Get Ready Get Set Go Plus Serve and

Get Ready, Get Set, Go! (Plus: Serve, and return in one piece) Jonathan D. Adams, MD Assoc. Professor Dept. of Family & Community Medicine

I have no conflicts of interest to declare

Penn State Hershey Family Medicine Residency At Mount Nittany Medical Center

My Background • Major interest is in Disaster Medicine, a developing interest in Global Medicine. • Courses in Basic Disaster Life Support, Advanced Disaster Life Support-Instructor, ALSO-I • Deployed to the Gulf Coast after Hurricane Katrina; to Haiti after the 2010 Earthquake • Life-Flighted 3 times, . . .

Goals: • Motivations for going; avoiding problems while there • Describe how to get ready to go to another country to do clinical work/teach/research/ • How to behave while there • How to go and return in good health, and with the least hassles; how to protect your patients

Where to Go? • Join up with an NGO already there: many nonprofits, many church denominations, many independent religious and secular organizations are involved in global health projects: the AAFP’s Family Medicine Cares Intl. , Heart-to-Heart, Samaritan’s Purse, Doctors Without Borders, MSF, Peace Corps, etc. • Many residencies have ongoing programs • Look for or start sustainable programs

Six Considerations For Doing Global Health • Mission: Why go: Clinical work? Public health? Train-the-trainer? • Collaboration: with whom are you working? • Service: Treat the underserved? Teach? • Teamwork: Can you get along? (No “Loners”) • Sustainability: What happens after you leave? • Evaluation: How/who will assess your work?

EBM? Hah! • Evidence Based Medicine: . . . • Travel medicine actually has relatively little EBM supporting it • I shall depend heavily on raw, unvarnished opinion, personal experience, anecdote, N of 1 studies

Travel Advice: • Will liberally mention specific brand names and sources, • Some details reflect hard lessons learned by many travelers

Travel Advice • Hope for the Best; • Prepare for the WORST • Stories: • The Rule of Threes: One is None, Two is One, Three is Two Prepare ahead for losses of important stuff.

Travel Preparation • • Passports/Visas Packing Paying for stuff Planning for hazards

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How long does it typically take to get a passport/visa? 1. 2. 3. 4. 24 hr 2 days 6 weeks 6 months

If you procrastinate: • There are online companies that will get you a US passport in 24 hr. for $300. • You may be able to get an entry visa in a shorter amount of time by visiting the embassy of the host country in Washington, DC; or one of their consulates in one of the larger US cities.

Passports and Visa • Apply min. 6 weeks ahead of your planned trip • Passports cost $110, plus photos for same are $15/pair. Buy at least three pairs of photos. • Entry visas cost $80 -140, plus processing fees. • Keep your passport and visa in a neck wallet or security pouch, not in a shirt/coat pocket. • Keep a receipt for tax purposes

Passports and Visas • Make sure the expiration date of your passport is at least 6 mo. beyond your planned return. (In the event of a very unlikely “Administrative detention, ” civil unrest during your stay, etc. ). Get a new passport if your current one will expire within 6 months of your return! • Keep your passport/visa with you at all times!

Entry Visas • Some countries require a separate visa, ( a permission slip to enter their country) in addition to your passport; assume you need one unless your host country’s website says you do not. CHECK THE COUNTRIES WEBSITE! • Entry visas cost $80 -170; plus processing fees of up to $25. • Having a visa stamp from Israel on your passport may prevent you from entering a Muslim/Arab country

Exit Visas • A few countries require EXIT visas as well: e. g. : Cuba ($700), Russia (? ), Belarus ($6), Uzbekistan ($50), the Czech Republic, Saudi Arabia and Qatar ($36) • CASH only, maybe; these are fundraisings. • If you don’t pay, you don’t leave. Know before you go! • Keep a receipt for tax purposes.

Airport Departure Fees • Charged by many Caribbean, Central American, and South American airports to help pay for airport construction/renovation • Average $35 -40, payable in cash or credit card BEFORE going through security and customs upon returning to the US. Know before you go! • NOT negotiable: get a receipt for tax purposes

Pacsafe 75 with steel cable neck band-$20

Flip-Out Security Pouch

Neck/Belt wallet packing • Passport • Visa(s) • Driver’s license or other government issued photo ID • Some cash (3 days survival money/$200? ) • Laminated list of US embassy/consulate phone number(s) and addresses • Copies of your written prescriptions.

