AwareofAware

Evolving news on the science, writing and thinking about Near Death Experiences (NDEs)

Archive for the tag “parnia”

28 Jan 2023
225 Comments

UNCOOL (updated on 29th January)

This post is a doozy, you will need to get your noodle into high gear as we will be delving into 4 publications on or related to the subject of NDEs during HCA (hypothermic circulatory arrest). Before we start, can I ask you a small favour. This blog costs money to create, and time to write. If you have been coming here for a while and enjoy reading what I write, then I would be grateful if you “bought me a coffee” (if you are rich, you can buy more than 1!). This site is trustworthy and used by media creators around the world to get appreciation for creators like me. You will need a credit card, provide the number, expiry, CVV number AND your zip code – the details are not passed on to me or held on the Buymeacoffee site (BTW it’s easy to forget the ZIP code which tripped me up when I tried it out for the first time today, you need to scroll across the details box). If I get lots of support it may motivate me to write more!

My Buy Me a Coffee page (yes, my real name is Orson…Ben Williams is a character in one of my novels)

Now to the blog. So this is not a great news blog for those longing for that illusive scientifically verified OBE, and may be bad news for Parnia’s HCA study, but there is a caveat with that.

So to the first paper (big shout out to Constiproute for alerting me to this one – how did I miss it!!):

Does Hypothermic Circulatory Arrest for Aortic Surgery Trigger Near-Death Experience? Incidence of Near-Death Experiences after Aortic Surgeries Performed under Hypothermic Circulatory Arrest

Ref: Manduit et al; Aorta (Stamford). 2021 Apr; 9(2):76-82. doi: 10.1055/s-0041-1725091

Brief summary of design, methods and results:

Design: It was a prospective study looking at consecutive patients who underwent thoracic aortic surgery between July 2018 and September 2019. Procedures without HCA were included to constitute a control group. The primary outcome was the incidence of NDE assessed with the Greyson NDE scale during the immediate postoperative course, via a standardized interview.

Results: None of the patients reported any recollection from their period of unconsciousness. There was no NDE experiencer in the study cohort.

This makes AWARE II look like a resounding success! The authors sound slightly bitter in their summary of the results, as far is it possible to sound bitter in a clinical study publication.

Firstly let’s get into the weeds. This is a well designed prospective controlled study which makes it a very credible study.

The procedure basically requires cooling the body to 21-28oC by using a bypass technique that cools the blood, and once this temperature is achieved circulation is halted. At this temp many of the metabolic processes that occur within cells are slowed to the extent that damage will not occur, particular to brain tissue. However, after 30 minutes things may get more dangerous and another technique is initiated that restores flow of fluid to the brain. Here are the numbers recruited.:

Overall ( n  = 101)HCA group ( n  = 67)Control group ( n  = 34)

All patients survived, and while it is not stated (something the editors or reviewers should have picked up) I assume that all were interviewed. Given data from previous NDE studies looking at CA survivors, you would expect about 6 reports of NDEs from the HCA group given that they were in circulatory arrest. However there were none.

In the lengthy discussion section a number of factors were listed as potential confounders which might have caused this lack of NDEs. Here they are verbatim:

  • The hypnotic agents and analgesics used during general anesthesia may induce retrograde amnesia, or merely prevent NDE, although some NDE during anesthesia have previously been described. 
  • The potential influence of modified neurotransmitter release and systemic inflammatory response induced by the CPB, along with the varying degrees of ischemia/reperfusion during aortic surgery, should also be taken into consideration. 
  • The duration of unconsciousness in our study (14.4 hours on average), inherent to the prolonged general anesthesia, might prevent the patient from remembering NDE events. Furthermore, the time between awakening from anesthesia and the patient’s interviews might have been too long.
  • The number of patients included in our study might also be too limited to evidence NDE, although the incidence rates reported among cardiac arrest survivors suggest that such cohort size should be adequate.
  • The level of hypothermia and the optional use of adjunctive cerebral perfusion during circulatory arrest might also play a crucial part. 

The first 4 are self explanatory. The issue of being under sedation prior to CA is something that I think is potentially relevant. Does the consiousness need to be consious when CA occurs for an NDE to occur? Not convinced personally since I can recall of NDEs that have been reported when patients were under anesthesia, had a CA during a procedure and consiousness started at that point with the NDE ensuing. Moreover we have the cases from the HCA study in Montreal (the original COOL study) led by Mario Beauregard. I will return to that in a moment.

