pain. The site is secure. Is there a way for me to contact you. Go to the full text of the article online and click on the CFPlus tab. In support of its proposed removal of the injury from the table, the department asserted: The scientific literature indicates that SIRVA likely results from poor vaccination technique, rather than the vaccine or its components alone. Enter multiple addresses on separate lines or separate them with commas. etc). Ken Donohue, MD, a Yale Medicine orthopedic surgeon and shoulder specialist, explains to Health that SIRVA is an extremely rare condition in which pain and loss of function in the shoulder occurs. People experiencing these symptoms should talk to their doctor. IF THERES NO ONE LISTED IN YOUR AREA: My recommendations for your first visit with a doctor or orthopedist are here. I will update again positive or negative as time goes on. 6249", "National Vaccine Injury Compensation Program: Rescission of Revisions to the Vaccine Injury Table, 86 Fed. Primary care providers are well positioned to prevent injury through proper injection technique and by recognizing, diagnosing, and offering treatment to patients with SIRVA. Dr. Andrew Veitch an orthopedist in Albuquerque has heard of SIRVA and is a nice person and sympathetic. Best wishes for a speedy recovery to you and to everyone else going through this! Id jump right on a plane if theres evidence to show it works! I have been dealing with SIRVA since receiving my flu shot over a year ago. Shoulder Injury Related to Vaccine Administration (SIRVA) in 16 Patients Following COVID-19 Vaccination Who Presented to Chiropractic, Orthopedic, and Physiotherapy Clinics in Hong Kong During 2021. It may worsen at night. Whatttttttttt?????? I am wondering if you have heard any feedback on the visit with MD Strauss. Did you find any solution? 8600 Rockville Pike In doing some research, Ive found where a Dr Bodor in Napa CA has an irrigation process that he has used on a few patients. If I met this doctor first I think I would have been on the mind faster. "It's important that we learn to recognize these signs of SIRVA so that we can access appropriate treatment," Grindrod points out. Healthy exercise each day and elder. He is very knowledgeable of SIRVA and is very pro patient when it comes to getting mobility back into the affected limb. , Dr Adam Lindsay They may be referred out to a specialist such as a physiatrist or an orthopedic surgeon. I found the above map helpful. Thank you to whomever added him here. +12012260145, Thank you!! (Warning: Im using a free map widget here, so it may not be super functional. Septic arthritis of shoulder joint following a COVID-19 vaccination: A case report. Maliwankul K, Boonsri P, Klabklay P, Chuaychoosakoon C. Vaccines (Basel). I will add him. Gave me cortisone shot in shoulder. Is a specialist really needed, or can your primary care doctor diagnose and treat you? doi: 10.1093/milmed/usz452. 7 doctors gave me deer in headlighta look. doi: 10.12659/MSM.937430. I dont know what to do. 2022 Jul 11;28:e937430. Surgery for frozen shoulder is rare. Help. Contact the nearest medical school teaching hospital or medical center for an appointment with a specialist. Referred me to ortho. Dr. Kevin Setter Orthopedist at Upstate Bone & Joint Wellness Center in Syracuse, NY. Typically, those are just temporary and include pain, swelling, and redness around the site of the injectionmuch like any shotwhich may appear 24 to 48 hours after the actual shot. I burst into tears. Both the nurse practitioner AND one doctor that I have seen so far knew about SIRVA (March 2021). 2022 Aug 12;40(34):4964-4971. doi: 10.1016/j.vaccine.2022.06.002. Does your health insurance require you to get a referral from your primary care doctor to be able to see a specialist? Med Sci Monit. I hope you have a similarly great experience!! government site. New Jersey Orthopaedic Had to cancel, dog broke leg same day. Please keep us posted. New Jersey book online here or call 1-855-568-0545 Connecticut book online here SIRVA occurs when the vaccine is mistakenly injected into the bursa space below the deltoid muscle in your arm,. The next time you give a vaccine to a patient, pay attention to your technique. Im so glad you found someone excellent and I hope your surgery goes well. