Contact Lens Care Workshop January, 2009

1. Contact Lens Care Workshop January, 2009 1 Evaluating the Effects of Contact Lenses, LensCases and “Soil” on Disinfection Efficacy of Contact Lens Care Products Charles Clavet, M.S.Winchester Engineering and Analytical Center, FDA

2. Contact Lens Care Workshop January, 2009 2 Purpose Previous study identified interaction between soft contact lenses and lens care products (Warburton et al. 2007) Recent outbreaks of Fusarium and Acanthamoeba keratitis of contact lens wearers using contact lens care products (multi-purpose lens care products; MPS)

3. Contact Lens Care Workshop January, 2009 3 Purpose Ophthalmic Devices Panel Meeting, June 2008: Several microbiological issues identified ISO 14729 Stand Alone Test: Effect of preservative uptake by lenses on disinfection efficacy is not addressed by current methods Measures potency of fresh solution (Best Case) Lenses not included (does not address interaction of lens with lens care product) Testing does not measure efficacy at decreased potency over time in lens cases Not “Real World”

4. Contact Lens Care Workshop January, 2009 4 Objective Obtain additional information regarding disinfection efficacy of MPS in the presence of lenses and “soil” MPS with Alexidine against Fusarium solani Absorption of Alexidine by Contact Lenses and Lens Cases and Its Effect on Disinfection Activity against Fusarium solani Warburton et al. Poster Q-426 American Society of Microbiology, 2007 2. MPS with PHMB against Staphlococcus aureus

5. Contact Lens Care Workshop January, 2009 5 Protocol to Determine Alexidine Uptake and its Effect on Biocidal Efficacy against F. solani after Various Soaking Periods This diagram illustrates the protocol used to determine alexidine uptake and its effect on biocidal efficacy against fusarium solani after various soaking periods. The lens is soaked in multipurpose solution in lens cases for various time periods. This provides an aliquot for biocidal efficacy and for chemical analysis. For biocidal efficacy, the used solution is inoculated with fusarium solani supplemented with soil following lens removal, and ISO 14729 is performed. The survivors are counted, and the log reduction is determined. For the No Lens/ multipurpose solution control, the solution is soaked in lens caes for various time periods, resulting in an aliquot for chemical analysis.This diagram illustrates the protocol used to determine alexidine uptake and its effect on biocidal efficacy against fusarium solani after various soaking periods. The lens is soaked in multipurpose solution in lens cases for various time periods. This provides an aliquot for biocidal efficacy and for chemical analysis. For biocidal efficacy, the used solution is inoculated with fusarium solani supplemented with soil following lens removal, and ISO 14729 is performed. The survivors are counted, and the log reduction is determined. For the No Lens/ multipurpose solution control, the solution is soaked in lens caes for various time periods, resulting in an aliquot for chemical analysis.

6. Contact Lens Care Workshop January, 2009 6 Lenses Studied This table depicts the lenses that were studied, and the tests which were performed. Column headings include Lens Material, Percent Water Content of Lens Material, Absorption Examined, and Multipurpose Biocidal Efficacy Tested after Soaking. Under Absorption Examined are Alexidine and Polyhexamethylene Biguanide (PHMB). Under Biocidal Efficacy Tested are Fusarium and Staphylococcus. There are five rows of lens materials; the first three are silicone hydrogels; balafilcon A (36% water) , lotrafilcon B (33% water), and galyfilcon A (47% water). The next two rows are conventional hydrogels: etafilcon A (58% water) and polymacon (38.6% water). Absorption was examined, and biocidal effiacy was tested in all cases, with the following exceptions: For galyfilcon A, PHMB, Fusarium, and alexadine were not done. For polymacon, fusarium was not done.This table depicts the lenses that were studied, and the tests which were performed. Column headings include Lens Material, Percent Water Content of Lens Material, Absorption Examined, and Multipurpose Biocidal Efficacy Tested after Soaking. Under Absorption Examined are Alexidine and Polyhexamethylene Biguanide (PHMB). Under Biocidal Efficacy Tested are Fusarium and Staphylococcus. There are five rows of lens materials; the first three are silicone hydrogels; balafilcon A (36% water) , lotrafilcon B (33% water), and galyfilcon A (47% water). The next two rows are conventional hydrogels: etafilcon A (58% water) and polymacon (38.6% water). Absorption was examined, and biocidal effiacy was tested in all cases, with the following exceptions: For galyfilcon A, PHMB, Fusarium, and alexadine were not done. For polymacon, fusarium was not done.