It is the fifth point that interests me and two papers that are cited in the section of the discussion that delves into this.

Electroencephalography During Hemiarch Replacement With Moderate Hypothermic Circulatory Arrest by Keenan et al in 2016

and

Deep hypothermic circulatory arrest: I. Effects of cooling on electroencephalogram and evoked potentials by Stecker et al in 2001

To summarize the key points, with the application of cerebral perfusion (used in both studies), the EEG does not in general become silent until the body has reached a temperature of 16oC. Below about 24oC it goes into burst suppression, during which consiousness is not possible. This is the status usually encountered during anesthesia.

In summary there are 3 states and outcomes to consider:

  1. Temp >16oC no circulation (artificial or natural) = isoelectric EEG or clinical brain death in under a minute.
  2. Temp >16oC with some kind of circulation, either natural or artificial = EEG activity of some kind.
  3. Temp <16oC with or without circulation = no EEG activity and clinical brain death.

Now I will discuss the Beauregard study from Montreal. The details were published in a journal as a letter which does not require peer review. It was more hypothesis generating than anything, and was supposed to be the launch pad for a larger scale prospective study, but it never happened. Anyway, here is a link to the letter:

Conscious mental activity during a deep hypothermic cardiocirculatory arrest? Beauregard et al 2011

In summary, it was a retrospective study looking at cases between 2005-2010 in which 33 patients underwent DHCA ( deep hypothermnic circulatory arrest), and were interviewed afterwards. 3 reported consious recollections, and one had an OBE, the details of which were later confirmed to be accurate. Given it was retrospective and in such a small cohort, the evidence is a little sketchy (unless you add it to the mountain of other evidence), however this is what has inspired further study. So there is one huge question to ask, why did Beauregard’s study have NDEs and Manduit’s not?

It is noteworthy that when looking at Keenan’s paper, the methods for HCA appeared to change around 2010-2013, with cooling often going to 21-28oC, whereas during DHCA conducted prior to 2010, it appears the body may have been cooled to 16oC or lower.

This may be the key difference between Beauregard’s (recruited 2005-2010) study and Manduit’s (recruited 2018-2019). However, given that in Manduit’s study only 31% of patients had ancilliary cerebral perfusion, therefore 69% would have had isolectric EEG (although they did not measure this), I am not sure this would make any difference in terms of potential for NDEs.

However, this is potentially hypothesis generating regarding the interation between consiousness and the brain in a dualist understanding of our existence, and which I will delve into during the discussion or in another post because I think this is enough for now.

Finally, this has implications for Parnia’s HCA study. Is he using DHCA cooling to 16oC, or MHCA (moderate HCA) and only going to 21-28oC. Is there cerebral perfusion? The answers could effect the outcome.

Wow, my brain is overheating – definitely not 16 or even 21-28oC…it is smoking!

Please review the papers yourselves and see if I am adding 2 and 2 and getting 762, but I think I may be right on this.

Finally, surely after that, you want to buy me a coffee

My Buy Me a Coffee page (yes, my real name is Orson…Ben Williams is a character in one of my novels)

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14 May 2022
24 Comments

You say tomat[e]o, I say toma[re]to – NDE/RED/CPRIC

Thanks again to the eternally vigilant “Z” for spotting this paper which begs the oft repeated question – are NDEs/REDs just another form of CPRIC (CPR induced consciousness)? It is a question that we have answered at length in many past posts but it is important to revisit this due to the context in which it is raised.

While Parnia is not the main author, his influence on it is present, and his work is mentioned and forms part of the analysis. The other authors are from Southmead in Bristol UK, Toronto and Cologne, Germany. Southmead Hospital has a neurology research centre associated with the University of Bristol, and I have been there a fair bit in recent years due to my work in sleep medicine and Alzheimer’s disease (work that has suddenly come to an abrupt end unfortunately due to the vagaries of government regulatory and reimbursement bodies)

https://www.sciencedirect.com/science/article/pii/S2666520422000418

Title of the paper: CPR-related cognitive activity, consciousness, awareness and recall, and its management: A scoping review

At first it seems that they are lumping NDEs/REDs in with CPR induced consciousness. From the intro:

“Two types of cognitive activity and awareness were identified [during CPR]. The first includes visible signs of consciousness such as combativeness, groaning, and eye opening and was referred to as CPR induced consciousness. The second, a perception of lucidity with visual and auditory awareness and recall without external signs of consciousness.”