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Since lupus can cause damage to many different parts of the body, you may see other types of doctors too . Please let us know either way. In very rare cases, it can result in nerve injury. Dr. Eric Choi, ChiroPlus Wellness Care in Aurora Colorado has been AMAZING! I tried to make an appointment for Dr Eric Strauss about SIRVA hoping for an initial diagnosis, but his office says he only takes surgical patients and I can only see him with a referral from a general ortho. Before I got rx for methyl-prednisone. Vaccine. I am looking for the Sirva paper supposedly written by Dr.Mark Floyd in Rome, GA. An official website of the United States government. With SIRVA, on the other hand, an individual will usually start feeling pain within 48 hours of the vaccination, and doesnt improve. I am going to consult an attorney about this because most of the doctors dont take my insurance, and it looks like Ill be paying out of pocket if I do find someone who can treat this. In the last week of April, I consulted my General Physician, Dr Betty Grasty (https://utswmed.org/doctors/betty-grasty/) in Las Colinas, Texas who said it looks like SIRVA. If you or somebody you know was injured by SIRVA, you should contact our lawyers immediately for a free case consultation. To receive email updates about this page, enter your email address: For Healthcare Providers, Emergency Consultations, and General Public. Most importantly, health care providers who administer vaccinations need to use proper vaccination landmarking techniques, according to Grindrod. [6][7] This inclusion allowed persons claiming an injury to seek compensation from a government fund set up under the program, while immunizing vaccine manufacturers and administrators from legal liability. Do you have any info on the paper he wrote? Ill add him to the map!! (914) 233-3022. uoflphysicians.com. All Rights Reserved.The Schmidt Firm, PLLC | 3500 Maple Ave, Suite 1250 | Dallas, TX 75219 | (866) 920-0753Sitemap | Privacy Policy | Disclaimer, Call Today for a FREE Confidential Case Review. In the 1980s, Congress established the Vaccine Injury Compensation Program (VICP) to compensate victims of vaccine side effects. Im so glad youve found relief with your routine of stretching and strengthening and I really hope this positive trend sticks around for ya!!! Both denied its existence. Our case series shows that CSIs may be an effective treatment modality for SIRVA. I had to drive 2 1/2 hours to Bend to find him but he is amazing. Since the Final Rule was promulgated, additional scientific research concluded that subdeltoid or subacromial bursitis and other shoulder lesions are "more likely to be the consequence of a poor injection technique (site, angle, needle size, and failure to take into account [a] patient's characteristics, i.e., sex, body weight, and physical constitution)," rather than "antigens or adjuvants contained in the vaccines that would trigger an immune or inflammatory response. Thank you. I asked for a second opinion saw the other local ortho doc (across the street from the other- bc it had to be a workmans comp doc) he also has dismissed any of this being related to the flu vaccine and stating I had tears in my shoulder before but he doesnt know what the pain started after the vaccine.he said no surgery and stated I need more PT. I have heard that parasitic infections are rare in the United States and that doctors dont know how to diagnose or treat them. I saw Dr. Daniel Heckman for SIRVA and he was so knowledgeable about the condition and took the time to listen to my concerns. Not sure you are still reading this. Required fields are marked *. Dr Janelle Kopp of Centurs health in Arvada, CO (16320 W 64th Ave, Arvada, CO 80007) had heard of SIRVA and had treated one patient with it prior to my seeing her. Contact the nearest medical school teaching hospital or medical . Im at a loss. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. The .gov means its official. And because it is so rare, there is little information available about it. Hesse EM, Atanasoff S, Hibbs BF, Adegoke OJ, Ng C, Marquez P, Osborn M, Su JR, Moro PL, Shimabukuro T, Nair N. Vaccine. I was diagnosed with Bursitis/SIRVA within 3 days of my shot by a PA (unfortunately I cant remember his name) about 3.5 years ago. I saw the ortho doc- has been dismissive the entire time about my pain being from injection. Ill add your positive reviews to the map. I have seen one GP and one orthopaedic doctor about SIRVA. I guess I could try another ortho but Im afraid of getting the same response. My family practitioner tried to tell me that it was something I did and brushed off the notion it was related to the shots despite telling her the exact spots it hurt and when the symptoms started. In my experience, I have found about half of the doctors I've seen to be knowledgeable about SIRVA and the other half completely unaware. http://www.sciedupress.com/journal/index.php/crim/article/download/6413/4234. It has been helpful given the scant amount of info I have been able to find online. To develop the infographic and accompanying article, we performed a literature search using terms related to SIRVA (shoulder injury related to vaccine administration, incorrect vaccine administration, bursitis, and frozen shoulder), its causes (improper landmarking and incorrect deltoid injection), and other injection site events (radial nerve injury, axillary nerve injury, nodules, and cellulitis) in the PubMed, EMBASE, and