7. Contact Lens Care Workshop January, 2009 7 Alexidine concentration (ppm) of lens case solution after lens soaking periods This table depicts the Alexidine concentration in ppm of lens case solution after lens soaking periods. There are 9 columns. The first column is lens material. The remaining 8 columns are the lens soaking periods: 0 hours, 4 hours, 8 hours, 12 hours, 24 hours, 48 hours, 72 hours, and 7 days. The lenses tested are: balafilcon A, lotrafilcon B, etafilcon A, galyfilcon A, polymacon, empty lens case, and control/ no lenses: solution directly from bottle. For balafilcon A, the Alexidine concentration in ppm following soaking were: Not Done (ND) at 0 hours, 2.1 at 4 hours, 1.6 at 8 hours, 1.4 at 12 hours, 0.3 at 24 hours, 0.0 at 48 hours, 0.0 at 72 hours, and 0.0 at 7 days. For lotrafilcon B, the Alexidine concentration in ppm following soaking were: Not Done at 0 hours, 2.7 at 4 hours, 1.5 at 8 hours, 1.5 at 12 hours, 0.8 at 24 hours, 0.3 at 48 hours, 0.2 at 72 hours, and 0.0 at 7 days. For etafilcon A, the Alexidine concentration in ppm following soaking were: Not Done at 0 hours, 2.4 at 4 hours, 1.3 at 8 hours, 2.2 at 12 hours, 0.9 at 24 hours, 0.0 at 48 hours, 0.1 at 72 hours, and 0.2 at 7 days. For galyfilcon A, the Alexidine concentration in ppm following soaking were: Not Done at 0 hours, 2.8 at 4 hours, 1.8 at 8 hours, 1.8 at 12 hours, 1.0 at 24 hours, 0.3 at 48 hours, 0.3 at 72 hours, and 0.2 at 7 days. For polymacon, the Alexidine concentration in ppm following soaking were: Not Done at 0 hours, 2.9 at 4 hours, 2.2 at 8 hours, 2.8 at 12 hours, 1.6 at 24 hours, 1.2 at 48 hours, 1.1 at 72 hours, and 1.1 at 7 days. For Lens Case/ no lenses, the Alexidine concentration in ppm following soaking were: Not Done at 0 hours, 3.5 at 4 hours, 4.0 at 8 hours, 3.8 at 12 hours, 3.9 at 24 hours, 3.5 at 48 hours, 3.7 at 72 hours, and 3.7 at 7 days. For Control/no lenses, the Alexidine concentration in ppm following soaking were: 3.9 at 0 hours, ND at 4 hours, ND at 8 hours, ND at 12 hours, ND at 24 hours, ND at 48 hours, ND at 72 hours, and ND at 7 days. This table depicts the Alexidine concentration in ppm of lens case solution after lens soaking periods. There are 9 columns. The first column is lens material. The remaining 8 columns are the lens soaking periods: 0 hours, 4 hours, 8 hours, 12 hours, 24 hours, 48 hours, 72 hours, and 7 days. The lenses tested are: balafilcon A, lotrafilcon B, etafilcon A, galyfilcon A, polymacon, empty lens case, and control/ no lenses: solution directly from bottle. For balafilcon A, the Alexidine concentration in ppm following soaking were: Not Done (ND) at 0 hours, 2.1 at 4 hours, 1.6 at 8 hours, 1.4 at 12 hours, 0.3 at 24 hours, 0.0 at 48 hours, 0.0 at 72 hours, and 0.0 at 7 days. For lotrafilcon B, the Alexidine concentration in ppm following soaking were: Not Done at 0 hours, 2.7 at 4 hours, 1.5 at 8 hours, 1.5 at 12 hours, 0.8 at 24 hours, 0.3 at 48 hours, 0.2 at 72 hours, and 0.0 at 7 days. For etafilcon A, the Alexidine concentration in ppm following soaking were: Not Done at 0 hours, 2.4 at 4 hours, 1.3 at 8 hours, 2.2 at 12 hours, 0.9 at 24 hours, 0.0 at 48 hours, 0.1 at 72 hours, and 0.2 at 7 days. For galyfilcon A, the Alexidine concentration in ppm following soaking were: Not Done at 0 hours, 2.8 at 4 hours, 1.8 at 8 hours, 1.8 at 12 hours, 1.0 at 24 hours, 0.3 at 48 hours, 0.3 at 72 hours, and 0.2 at 7 days. For polymacon, the Alexidine concentration in ppm following soaking were: Not Done at 0 hours, 2.9 at 4 hours, 2.2 at 8 hours, 2.8 at 12 hours, 1.6 at 24 hours, 1.2 at 48 hours, 1.1 at 72 hours, and 1.1 at 7 days. For Lens Case/ no lenses, the Alexidine concentration in ppm following soaking were: Not Done at 0 hours, 3.5 at 4 hours, 4.0 at 8 hours, 3.8 at 12 hours, 3.9 at 24 hours, 3.5 at 48 hours, 3.7 at 72 hours, and 3.7 at 7 days. For Control/no lenses, the Alexidine concentration in ppm following soaking were: 3.9 at 0 hours, ND at 4 hours, ND at 8 hours, ND at 12 hours, ND at 24 hours, ND at 48 hours, ND at 72 hours, and ND at 7 days.