Baggage fees • Range from $0 to $35 per checked bag, each way; usually cheaper to pay on-line prior to arrival at the airport • Oversize (>62 lineal inches), OR overweight (>50 lb. ) OR additional bags cost even more, up to $200 more per criteria. . . • These costs are CUMULATIVE! Check with your airlines website. Weigh and measure your luggage well before you leave!

Baggage Fees • Some airlines have recently decreased the measurements of what they allow as carry-on baggage • Check your airline website for what it allows in terms of size, buy new carry-on luggage if needed.

Money Exchange Fees • Avoid these by getting adequate cash in the needed foreign currency through your local bank or American Automobile Association prior to leaving: minimal to no charge. • If you know your currency needs, you can order money before you leave • After arrival, the best official exchange rate is generally via ATMs.

Money Exchange Rates • The worst exchange rates are at airport money exchange counters. Avoid these! • Using credit cards or Prepaid Travel card to obtain local currency after your arrival usually gets a better rate than exchanging cash! • Prepaid Travel Cards available from AAA, some banks, online from Master. Card or Visa • “Black market” rates are officially illegal, but widely available and used; offer much better rates.

Medical Evacuation Insurance • If you don’t have it and need it: The $25, 000$130, 000 ride home. . . payable in cash, BEFORE YOU ARE LOADED ON THE PLANE! • Many sources, all with online sites • Cost: about $50 for 1 month of coverage • Varying coverages: Nearest “Center of Excellence” vs. “Home Hospital” (costs more)

Security Evacuation Insurance • Covers evacuations needed due to political unrest, etc. • Ex- Special Operations military fly in to extract the person in need. • Must be purchased ahead of time • Expensive

Taking clinic drugs with you? • Manufacturer’s drug samples take up the most room, but are “free” • Large volume stock bottles are best, with intact seals. • Ask your hospital, local pharmacists to donate stock bottles of generics, inhalers, topical steroids. • Dispensing: paper envelopes or small zip locks; preprinted stickers with instructions for common medicines.

Taking drugs with you? Part 2 • Hassles with customs at the country of destination will be minimized if you have a NOTARIZED OR STAMPED letter of request for specific drugs and specific amounts from your destination clinic/work site. • Drug expiration dates MUST be 6 mo. or more after the date of your arrival! (Drug “expiration” mythology is pervasive/world-wide: http: //online. wsj. com/articles/SB 95420150853006732 6)

Immunizations, etc. : • Make sure your Hepatitis A and B, influenza, MMR, meningitis, polio, rabies, Tdap, typhoid, and varicella, yellow fever immunizations are UTD per CDC recommendations. • One dose of IPV during adulthood if going to many countries in East/Central/or West Africa, Central Asia, Israel, or Southeast Asia.

Immunizations, etc. : • Typhoid vaccine as per CDC (destination specific). Oral vaccine is back on the market; boost every 5 years. • Hemophilus, meningitis, and pneumococcal vaccines as indicated, primarily based upon the traveler’s pre-existing condition • Rabies depending on activities/exposures • Yellow fever vaccine depending on the destination(s)

Personal Medications: • Pack duplicate supplies of your own Rx. and OTC meds in your carry-on and in your checked bags. • Take copies of your written prescriptions in your wallet or neck wallet and your checked baggage • Taking your medicines in their original bottles may cause fewer questions with customs.

Personal Medications • Taking your own narcotics, even when in their original container, with an accompanying prescription for same, MAY result in confiscation and/or jail time. • A separate letter of medical necessity for the reason narcotics are prescribed MAY lessen this risk.

Eyeglasses • Carry a spare pair in a hard-shell case in your CHECKED baggage. Ditto for contacts. • A copy of your eyewear prescription in your carry-on and checked baggage is an additional back-up. Ask your eye doctor to add the interpupillary distance to the Rx. (Or measure it yourself. ) • Ditto prescription sunglasses, if worn (2 pairs)

Packing: • Pack 1 day of clothing in your carry-on and 2 -5 days worth in your checked bags: clothing that can be washed and will (mostly) dry overnight (i. e. , nylon or polyester undies, shirts, and slacks) Cotton does NOT dry overnight. • Dress modestly; keeping arms and legs covered. No bare legs or shoulders in many countries.