This is then clarified further in the discussion:

“It could be assumed that pain and distress would be expected in patients showing overt physical signs of con- sciousness through CPR. On the other hand, there have also been cases documented where survivors experiencing more transcendental post cardiac arrest experiences whilst not showing signs of pain or distress have benefited from the experience with it having a positive impact on the patient’s life. When considering treatment options, it may be beneficial to consider these two experiences as two separate entities.”

You reckon!? I suspect that the last sentence was most likely due to Parnia’s influence as a co-author.

All of the key pieces of AWARE data published and presented to date, from I (2014) and II (2019), is included in this review, and therefore, in this paper at least, NDEs are lumped in with CPRIC as events of consciousness that occur DURING CPR – related to CPR. This last point is the most important. Association and causation are two different things, and while the first type of experience, where there are physical signs of consciousness, are undoubtedly caused by CPR, the second, RED/NDE type, is only associated in these cases with CPR. The fact that NDEs have been reported outside of the context of CPR further differentiates them from CPRIC, but this is not discussed in the paper, and these types of experience seem to have been put aside for now by Sam Parnia, most likely for very good reasons, possibly to narrow the field of research to experiences that occur in strictly defined situations with scientifically measurable outcomes.

However, despite the fact that the paper does concede that NDE type events are only associated with periods during which CPR is being conducted, you can guarantee skeptics will cite this paper as further evidence that REDs are due to physiological reasons, and nothing else.

As an aside, having lived on both sides of the pond, I can attest to the fact that you really do need to get your pronunciation of the word describing the small round red vegetable correct to be understood. I remember asking a stewardess on a flight to Ottawa for a can of tomato juice, and being a recent arrival to North America, I was still saying Toma[re]to…and despite repeating it 3 times she had no idea what I was saying. It was very strange indeed, I might as well have been asking for a football, it seemed impossible for her to make the connection between the word I was saying and the numerous cans of the substance she had right in front of her on her trolley. It was only when I said Tomat[e]o that she understood. From that point on I reluctantly adopted the local dialect when it came to certain words, particularly important due to the fact that at the time I was smoking and working in HIV (English smokers will know exactly what I am referring to!) Having returned to the UK I have managed to revert back to the mother tongue, except for the word loo…just can’t use it any more, so I still find myself saying washroom! My wife laughs at me for not returning to the British vernacular for the word toilet, despite the fact that she is a Kiwi and therefore has to juggle 3 forms of English in her head. The only concession I make on this is to use the word “bog”, which is another English word to describe toilet, but I generally do not use it other than when I am in a pub with a group of mates, since this word is not deemed polite.

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27 Jan 2018
99 Comments

Brand New Findings Revealed?

Thanks to Eduardo for picking this one up. I am extremely busy at the moment so don’t always have the time to trawl the networks for anything Parnia or NDE related, so appreciate when others email me links or post them in discussions. I felt this was worth pulling out. It was aired earlier this week on Dr Oz on January 22nd 2018. Dr Oz opens the segment with the announcement that brand new findings are going to be revealed (in the show). He then introduces Dr Parnia…well have a look yourself, click on the picture of our favorite intensive care doctor to access the video:

Parnia

Is this a sleight of hand or is there actually new data, or “brand new findings”?

Dr Parnia on one hand seems to describe the design of the most recent iteration of AWARE, AWARE II, then slips in “we did a study…” talking about the results from AWARE I. Given that he categorically stated in emails and on his Twitter feed that the results from AWARE II won’t be made public until after the study is finished in 2020, and that at this stage they have only recruited 350 or so, one can only assume that he is referring to AWARE I. However, the confidence he has in the assertions he makes seem to be growing stronger, which makes me believe that AWARE II has got some verified hits. AWARE I did not have any properly confirmed OBEs (i.e. validated sightings of pictures). There were some interesting accounts, and without doubt some real NDEs, and OBEs, but without the visual confirmation, they are nothing more than has been reported from countless other studies or independent accounts.