8. Contact Lens Care Workshop January, 2009 8 Biocidal Efficacy of Alexidine Against F. solani with Addition of “soil” After Lens Soaking Periods This table depicts the biocidal efficacy of alexidine against F. solani with the addition of soil after lens soaking periods. There are 8 columns. The first column is lens material. The next column is disinfection time (hours). The remaining 6 columns are the log reductions after the various lens soaking periods: 0 hours, 4 hours, 12 hours, 24 hours, 72 hours, and 7 days. The lenses tested are: balafilcon A, lotrafilcon B, etafilcon A, and control/ no lenses: solution directly from bottle. Disinfection times included both 4 and 24 hours. For balafilcon A/ 4 hours disinfection, the log reduction was Not Done (ND) at 0 hours, >3 at 4 hours, >3 at 12 hours, -0.6 at 24 hours, -0.7 at 72 hours, and 0.1 at 7 days. For balafilcon A/ 24 hours disinfection, the log reduction was ND at 0 hours, >3 at 4 hours, >3 at 12 hours, -1.6 at 24 hours, 0.8 at 72 hours, and 0.1 at 7 days. For lotrafilcon B/ 4 hours disinfection, the log reduction was ND at 0 hours, >3 at 4 hours, >3 at 12 hours, >3 at 24 hours, -0.3 at 72 hours, and 0.3 at 7 days. For lotrafilcon B / 24 hours disinfection, the log reduction was ND at 0 hours, >3 at 4 hours, >3 at 12 hours, >3 at 24 hours, 1.5 at 72 hours, and 2.9 at 7 days. For etafilcon A/ 4 hours disinfection, the log reduction was ND at 0 hours, >3 at 4 hours, >3 at 12 hours, >3 at 24 hours, -0.7 at 72 hours, and 0.4 at 7 days. For etafilcon A / 24 hours disinfection, the log reduction was ND at 0 hours, >3 at 4 hours, >3 at 12 hours, >3 at 24 hours, 1.3 at 72 hours, and 2.9 at 7 days. For Control – No Lenses/ 4 hours disinfection, the log reduction was >3 at 0 hours, ND at 4 hours, ND at 12 hours, ND at 24 hours, ND at 72 hours, and ND at 7 days. For Control – No Lenses / 24 hours disinfection, the log reduction was>3 at 0 hours, ND at 4 hours, ND at 12 hours, ND at 24 hours, ND at 72 hours, and ND at 7 days. This table depicts the biocidal efficacy of alexidine against F. solani with the addition of soil after lens soaking periods. There are 8 columns. The first column is lens material. The next column is disinfection time (hours). The remaining 6 columns are the log reductions after the various lens soaking periods: 0 hours, 4 hours, 12 hours, 24 hours, 72 hours, and 7 days. The lenses tested are: balafilcon A, lotrafilcon B, etafilcon A, and control/ no lenses: solution directly from bottle. Disinfection times included both 4 and 24 hours. For balafilcon A/ 4 hours disinfection, the log reduction was Not Done (ND) at 0 hours, >3 at 4 hours, >3 at 12 hours, -0.6 at 24 hours, -0.7 at 72 hours, and 0.1 at 7 days. For balafilcon A/ 24 hours disinfection, the log reduction was ND at 0 hours, >3 at 4 hours, >3 at 12 hours, -1.6 at 24 hours, 0.8 at 72 hours, and 0.1 at 7 days. For lotrafilcon B/ 4 hours disinfection, the log reduction was ND at 0 hours, >3 at 4 hours, >3 at 12 hours, >3 at 24 hours, -0.3 at 72 hours, and 0.3 at 7 days. For lotrafilcon B / 24 hours disinfection, the log reduction was ND at 0 hours, >3 at 4 hours, >3 at 12 hours, >3 at 24 hours, 1.5 at 72 hours, and 2.9 at 7 days. For etafilcon A/ 4 hours disinfection, the log reduction was ND at 0 hours, >3 at 4 hours, >3 at 12 hours, >3 at 24 hours, -0.7 at 72 hours, and 0.4 at 7 days. For etafilcon A / 24 hours disinfection, the log reduction was ND at 0 hours, >3 at 4 hours, >3 at 12 hours, >3 at 24 hours, 1.3 at 72 hours, and 2.9 at 7 days. For Control – No Lenses/ 4 hours disinfection, the log reduction was >3 at 0 hours, ND at 4 hours, ND at 12 hours, ND at 24 hours, ND at 72 hours, and ND at 7 days. For Control – No Lenses / 24 hours disinfection, the log reduction was>3 at 0 hours, ND at 4 hours, ND at 12 hours, ND at 24 hours, ND at 72 hours, and ND at 7 days.