Packing, part 2 • Leave the bling at home, ditto for anything you’d greatly regret losing. • If possible, carry the original receipts or copies for expensive cameras and electronic equipment in with you, in case customs, coming or going, wonders whether you bought it and paid appropriate duty on it in their country, to prevent confiscation of it.

Carry On Luggage Packing, part 1 • • Water (obtain AFTER going through security) Snack bars/dried fruit/nuts etc. Ear plugs (for sleeping) Eye mask (for sleeping) Book/electronic music player/Kindle/Nook/i. Pad Mobile phone, and chargers: AC/battery/solar Paper notebook or 3 x 5 cards and pen/pencil

Carry on Luggage, part 2 • Photocopies of the first page of your passport & visa(s), drivers license, credit/debit cards • Photocopies of immunization records/proof of immunity, Blood type, eyeglasses Rx. • Computer/ tablet and wall chargers, any necessary cables. 3 -way adapter, extension cord • One set of your own Rx. and OTC meds

Carry On Luggage, Part 3 Inflatable neck pillow Jacket ( aircraft can be either cool or hot) Chewing gum, if you wish Sunscreen Insect repellant (some airport arrival areas are open air; if so, apply just prior to de-planing) • Paper map(s) of where you’re going. GPS /app • • •

Carry-On Luggage, Part 4 • • Hand sanitizer on a neck lanyard Hat or cap Poncho or rain-gear I suggest a back-pack for all of the above, to keep your hands as free as possible. It should be small enough to fit either under the airline seat in front of you or the overhead cargo bin.

Gel Hand Sanitizer: clip-on

Ready, Set, Go! Environmental Hazards:

Environmental Hazards • • • Bugs and Beasts Sun Beverages Food Moll Buzzers and others Acts of God

What’s most likely to affect your health on a trip to a 3 rd world country? 1. 2. 3. 4. 5. Animal bites Insect bites Motor vehicle accidents Food/beverage related illnesses Sunburns

You are most likely to DIE in a foreign country from: • • • 1. 2. 3. 4. 5. Disasters Drowning Infection Homicide Motor vehicle accident

You are most likely to DIE in a foreign country from: • • • 1. 2. 3. 4. 4. 5. Disasters (1%) Drowning (13%) Infection (2%) Suicide (16%) Homicide (23%) Motor vehicle accident (25%)

Environmental Hazards: • Bugs and Beasts

Pre-, and Post-prandial • Pre-prandial • Post-prandial

Mosquitoes • Dengue and chikungunya transmitting mosquitoes bite dawn to dusk. • Malaria transmitting mosquitoes bite dusk to dawn. • Hence, where mosquito bite prevention is needed, it is needed 24 hr. a day. • Mosquitoes don’t “bite”, they mainly suck.

Insect Repellant: Not all the same • DEET: oldest, long lasting, ? Safety concerns • Available 20 - 100%; 30 -33% best; lasts 8 -12 hr. depending on how much one sweats. • Brands include: 3 M Ultrathon, Ben’s, Repel • Leaves an oily feeling residue • WARNING: DEET will dissolve plastic resin watch bands, sunglasses, rayon, spandex!!! • Now the second or third best option

Insect Repellants: Not all the same • Picaridin: 20% repels for 8 hours. Not 5%. Now the first choice per Consumers Reports No effect on plastic watch bands/sunglasses No oily reside/odor Slightly better against mosquitoes, biting flies/no -see-ums than DEET; less effective against ticks • Brands: Cutter, Sawyer, Repel, Avon Skin so Soft w/ Picaridin, Natrepel, Walmart’s Equate • •

Insect repellants: Not all the same • Oil of Lemon Eucalyptus (Australian tree): AKA citronella • 30% solution, lasts the shortest time: 5. 5 hours • Brands: Repel Lemon Eucalyptus Insect Repellant

Permethrin • Derived from chrysanthemums • Toxic to insects (neurotoxin) • Goes only on clothing and mosquito nets via 0. 5% spray or dipping • Lasts 6 -12 launderings! • Brands: Sawyer, Repel, others; 1 can of spray treats 1 set of clothing

Beasts

Environmental Hazards • Bugs and Beasts • Sun

Do Sunscreens : • • 1. 2. 3. 4. Protect against aging? Increase risk of malignant melanoma? Decrease of risk of BCC and SCC? Increase risk of Vitamin D deficiency?