I do wonder why he is doing this. Is it to plug his book (Dr Oz does that at the end of the segment)? On some days he seems keen to protect the integrity of the study by not disclosing any preliminary results, but on others he does this kind of stuff. I guess there’s nothing specifically wrong with it, but from my perspective as a scientist, I do find the hyperbole attached to this format of show to be distracting and potentially tainting the credibility of the research, especially when the headlines do not match the reality. From what I can see there are no new major findings presented in this show.

As I say above, I can only assume that he is so confident now in producing paradigm shifting results, that he knows that in the long term, this will not cause any damage.

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27 Oct 2014
6 Comments

Phase II of the AWARE study announced

There was me thinking I’d wasted an awful lot of time writing a book and creating a website that had its focus of interest on the AWARE study, which appeared to be completed following the recent publication of results, when in fact the fun has only just begun. Today I received an email from the Horizon Research Foundation, one of the organizations that provided funding for the original study (link to site at bottom of post), stating that phase II had begun in the UK. This is obviously very exciting news, not least because this website now has a reason to continue to exist! In all seriousness, Dr. Parnia had told me in our recent exchange that they were looking at various options. It will be interesting to see if he is still the lead investigator given that he is now based on Long Island, NY…I will endeavor to find out.

As I mentioned in my previous post, which describes the kind of barriers I suspect that they are up against, they will need to aim to include at least 10,000 Cardiac Arrests to have any chance of a scientifically validated OBE. This is due to the fact that not many survive, and of those that do, a significant proportion would be excluded from further analysis. To boost their chances of success they should focus on areas of the hospital which had the highest incidence of CA in the first AWARE study, and increase the number of targets in these areas.

Another consideration, if they didn’t do this in the original study, would be to introduce an element of “blinding” (a term used to describe techniques of research that insure that investigators and subjects are unaware of whether an active intervention is being administered or not). This could be achieved  by insuring that the post CA interviewers were unaware of the content of the pictures in the target areas.

Finally I would like to wish the AWARE study team good luck in their noble quest to continue researching this most important of areas. The results from AWARE phase I, as well as shedding light on the difficulties of performing high quality scientific research on NDEs, have also validated the incidence of NDE (~10% of survivors) and OBE (~25% of NDEs) from earlier studies. This, along with the semi-validated OBE from AWARE I, provides further circumstantial evidence of the validity of these phenomena…my hope is that it will not to be long before this group, or others, provide incontrovertible evidence. If they do, you can be sure you will hear about it here. In the mean time I will continue to examine the implications of other emerging research on NDEs, and post any relevant insights from time to time on this blog.

 

aware logo

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18 Oct 2014
2 Comments

The Fat Lady Sings…or not.

I contacted Dr. Parnia this week to find out the fate of the AWARE study, not least because I wanted to know if there was still a possibility of proving my hypothesis or not, and this was part of his response:

“The plan is to use different resources to continue research into the areas explored during the AWARE study. As with any research endeavor one study raises questions and [opens] new avenues for further research, and AWARE is no different. The details will need to be worked out. However, I think the AWARE results have opened new areas for exploration for ourselves and others in the field. I am sorry that we cannot discuss this in more detail however we hope there will be new studies generated in the coming years.”

My understanding of this is that the AWARE study is complete, and the results published last week in Resuscitation are the final results from this study. However, this does not appear to be the end of the story, and it seems that new studies may be undertaken, using the experience the investigators gained from AWARE, to gain further insight into NDEs and hopefully one day validate OBEs.

So where does this leave my hypothesis. Just to remind you:

“Even if the AWARE study only has one or two verified OBEs, then this will prove the existence of the soul.”

Given that the AWARE study produced no scientifically validated OBEs (a subject seeing a card), you might be inclined to think that my hypothesis had been disproven, however, that would be wrong. Having now fully digested the results from the study, I have come to realize that my hypothesis was based on some very important false assumptions about the powering of AWARE.