9. Contact Lens Care Workshop January, 2009 9 Summary: Alexidine Against F. solani MPS alone + soil in cases: Concentration of Alexidine essentially constant up to 7 days

10. Contact Lens Care Workshop January, 2009 10 Summary: Alexidine Against F. solani Alexidine + Lens + Soil + Case: Concentration of Alexidine decreased from 3.9 ppm to = 0.2 ppm for all lens except polymacon (1.1 ppm at 7 days) 4 and 12 hr soak MPS effective (> 3 log reduction) against F. solani for all lens 24 hr soak MPS effective against F. solani for all lens except balafilcon A lens

11. Contact Lens Care Workshop January, 2009 11 Protocol for Determining PHMB Uptake and its Effect on Biocidal Efficacy against S. aureus after Various Soaking Periods This diagram illustrates the protocol for determining PHMB uptake and its effect on biocidal efficacy against S. aureus after various soaking periods. The lens is soaked in multipurpose solution in lens cases for various time periods. This provides an aliquot for biocidal efficacy and for chemical analysis. For biocidal efficacy, the used solution is inoculated with S. aureus and supplemented with soil following lens removal, and ISO 14729 is performed. The survivors are counted, and the log reduction is determined. For the No Lens/ multipurpose solution control, the solution is soaked in lens caes for various time periods, resulting in an aliquot for chemical analysis. This diagram illustrates the protocol for determining PHMB uptake and its effect on biocidal efficacy against S. aureus after various soaking periods. The lens is soaked in multipurpose solution in lens cases for various time periods. This provides an aliquot for biocidal efficacy and for chemical analysis. For biocidal efficacy, the used solution is inoculated with S. aureus and supplemented with soil following lens removal, and ISO 14729 is performed. The survivors are counted, and the log reduction is determined. For the No Lens/ multipurpose solution control, the solution is soaked in lens caes for various time periods, resulting in an aliquot for chemical analysis.