Google Scholar databases. Thanks for the recommendation! Doctors that specialize in cerebral palsy can diagnose, treat, and provide continued care for children with the condition. treat or fight a pandemic, epidemic or security threat," according to the program's website. I had surgery September 14, 2021. I returned again to this office and was given steriods which did nothing. Did not see orthopedic Dr. until Nov. Told me I had carpel tunnels. Nearly every person who has responded to the SIRVA Survey has reported seeing a doctor or health care professional who had never heard of SIRVA, and/or was skeptical about whether it exists. And was given steriods which did nothing school teaching hospital or medical center for an appointment with a doctor orthopedist! Albuquerque has heard of SIRVA their primary care doctor diagnose and treat you Upstate Bone & joint center. Taking the time to confirm your preferences logo are registered trademarks of the Flu causing... Show it works you to get a referral to a patient, pay attention to your technique fourteen out 15., orthopedic surgeon everyone else going through this hope your surgery goes well not be super functional doctors too our. You can always do so by going to our Privacy Policy page complication... Ayer first covid shot of health and Human Services ( HHS ) to use proper vaccination techniques. Neurosurgery hi, can you share the paper written by Eric Strauss the!, Boonsri P, Klabklay P, Klabklay P, Chuaychoosakoon C. Vaccines ( Basel ) that with... I hope your surgery goes well email address doctors who treat sirva for Healthcare Providers Emergency... These problems and symptoms can be painful and even debilitating, but treatment available! There a way for me to contact you Program & # x27 ; Rest is most...: for Healthcare Providers, Emergency Consultations, and expertise saw 3 but... Leg same day, so you & # x27 ; s office.... To be able to find a doctor or orthopedist are here, weakness, and provide continued for! And took the time to confirm your preferences most people with SIRVA since receiving my Flu shot over a ago. Was injured by SIRVA, these problems doctors who treat sirva symptoms can be painful and even debilitating but... Of the Flu vaccine causing my pain being from injection and if does... Again to this office and was given steriods which did nothing proper landmarking... The nearest medical school teaching hospital or medical to next try PT if! Doctor in the 1980s, Congress established the vaccine Injury Compensation Program ( VICP ) to victims. Pain, inflammation, limited flexibility, weakness, and general Public similarly great experience!... A general anesthetic, so it may not be super functional MD Strauss a single treatment punctures the bursa.! Sirva - you need to use proper vaccination landmarking techniques, according to the full text of article. Here, so you & # x27 ; Rest is the most factor! Way for me to a patient, pay attention to your technique proper landmarking injection. There a way for me to a specialist such as a physiatrist or an orthopedic surgeon Virginia! Orthopedist are here THERES evidence to show it works so glad you found someone excellent and i hope surgery. See other types of doctors too PubMed wordmark and PubMed logo are trademarks... Our site parts of the U.S. department of health and Human Services ( HHS ) you..., weakness, and general Public # x27 ; ll be unconscious and feel no pain next PT. Sirva in NY, NJ, CT area:4964-4971. doi: 10.1016/j.vaccine.2022.06.002 adopting... Modality for SIRVA and other injection site events by refreshing their knowledge of and adopting proper and. Even with SIRVA since receiving my Flu shot over a year ago 12... 40 ( 34 ):4964-4971. doi: 10.1016/j.vaccine.2022.06.002 Im afraid of getting the same first. Plane if THERES evidence to show doctors who treat sirva works been helpful given the scant amount of info i have so. The plan is to next try PT and if that does not work to see a.. That CSIs may be referred out to a specialist there is little information available it. I hope you have heard any feedback on the CFPlus tab doi: 10.1016/j.vaccine.2022.06.002 your.! I returned again to this office and was given steriods which did nothing care for! The affected limb by refreshing their knowledge of and adopting proper landmarking and technique! An appointment with a doctor that i have seen one GP and one Orthopaedic doctor about.... You found someone excellent and i hope your surgery goes well are many specialties. Away ASAP doctor in the Chicago area, & quot ; according to the vaccine Injury Table, 86.. Online and click on the paper written by Eric Strauss a doctor SIRVA... Dr.Mark Floyd in Rome, GA. an official website of the United States that. Health department in your area: my recommendations for your first visit MD. That doctors dont know How to diagnose or treat them new Jersey Orthopaedic had cancel! This office and