When I originally made the hypothesis, it was based on my understanding of the study design as initially presented back in 2008. The specifics of the design were quite vague, but the wording was something along the lines of “data from about 1000 or more Cardiac Arrests (CA) would be used”. I took this to mean that there would be a 1000 or more surviving cases eligible for inclusion; that all these survivors were interviewed; and that all had the potential to see the pictures on the shelves. Using this base number of a thousand, and the fact that only 10% of survivors have an NDE, and only about 25% of those have an OBE (2.5% overall rate of OBEs), and that although the shelves might be in the room, they might not be in the right place, or the patient might not notice, or they might not remember (I reckoned about 10% of OBEs would recall seeing it), I predicted that a very small number, maybe even only a couple of those original 1000 would see the card. In other words, my hypothesis might have been more accurate if I had stated it thus:

“Given the rareness (~2.5%) of reported OBEs in subjects surviving CA, and the study’s limitations with regard to ability to insure that validation cards are reported by these subjects, the AWARE study would only need to produce an incidence of validated OBEs of 0.25% to prove the existence of NDEs.” (the 0.25% comes from my estimation that only a couple of survivors out of about 1000 would validate).

There were two assumptions that I made that were false:

  1. There would be 1000 CA survivors who were eligible for inclusion and were interviewed.
  2. All of these would be in rooms or areas with validation cards.

The reality:

  1. In spite of there being 2060 CAs, there were only 330 survivors, and of these only 101 were included in the final analysis who were both eligible and who completed the requisite interviews.
  2. Only 22% of all CAs took place in areas with validation cards…this point is exemplified by the fact that neither of the 2 subjects who reported OBEs were in one of these areas.

Two of the other assumptions I made were correct:

  1. About 10% of CA survivors report an NDE (9)
  2. 25% of people reporting an NDE report an OBE (2)

The “other” assumptions were conjecture (these basically reduce the chances of seeing and recalling a card by about 90%). However, if I had used the more accurately stated version of my hypothesis that I quote above, namely that only 0.25% of subjects who survive a CA, who were: eligible for inclusion; had been interviewed; AND who were in areas with a validation card, then this study would only produce 0.055 (0.0025 X 22) validated OBEs.

In other words, given the results as presented in the paper, and my additional assumptions about the ability of patients to see or recall validation cards if they were in the right areas, then this study only had a 1 in 18 chance of producing 1 solitary validated OBE (1/0.055). That translates to a 6% chance of this study producing a positive result.

Let’s be very generous and just drop my “other” assumptions for a moment, and instead assume that all patients who survived a CA, completed an interview and were in areas with a validation card (this would be about 22 patients – 101 X 22%) were able to see and recall that card if they had an OBE (which is about 2.5% of CA survivors according to previous studies, and indeed this study). That would mean that this study would produce 0.55 (22 X .025) subjects with a scientifically validated OBE.

To summarize the math, given the number of eligible subjects who were in areas with validation cards, and being incredibly generous with regard to the ability of these subjects to see and recall these cards if they had an OBE, at the start of this study, there was a 1 in 2 chance of producing only 1 validated OBE. Given the fact that we now know that the 2 OBEs occurred in areas without cards, the study in fact had no chance at all of producing a positive result. Ultimately this study was hopelessly underpowered (I explain powering in a previous post and in my book).

It would be easy to blame the investigators for not designing the study better, and in the first version of my book I was indeed a little harsh in this respect. However, this was the first large study of this kind, so they are allowed to be less than perfect, but more importantly, it’s hard to see, even with hindsight, how you could significantly improve the odds of insuring that all NDEs occurred in areas with the cards, and having a sufficient number of subjects who were eligible.

Going forward, if Dr. Parnia and/or other investigators are proceeding with this research, then they might want to consider the following suggestions:

  • Go over all the data from the AWARE study and identify the areas, across different hospitals, with the highest incidence of CAs
  • Recruit more centers (or run the study for longer, with the goal of recruiting sufficient eligible survivors), and place the validation cards, or some improved validation method, in these high incidence areas only
  • Maybe have more than just one validation card in each of these areas to overcome the problems I included in my other assumptions

If a study was undertaken that placed cards in areas in such a manner that 50% of all CAs took place in a validation zone (instead of just 22%), and there were sufficient cards to insure that the chances of a patient not seeing the cards were much reduced, perhaps increasing the odds of someone who has an OBE seeing and recalling the cards from about 10% (my original assumption), to a figure close to 33%, then the chances of success would be much higher, but don’t hold your breath, this ain’t gonna happen tomorrow.