12. Contact Lens Care Workshop January, 2009 12 PHMB concentration (ppm) of lens case solution after lens soaking periods This table depicts PHMB concentration (ppm) of lens case solution after lens soaking periods. There are 8 columns and 6 rows. The first column is lens material. The remaining columns are the lens soaking periods, 0, 6 12, 24, 48, and 72 hours, and 7 days. The lens materials are balafilcon A, lotrafilcon B, etafilcon A, polymacon, Lens Case/ no lenses, and Control/ no lenses. For balafilcon A, the PHMB concentration (ppm) of lens case solution was Not Done (ND) at 0 hours, 0.6 at 6 hours, 0.4 at 12 hours, 0.5 at 24 hours, 0.4 at 48 hours, at 0.4 at 72 hours, and Below Limit of Detection (BL) at 7 days. For lotrafilcon B, the PHMB concentration (ppm) of lens case solution was ND at 0 hours, 1.1 at 6 hours, 1.0 at 12 hours, 0.9 at 24 hours, 1.0 at 48 hours, 0.9 at 72 hours, and 0.6 at 7 days. For etafilcon A, the PHMB concentration (ppm) of lens case solution was ND at 0 hours, 0.3 at 6 hours, 0.3 at 12 hours, 0.3 at 24 hours, BL at 48 hours, BL at 72 hours, and BL at 7 days. For polymacon, the PHMB concentration (ppm) of lens case solution was ND at 0 hours, 0.8 at 6 hours, 0.7 at 12 hours, 0.5 at 24 hours, 0.4 at 48 hours, 0.4 at 72 hours, and 0.4 at 7 days. For Lens Case – No Lenses, the PHMB concentration (ppm) of lens case solution was ND at 0 hours, 1.0 at 6 hours, 1.0 at 12 hours, 1.0 at 24 hours, 1.0 at 48 hours, 1.1 at 72 hours, and 0.6 at 7 days. For Control – No Lenses, the PHMB concentration (ppm) of lens case solution was 1.0 at 0 hours, and ND for the remaining times. This table depicts PHMB concentration (ppm) of lens case solution after lens soaking periods. There are 8 columns and 6 rows. The first column is lens material. The remaining columns are the lens soaking periods, 0, 6 12, 24, 48, and 72 hours, and 7 days. The lens materials are balafilcon A, lotrafilcon B, etafilcon A, polymacon, Lens Case/ no lenses, and Control/ no lenses. For balafilcon A, the PHMB concentration (ppm) of lens case solution was Not Done (ND) at 0 hours, 0.6 at 6 hours, 0.4 at 12 hours, 0.5 at 24 hours, 0.4 at 48 hours, at 0.4 at 72 hours, and Below Limit of Detection (BL) at 7 days. For lotrafilcon B, the PHMB concentration (ppm) of lens case solution was ND at 0 hours, 1.1 at 6 hours, 1.0 at 12 hours, 0.9 at 24 hours, 1.0 at 48 hours, 0.9 at 72 hours, and 0.6 at 7 days. For etafilcon A, the PHMB concentration (ppm) of lens case solution was ND at 0 hours, 0.3 at 6 hours, 0.3 at 12 hours, 0.3 at 24 hours, BL at 48 hours, BL at 72 hours, and BL at 7 days. For polymacon, the PHMB concentration (ppm) of lens case solution was ND at 0 hours, 0.8 at 6 hours, 0.7 at 12 hours, 0.5 at 24 hours, 0.4 at 48 hours, 0.4 at 72 hours, and 0.4 at 7 days. For Lens Case – No Lenses, the PHMB concentration (ppm) of lens case solution was ND at 0 hours, 1.0 at 6 hours, 1.0 at 12 hours, 1.0 at 24 hours, 1.0 at 48 hours, 1.1 at 72 hours, and 0.6 at 7 days. For Control – No Lenses, the PHMB concentration (ppm) of lens case solution was 1.0 at 0 hours, and ND for the remaining times.

