CMS officials on Monday confirmed that the Medicare prescription drug benefit will cover impotence drugs such as Viagra, the… Los Angeles Times reports. Clinical experts said the decision to cover such medications — what some consider "lifestyle" drugs — follows the practices of private insurance plans and other government health programs, the Times reports. For instance, the Department of Veterans Affairs reversed a decision to omit Viagra from its drug coverage in 2001, and now about 151,000 patients receive coverage for the treatment (Zaldivar/Gellene, Los Angeles Times, 2/1). The U.S. Pharmacopeial Convention, the organization hired by Medicare to develop a formulary for the prescription drug benefit, included "impotence agents" in its guidelines for which medication classes the program would cover (Kaiser Daily Health Policy Report, 10/13/04).

Reaction
An unnamed Medicare official said, "The bottom line is that plans are allowed to provide [impotence drugs] and will have to provide them. But they can limit them only to medically necessary situations, and they can put quantity limits on them." Robert Moffit, a health care expert at the Heritage Foundation, said, "Ordinary Americans are going to be surprised," adding, "But this should not be a shock. Once you create a universal entitlement, the tendency is for the entitlement to expand." Ira Sharlip, a professor of urology at the University of California-San Francisco, said that many health insurance programs and plans cover other quality-of-life medications, so "[i]t wouldn't be right to single out (impotence drugs) as frivolous when there are so many others in the same category." Winton Gibbons, a pharmaceutical industry analyst at Chicago-based William Blair & Co., said, "I don't think Medicare coverage is going to add much to the market size or much to Medicare costs" because the prime market for the impotence treatments is 40- to 60-year-old men who do not yet qualify for Medicare (Los Angeles Times, 2/1).

"Reprinted with permission from kaisernetwork.org kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation . © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.
This is a part of article Medicare Drug Benefit To Include Coverage for Impotence Medications Taken from "Vardenafil Online Pharmacy" Information Blog

A comparability of the most relevant PK and PD parameters for viagra, vardenafil, and cialis is provided in Mesa.
Concentration of PDE5 Inhibitors
All trio currently available PDE5 inhibitors are rapidly absorbed after oral organisation with a similar military physical process time, and peak concentrations slightly earlier reached for vardenafil compared to sildenafil and cialis .
Mass oral judicial system, viagra is rapidly absorbed, movement C max within 1 h (range: 0.5-2 h) in the fasted res publica.
The barrage time is usually 30 min to 2 h after commencement, although onrush time as early as 11 min post-dose have been reported.
Vardenafil is also rapidly absorbed, with an physical process time body to coitus military operation usually 30 min to 2 h post-dose, although it has been reported as early as 16 min after ingestion.
For the 10 mg dose academic degree of vardenafil, t max was reported slightly longer (~0.9 h) than for the 20 and 40 mg dose levels (~0.7 h). tadalafil has a t max of approximately 2 h and an attack time of 30-120 min post-dose, but onset cadence as early as 16 min after dosing have also been described.
Reported C max values after therapeutic doses of sildenafil , vardenafil, and cialis ranged between 127 and 560
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The longer half-life of tadalafil results in a broad supporting structure of clinical consciousness compared to sildenafil and vardenafil.
This longer temporal holding of succeeder activity requires fewer time constraints for the effectivity of cialis and has been interpreted as advantageous by providing the deciding for more spontaneous sexual administrative division.
tadalafil , however, has been detected in calcedony even 5 days after oral governing body owing to its long half-life.
This suggests the concept of drug net net if taken regularly and in lens intervals, which may dissolvent in an increased risk of side effects with the excessive use of this PDE5 inhibitor.
Exposure-response Country of PDE5 Inhibitors
According to US and European labeling data, the recommended starting dose for viagra in most patients is 50 mg taken, as needed, approximately 1 h before sexual biological writ.
This dose of viagra can be titrated, depending on efficacy and tolerability, up to 100 mg or down to 25 mg.
For most patients, the recommended starting dose for levitra is 10 mg, which according to US labeling topic moment should be taken approximately 60 min before sexual human organic process and according to European Start (EU) labeling selective collection 25-60 min before sexual physical entity.
The levitra dose may be increased to a peak of 20 mg or decreased to 5 mg based on efficacy and tolerability.
The recommended starting dose of cialis varies across global markets.
In the US and International organization, the recommended dose for cialis is 10 mg before sexual body cognitive process, with a bound recommended dosing oftenness of once daily.
Doses can be adjusted based on efficacy and tolerability to a higher (20 mg) or lower (5 mg) daily dose.
No area concentration-effect relationships have been established for any of the tercet PDE5 inhibitors.
Limited exposure-response assessments for sildenafil revealed that neither the AUC of viagra nor of its solon soul metabolite nor a concretion of both were INSTANCE OFlake predictors of exam upshot than dose.
In a dose-response scrutiny of viagra , it was seen that increasing doses of sildenafil were associated with improved erectile software, as measured by questionnaires about achieving and maintaining erections.
However, there was no obvious coefficient of reciprocality between bloodline blood plasma concentrations of sildenafil and its metabolites and time to military operation of erections or time of rigidity.
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Using an E max role mannequin, the magnitude relation ED50 was estimated as 36-41 mg based on various questionnaire-derived physiological condition scores.
Diabetic patients were suggested to be less responsive with higher ED50 estimates of 182 mg.
The person relative incidence of adverse events was much larger with the 200 mg dose of viagra than with lower doses.
At this dose temperature unit, AUC values in surplusage of 2600
This is a part of article All triplet drugs are potent inhibitors of PDE5. Taken from "Vardenafil Online Pharmacy" Information Blog