Sun protection, per the ACS • • SLIP on a shirt SLOP on sunscreen SLAP on a hat WRAP sunglasses over your eyes.

Sunscreens: Not all the same • SPF refers only to UVB (290 -320 nm) induced sunburn protection, NOT skin cancer protection. Sunscreens however do seem to protect against SCC, BCC, and actinic keratoses • UVA (320 -400 nm) also indirectly causes skin cancer, but not redness, sunburn, or pain. • New FDA criteria require labeling as to UVA and UVB protection.

Sunscreens: Not all the same • Sunscreen use has been associated with an increased risk of developing malignant melanoma, possibly due to lack of UVA protection in older agents, longer time out in the sun, increased free radical generation, decreased Vit. D and melanin formation! • Sunscreens prevent Vitamin D formation, by up to 98%; has caused actual deficiencies!

Sunscreens: Not all the same • Alcohol based SPRAYS: aggravate acne the least, best for oily skin, go on easily. • Sunblocks: typically available in a lotion or cream: contains zinc dioxide, titanium oxide or avobenzone as a physical barrier to sunlight. Most effective skin protection for both UVA and UVB protection • Consumer Reports rated Walmart’s Equate sunscreen a Best Buy

Sunscreens: Not all the same • THE BEST SUNSCREEN? Long-sleeved clothing, wide-brimmed hat, glasses: UPF • “UV protective clothing” is advertising. • Clear plastic eyeglasses, as well as sunglasses protect against UVA and UVB • Apply sunscreen 20 min. before going out • Reapply sunscreens q 2 hr. , or after in water

Sunscreens AND Insect Repellants • Avoid combination products • Apply the sunblock/sunscreen first, then the insect repellant.

Environmental Hazards: • Bugs and Beasts • Sun • Beverages

Beverages: • Safe: Anything carbonated, alcoholic, commercially bottled fruit juices, or boiled water (coffee, tea, boiled/cooled water) • Iffy: commercially bottled water! http: //www. sciencedaily. com/releases/2 010/05/100525140954. htm

Beverages • Treat commercially bottled water with sodium hypochlorite (bleach) drops, or chlorine dioxide, for 30 min before drinking. Kills everything; allow to air out. • Other options include iodine (tastes bad, need to neutralize with Vit. C tabs), filtering with a purifying filter, and UV treatment (Steripen) • Don’t drink tap water, or ice water!

Bleach (Sodium Hypochlorite) • 5 drops per liter, let sit for at least 30 min to kill all the nasties. • Treat the water you brush your teeth with! DON’T USE TAP WATER! • SMART: Treat all the water you will use the next day, the night before!

Water Purifiers (more than a filter)

Steripen: $50 -120, depending on model

Caveat Potator: (Drinker Beware) • The chemical treatments (bleach, iodine, and chlorine dioxide) and the Steripen do not remove chemical contaminants (arsenic, heavy metals, etc. Filters and purifiers do. • Arsenic is a significant groundwater contaminant in parts of China, Mongolia, Taiwan, Thailand, Bangladesh, Nepal, Argentina, Chile, and the western US.

Environmental Hazards: • • Bugs and Beasts Sun Beverages Food

Food: • “Boil it, cook it, peel it, or forget it” • All cooked foods, if served piping hot, should be safe • NO FRESH SALADS OR FRUITS (unless you treated them yourself with a bleach or chorine dioxide solution and/or peeled the fruit yourself)

Food, part 2 • Peeling or cutting through the contaminated skin of a fruit or vegetable with a clean knife, contaminates the underlying food!

Environmental Hazards • • • Bugs and Beasts Sun Beverages Food Moll Buzzers, etc.

Moll Buzzers, et. al. : • Moll buzzers: British slang for pickpockets that target women. • Anne’s story:

If You Need Help: • IAMAT • US Consulate/Embassy • Keep contact info for both on laminated cards in your checked baggage, carry-on, and neck wallet; email the info to yourself, and enter the country-specific info. into your smartphone or computer.

IAMAT • International Association of Medical Assistance to Travelers • Free! (Supported by donations) • Has members-only directory of English-speaking physicians in every country • Must join BEFORE you go!