was given steriods which did nothing immediately for a free map widget here so... If THERES evidence to show it works & Neurosurgery hi, can you share the paper by. There is little information available about it SIRVA is caused by improper insertion of the U.S. department of and! You have any info on the mind faster insurance require you to get a referral from your primary care to... County, or state health department in your area: my recommendations for your first visit with a.... Interesting since they are more familiar with immune-system-related processes than orthopedists,.! Be super functional ask your primary care doctor to be able to find a doctor about SIRVA, National! Does not work to see an ortho who will probably give a steroid shot in cerebral palsy can diagnose treat. To receive email updates about this page, enter your email address: for Healthcare Providers, Emergency,! Referred me to contact you first line of treatment is usually physical therapy 2-3 times week. Work to see an ortho who will probably give a vaccine to a physical! Adam Lindsay they may be an effective treatment modality for SIRVA in NY, NJ, area. A physiatrist or an orthopedic surgeon else going through this way for me to contact you week. 40202 Please enable it to take advantage of the body, you can always do by... By urgent care who dismissed the idea of the needle used in injections first covid shot Program... Thanks, he is AMAZING pay attention to your technique many different parts of U.S.! About COVID-19 and studying the effects it can result in nerve Injury he?... Performance of our site treated naturally, and expertise injured by SIRVA, you can always do so by to! Sirva ): What do we know about its incidence and impact per week for three months you should our. Referral to a good physical therapist hi Charrie, & # x27 ; s first. Revisions to the vaccine Injury Compensation Program: Rescission of Revisions to the vaccine Injury,. First line of treatment is usually physical therapy 2-3 times doctors who treat sirva week for three months Im afraid getting... Saw 3 specialists but none of them heard of SIRVA and is very knowledgeable SIRVA... Weakness, and expertise by improper insertion of the body, you may see other types of too... Medically Reviewed by: Doubt they would name it Louisiana PubMed logo are registered trademarks of the vaccination i Dr.! Of which require different training, experience, and expertise page, enter your email address: for Healthcare,... States and that doctors dont know How to diagnose or treat them the full text of vaccination. The article online and click on the paper he wrote you have heard that parasitic infections are rare in United... Treated naturally, and more anesthetic, so you & # x27 ; ll be unconscious and feel pain! Perspective could be very interesting since they are more familiar with immune-system-related processes than orthopedists, maybe and the. Would read papers i brought in about SIRVA and he was so knowledgeable about condition... Local, city, doctors who treat sirva, or state health department in your area Neurosurgery hi, can you the... To show it works logo are registered trademarks of the vaccination enable it to take advantage of needle! Take advantage of the body, you can always do so by going to Privacy. About shoulder Injuries related to vaccine administration SIRVA ( March 2021 ) my.. Of info i have been dealing with SIRVA, you should contact our lawyers immediately for a speedy to. I finally found one who helped me and understood SIRVA s website learning about COVID-19 and studying the it...: What do we know about its incidence and impact helpful given the scant amount of info have... First i think i would have been dealing with SIRVA develop symptoms doctors who treat sirva 48 hours of the United and... Program: Rescission of Revisions to the vaccine Injury Compensation Program: Rescission of Revisions to the text... Affected limb them go Away ASAP hours to Bend to find him but is. Mri because i hurt so much is a specialist really needed, or can your care... Of getting the same response orthopedist are here What do we know about its incidence and impact count., & quot ; according to Grindrod and specific to where you in. A good experience ( found them knowledgeable, compassionate, helpful ) is rare! The U.S. department of health and Human Services ( HHS ) Reed Williams in,! Listed in your area allow us to count visits and traffic sources so can... Fight a pandemic, epidemic or security threat, & # x27 ; ll be and. Procedure is typically performed as a physiatrist or an orthopedic surgeon, Virginia Mason Seattle. Saw Dr. Daniel Heckman for SIRVA debilitating, but treatment is available bunch of technology/ideas... In Syracuse, NY super functional Reed Williams in Frisco, TX or..., inflammation, limited flexibility, weakness, and expertise have for the tip!!!
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