In the instance that a study was designed in just such a way as to meet these criteria, then using the numbers of patients from this study who had a CA and who were eligible and interviewed 101/2060 (5%), you would need to aim to run the study for long enough to include 10,000 CAs to have a chance of capturing just 2 scientifically validated OBEs (10,000 X 50% (% CAs in validation area) X 5% (% who survived + eligible + interviewed) X 10% (% subjects who had NDE) X 25% (% of NDEs with OBE) X 33% (% who saw and remembered the card)).

10,000 Dr. Parnia! I hope you are more patient than me, either that or you are able to motivate a small army of researchers willing to take part.

Finally, I just want to restate that my hypothesis has not been disproven, and I would like to refine the wording, using the same underlying principles, in the following manner using correct assumptions:

“In the instance that a sufficiently well powered and designed study records post CA interviews with eligible CA survivors in areas equipped to validate OBEs, then an incidence rate of validated OBE of ~1% among these survivors would prove that NDEs are real. In other words, in a study that aimed to recruit 10,000 CAs, which produced 250 eligible survivors, only 2-3 would be needed to prove NDEs are real, and by inference, that the soul exists.”

Given that we are obviously only at the beginning of this journey, and relying on a renewed surge of energy from the admirable Dr. Parnia and his colleagues for this journey to even continue, I will keep posting on this blog, because even though the AWARE study might be over, this area of research and the subject of NDEs is far from dead.

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07 Oct 2014
4 Comments

As I said before…

So, I have now had a chance to review the entire paper that has been published in Resuscitation, and I hate to say it, but I told you so.

In a previous post I pointed out that it is common practice for key results to be released at conferences, and subsequent publications in journals to be a rehash of these results but with far more detail, and discussion, and that is precisely what has happened with this first full publication from the AWARE study (I say first, as I suspect that there will be more in years to come, especially given the recent sizeable grant given to the team by the Templeton foundation). This data has been presented in summary form in Dr Parnia’s book and at the American Heart Association last year.

Basically there were two NDEs which had visual or auditory recall…in other words, they saw or heard stuff. Only one of these was verifiable and involved a 57 year old man who was able to describe accurately what occurred while the resuscitation team got to work on him, and while he was fully unconscious according to the attending Health Care Professionals (HCPs) and the equipment to which he was connected. This account is as plausible as any from the hundreds, if not thousands of similar accounts that have been published in various books and scholarly journals on this subject over the past few decades.

Importantly, there were no instances where patients were able to confirm their NDE by seeing one of the objects inserted on a shelf specifically for the purpose of verifying an out of body experience (OBE). This is disappointing, but when one reads the full details from the paper, it is hardly surprising. As I discuss in my book, Aware of Aware*, the chances of anyone actually seeing one of these objects and recalling seeing it are extremely small, and now that we are able to see the full results from the study, I have come to realise they are even smaller than I originally suggested. (*available in multiple markets as a paperback or ebook at Amazon).

The numbers:

  • There were 2060 cardiac arrests that could potentially have been included in this study
  • Only 330 of these subjects survived
  • Of these 330, only 140 were eligible for further analysis
  • Of the 140, only 101 completed interviews allowing for determination of the incidence of an NDE type experience
  • Of these only 9 (9%- sound familiar?) reported sufficient core elements of the NDE scale to qualify as an NDE
  • As mentioned before, only 2 reported OBEs, one was unable to follow up due to poor health

Other noteworthy facts from the study:

  • Only 22% of the Cardiac Arrests occurred in areas that had shelves with objects installed
  • Neither of the reported OBEs occurred in these areas

The fact these numbers are very much in line with what has been stated before in other studies is reassuring as it does help to underscore the reproducability of results from NDE studies, and consistency across such measures as incidence of NDE and incidence of OBE. However, does the AWARE study say anything new of significance…answer…No. Does it prove NDEs…as much as I would like to say it does, no, it doesn’t. Does that mean that it never will…time will tell, and I suspect that eventually, due to more cases, and better techniques it will, until then we are left exactly where we were yesterday.

Finally, once again we see the figure of 10% come up. As I have mentioned and discussed in numerous posts prior to this, and I discuss in my book, this number is important and we need to ask the question, why do children experience much higher rates of NDE than adults. For reasons I have mentioned previously, it cannot just be a function of memory

While we are still waiting for hard evidence for the existence of the soul through a verified OBE/NDE, I believe those of us who already believe it, should be more concerned about the possibility that this soul we are born with can actually die, and if so, how do we avoid this outcome?

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