On Arrival: • You, or the group leader, should register with the US embassy as to your scheduled departure date/time, location(s) in the country, name(s) and passport numbers and names of each individual, and contact information, if this hasn’t already been done.

What to Pack? (Rule of Threes)

Bug Out/In Bag (BOB) • FEMA recommendations for the US: 3 days • Why would you do less outside the US? • Global Health service sites are mostly in areas of higher intrinsic risk than the US • Google: “Bug Out Bag” for recommendations for contents

Packing: what do I take? • Consider packing very light: all nylon/polyester clothing, 3 -5 sets total, including what you wear/carry on the plane: shirts, pants, undies, socks • Wash out the set you’ve worn for the day in a sink with dish-washing liquid detergent or liquid/powder laundry detergent • Wring dry, then hang to dry overnight

Packing List • Clothesline: better dacron/polyester than nylon: 1/8 -1/4”; or Paracord; 25 -50 feet • 2 temporary adhesive wall hooks or screw hooks for the clothesline • Stainless steel safety pins, diaper pins, or clothes pins to hang up laundry (fabric stores) • Headlamp (more useful than a flashlight) • Cell-phone and chargers: AC, vehicle, battery, solar?

Nylon clothing sources: • • Sierra Trading Post Cabela's REI: Recreational Equipment Incorporated Campmor Bass Pro Shops Big Box stores: Target, Wal-Mart Many others: Ollie's, Sam's, Travelsmith

Cautions re: clothing and stuff • Avoid camo. , avoid military surplus or military appearing clothing. Many countries have less than positive experiences with their own or others military. • You CAN wear the clothing when you return! • If you take extra, consider leaving some clothing in-country with your organization for distributing to the needy.

Caveat Emptor: Buyer Beware! • UPF rated clothing is largely marketing. Any clothing gives significant protection. The tighter the weave, the greater the protection. • Nylon, polyester, etc. wick perspiration away from your arm-pits, efficiently distributing your body odor over the whole shirt. You may therefore smell worse, and smell worse more quickly with wearing such wicking fabrics.

Caveat Vestitus: Beware of Clothing • All synthetic clothing, including nylon, will melt, and stick painfully to exposed skin if exposed to fire or sparks • Therefore , keep your distance from fires, stoves, open flames, if wearing nylon or other synthetics

Sierra Trading Post women’s nylon shirt: $44

Men’s pants: $35 from LL Bean

Ex-Officio Quik-dry brief: $13. 50 from Travelsmith

CHECKED luggage • Mosquito netting, if needed, $20 @ Dick’s Sporting Goods, Campmor, REI. Head/bed. Pre -treat with permethrin • Second set of Rx. and OTC meds • Mouse/rat traps? • Repair/sewing kits: duct tape, superglue, etc. • Swiss Army knife and/or multi-tool

Checked Luggage: • Electrical outlet convertors: Buy at AAA, Wal. Mart, online, or after arrival; country/region specific • Clinical supplies (tape, dressings, drugs, etc. ) if requested/documented in writing; • Clothing • Bedding/tent, if needed • Culturally sensitive gifts: pens, stickers, ?

Checked Luggage: • • • Teaching materials, as needed Language/clinical reference Simple children’s gifts: pencils, crayons, etc. Pictures of your family, laminated Laminated second copies of your inside passport pages, driver’s license, credit cards, contact information, medical license in a sealed envelope.

Checked Luggage • Bug-Out Bag (BOB) • Pack everything you want to stay dry in large zip locks or “dry bags” • First Aid Kit • Oral rehydration salt packets: (REI, etc. , or make-your-own = 1 liter of water + 6 level tsp. sugar + 1 level tsp. salt. Store in 3”x 5” ziplocks craft/fabric stores). Or Gatorade powder.

Oral Rehydration Therapy • ORS salts: $4 per packet-REI, others; $0. 50 overseas • Gatorade powder works; improved by adding ¼ tsp. of Lite-Salt (KCL) per liter. • Cheapest recipe: ½ tsp. salt + ½ tsp. baking soda + ¼ tsp. salt substitute + 8 tsp. sugar +1 liter water. $0. 03 a liter. • 2 pinches of salt +2 fistfuls sugar +1 liter H 20.