13. Contact Lens Care Workshop January, 2009 13 Biocidal Efficacy of PHMB against S. aureus with addition of “soil” after Lens Soaking Periods This table depicts the biocidal efficacy of PHMB against S. aureus with the addition of soil after lens soaking periods. There are 7 columns and 7 rows. The columns include lens material, disinfection time, and the following lens soaking periods: 6, 12, 24, and 72 hours, and 7 days. The lens materials are balafilcon A, lotrafilcon B, etafilcon A, polymacon, Lens Case Control Plus Soil, Control (No Lenses) Plus Soil, and Control (No Lenses) Less Soil. For all lenses, disinfection time was 6 hours. For balafilcon A, the log reduction was 3.0 at 6 hours, 3.0 at 12 hours, 2.1 at 24 hours, 0.2 at 72 hours, and 0.13 at 7 days. For lotrafilcon B, the log reduction was 3.1 at 6 hours, 3.5 at 12 hours, 2.5 at 24 hours, 3.3 at 72 hours, and 2.3 at 7 days. For etafilcon A, the log reduction was 3.0 at 6 hours, 3.1 at 12 hours, 0.84 at 24 hours, -0.2 at 72 hours, and -0.16 at 7 days. For polymacon, the log reduction was 3.1 at 6 hours, 3.1 at 12 hours, 2.2 at 24 hours, 1.1 at 72 hours, and 1.4 at 7 days. For Lens Case Control Plus Soil, the log reduction was 3.2 at 6 hours, 4.0 at 12 hours, 2.6 at 24 hours, 3.9 at 72 hours, and 2.8 at 7 days. For Control (No Lenses) Plus Soil, the log reduction was 3.5 at 6 hours, >4.0 at 12 hours, 3.1 at 24 hours, 3.9 at 72 hours, and 3.2 at 7 days. For Control (No Lenses) Less Soil, the log reduction was >4.4 at 6 hours, >4.0 at 12 hours, >4.0 at 24 hours, 3.9 at 72 hours, and 4.1 at 7 days. This table depicts the biocidal efficacy of PHMB against S. aureus with the addition of soil after lens soaking periods. There are 7 columns and 7 rows. The columns include lens material, disinfection time, and the following lens soaking periods: 6, 12, 24, and 72 hours, and 7 days. The lens materials are balafilcon A, lotrafilcon B, etafilcon A, polymacon, Lens Case Control Plus Soil, Control (No Lenses) Plus Soil, and Control (No Lenses) Less Soil. For all lenses, disinfection time was 6 hours. For balafilcon A, the log reduction was 3.0 at 6 hours, 3.0 at 12 hours, 2.1 at 24 hours, 0.2 at 72 hours, and 0.13 at 7 days. For lotrafilcon B, the log reduction was 3.1 at 6 hours, 3.5 at 12 hours, 2.5 at 24 hours, 3.3 at 72 hours, and 2.3 at 7 days. For etafilcon A, the log reduction was 3.0 at 6 hours, 3.1 at 12 hours, 0.84 at 24 hours, -0.2 at 72 hours, and -0.16 at 7 days. For polymacon, the log reduction was 3.1 at 6 hours, 3.1 at 12 hours, 2.2 at 24 hours, 1.1 at 72 hours, and 1.4 at 7 days. For Lens Case Control Plus Soil, the log reduction was 3.2 at 6 hours, 4.0 at 12 hours, 2.6 at 24 hours, 3.9 at 72 hours, and 2.8 at 7 days. For Control (No Lenses) Plus Soil, the log reduction was 3.5 at 6 hours, >4.0 at 12 hours, 3.1 at 24 hours, 3.9 at 72 hours, and 3.2 at 7 days. For Control (No Lenses) Less Soil, the log reduction was >4.4 at 6 hours, >4.0 at 12 hours, >4.0 at 24 hours, 3.9 at 72 hours, and 4.1 at 7 days.

14. Contact Lens Care Workshop January, 2009 14 Summary: Polyhexamethylene Biguanide (PHMB) against S. aureus MPS alone + soil in cases: Concentration of PHMB essentially constant up to 7 days Biocidal activity (log reduction) essentially unchanged up to 7 days

15. Contact Lens Care Workshop January, 2009 15 Summary: Polyhexamethylene Biguanide (PHMB) against S. aureus PHMB + Lens +Soil + Case: Antibacterial activity > 3 log up to 12 hr soaks Etafilcon A lens: lowest PHMB concentration and lowest log reduction Lotrafilcon B lens: highest PHMB concentration and highest log reduction

16. Contact Lens Care Workshop January, 2009 16 Conclusions Alexidine and PHMB concentrations in MPS decrease over time in presence of lens Biocidal efficacy against F. solani and S. aureus decrease over time in presence of lens as early as 24 hr soak Lens material affects disinfectant concentration and biocidal efficacy Recommended soak times for MPS effective against F. solani (4 hrs) and S. aureus (6 hrs)

17. Contact Lens Care Workshop January, 2009 17 Acknowledgements Collaborators: FDA/ORA/WEAC M. Chaput, J. Gonzalez, T. To FDA/ORA/SRL: B. Henry, S. Holliday CDRH/FDA V. Hitchins, J. Hutter, A. Lucas, J. Saviola, M. Smith, K. Warburton CDC: J. Noble-Wang

18. Contact Lens Care Workshop January, 2009 18 Thank you.Questions?