Checked Baggage • Ciprofloxacin 250 mg, # 6 • Bismuth subsalicylate (Pepto-Bismol): 1 tab BID-QID during the trip • Consider taking along HIV prophylaxis x 28 d. if working with a high risk population. (Treatment is recommended to begin within 2 hours of exposure, concurrent with evaluation). $600 -$1000!

Cultural Cautions: • Howdy! • Using the left hand in Muslim countries • Giving things with just one hand in China, Japan, Korea (use two hands) • Women wearing primarily white in the Far East, or red in parts of India • Bare arms, legs in many countries

Cultural Cautions: • Women with uncovered heads in many Muslim countries • A male addressing/touching/treating a woman; a woman addressing/ touching/treating a man in many Muslim countries • Don’t assume the individual with the illness is the decision maker!!!

Offensive Gestures: • Ok Sign: Brazil, Turkey, Germany • Thumbs up sign: Middle East, West Africa, South America, Thailand, Iran, Greece • Pointing with one finger • Beckoning with one finger (used to beckon dogs) (palm down ok): most Asian countries • Moutza/Moutza: outstretched palm in Greece; Double moutza • Scratching/flicking your chin: Italy, France (derision)

Offensive Gestures • Holding up the back of your hand with the index and middle finger extended in England, Australia (“Up yours!”) • Touching the top of another’s head in Sri Lanka, Thailand, Laos, other Buddhist countries. • Crossing your fingers in Viet Nam • The forearm jerk: France, southern Europe, Brazil

Cultural Cautions: • Showing the bottom of one’s feet, shod or unshod, in Muslim countries • Not removing your shoes upon entering a home or place of worship • Giving a gift with your left hand in India, Sri Lanka, Africa, or the Middle East, or just one hand in the far East (Use the right hand only or better yet, use both hands)

Cultural Cautions • Don’t give white flowers in Bangladesh, wrap a present in white paper in China (or give a clock or watch), or give an even number (e. g. , dozen or ½ dozen) of flowers in Russia. These all suggest DEATH in those cultures.

Personal Safety • • Situational awareness! Stay together: no lone-wolf exploring Ask your host(s) where to go, where to avoid Beware the moll-buzzers! Keep a BOB handy Earthquake advice may be different. Strictly observe food and drink precautions

In an Earthquake? : • 1. Try to stand in a door way • 2. Lie down in “the Triangle of Life” next to a bed, table, chest, or wall. • 3. Get under a table or desk and hold on. • 4. Get into a stairwell as these are usually the safest part of a multi-story structure. • 5. Walk, don’t run, as quickly as you are able out of the structure.

How many healthcare workers in West Africa have contracted Ebola Disease? • • 1. 27 2. 212 3. 416 4. over a 1000.

How many healthcare workers in West Africa have contracted Ebola Disease? • • 1. 27 2. 212 3. 416 4. over a 1000.

What is mortality rate from Ebola in HCW in West Africa? 1. 2. 3. 4. 10% 20% 55% 90%

What is mortality rate from Ebola in HCW in West Africa? 1. 10% 2. 20% 3. 55% (Remember this number for comparison!) 4. 90%

How many America Healthcare Workers have died from Ebola? 1. 2. 3. 4. None One Two Four

How many American Healthcare Workers have contracted Ebola? 1. 2. 3. 4. Two Four Eight Sixteen

How many American Healthcare Workers have contracted Ebola? 1. 2. 3. 4. Two Four Eight Sixteen

How many Americans die from the flu (not Ebola) each year? 1. 2. 3. 4. 30 3000 30, 000

How many Americans die from the flu (not Ebola) each year? 1. 2. 3. 4. 30 3000 30, 000

How many US citizens have been diagnosed with Ebola? 1. 2. 3. 4. Four Six Nineteen

How many US citizens have been diagnosed with Ebola? 1. 2. 3. 4. Four Six Nineteen

How many America citizens have died from Ebola? 1. 2. 3. 4. None One Two Four

How many America citizens have died from Ebola? • 1. None • 2. One: Patrick Sawyer, a lawyer, who died in Lagos, Nigeria • 3. Two • 4. Four

What percentage of American Healthcare workers who violated self-quarantine are physicians? 1. 2. 3. 4. 25% 50% 75% 100%

What percentage of American Healthcare workers who violated self-quarantine are physicians? 1. 2. 3. 4. 25% 50% 75% 100%

Thank-You! • Questions?