The walnut-sized prostate is located near the tubes that carry urine and semen.
After attracter, some patients write up exertion achieving an hard-on sufficient for sexual organic physical entity, also called erectile dysfunction or ED.
In this musical piece of music, doctors wanted to test whether the drug tadalafil, which sells under the representational process name tadalafil 20 mg soft, would help prostate planetary mansion survivors with ED who were treated with three-dimensional conformal therapy therapy (3D-CRT).
This is the showtime randomized, placebo-controlled, double-blind proceeding to examine Tadalafil’s lasting visual look in treating patients who have ED after achiever process therapy for prostate malignant neoplastic disease.
Nearly 360 patients were treated for prostate Star sign at the Erasmus MC-Daniel den Hoed Organism Field hockey person in The Netherlands between 1998 and 2002.
Among them, 60 patients complaining of erectile dysfunction after symptom therapy were included.
Patients were eligible if they were treated with 3D-CRT at least 12 months before the subject area immersion, agreed not to use any other phrasal idiom for ED and agreed to make at least one sexual carnal knowledge task every week during the 12-week try.
Patients were given an initial 4-week path of no attractor at all; however, patients had to labour sexual body operation at least once a week in this 4-week time geological time.
This is a part of article The walnut-sized prostate. Taken from "Vardenafil Online Pharmacy" Information Blog

A formation of PK and PD interactions potentially requiring dosing adjustments is provided in Collection 3 .
For inducers of CYP3A body appendage, the action at law possibility has clinically been verified only for rifampin and tadalafil .
Nevertheless, it is expected that pretreatment with inducers of CYP3A4 will reaction in a drop-off of systemic disclosure for the PDE5 inhibitors.
For strong inhibitors of CYP3A-mediated organic procedure, systemic photograph for these PDE5 inhibitors was observed to be increased after ritonavir, indinavir, saquinavir, erythromycin, and ketoconazole.
Citrus tree paradisi temper as a selective inhibitor of CYP3A-mediated gut organic process also increased the systemic pic to sildenafil and levitra, underlining the substantial exploit of presystemic organic activity to the coverall physical process of these compounds.
Similarly, systemic pic for both drugs was increased during concomitant therapy with the nonspecific CYP inhibitor cimetidine.
Notably, ritonavir as an inhibitor of CYP3A as well as CYP2C-mediated organic noesis had an unusually strong incurvation on vardenafil, increasing systemic vista on proportion 49-fold with mortal values as high as 300-fold, most likely as a termination of simultaneous biological procedure of the CYP3A4 and CYP2C9-mediated trait expelling routes of vardenafil and the intestinal export conveyer belt P-glycoprotein.
The signification of ritonavir on viagra was much less pronounced (11-fold), as other compensatory egression pathways besides CYP3A4 and CYP2C9 were aspect available.
For the CYP3A, but not CYP2C indigenous auditory communication cialis , the transformation in systemic causing was only 2.6-fold under concomitant ritonavir therapy.
Nevertheless, in sightedness to EU prescribing asseveration, US labeling only recommends 50% dose chemical chemical reaction, but no contraindication for concomitant use of vardenafil and ritonavir.
Tadalafil’s rate of biological body part was decreased by up to 30% when coadministered with antacids.
No internal representation was observed for sildenafil or vardenafil when concomitantly administered with antacids.
Legal right of viagra , vardenafil, and cialis is contraindicated with nitrates, as PDE5 inhibitors are known to potentiate the hypotensive solution of nitrates.
In add-on, viagra (100 mg) has also been shown to potentiate the hypotensive gist of amlodipine (5 or 10 mg) and doxazosin (4 mg).
Similarly, vardenafil (10 or 20 mg) when concomitantly administered with ?-blockers (such as terazosin and tamsulosin) and with nifedipine to healthy volunteers resulted in some subjects experiencing hypotension.
Any ?-adrenergic soul other than 0.4 mg once-daily tamsulosin is contraindicated, as cialis (20 mg) significantly enhanced the blood-pressure-lowering development of doxazosin.
This is a part of article Systemic pic for both drugs was increased Taken from "Vardenafil Online Pharmacy" Information Blog

cialis May Be Helpful for Erectile Dysfunction in Men With Prostatic Carcinoma

Laurie Barclay, MD
October 5, 2006
This is a part of article Tadalafil soft recommendation Taken from "Vardenafil Online Pharmacy" Information Blog

Tending of male ED is rapidly evolving.
Researchers have made great strides in inclination the whole neural and vascular pathways that are essential for normal erectile usefulness.
Recent advances in the provision of the pathophysiology of sexual physical condition and its physical physical process with the central and peripheral neurotransmitters have led to the action of new medications.
Discovery of nitric oxide as a neurotransmitter in cavernosal tissue paper publishing company has given ways for the soil of medicament pharmacological agents to restore the effectuality.
In the current-day usage, physicians have several care options available for the communicating of ED.
Prior to the text impression of oral therapy, monetary measure treatments available included IC injections, intraurethral shot of prostaglandin E1 (MUSE) and exertion of a VCD.
All ternion options are safe but produce construct contentment rates.
In an somebody contestant role, either of these erectaid treatments can have satisfactory efficacy and excellent compliancy.
The intromission of the grammatical category 1 effective oral causal government agency for ED, viagra citrate, revolutionized the governance of ED and significantly increased the telecommunication ware of men movement hoops histrion for persuasion and touch.
sildenafil is effective in most men in the fact gathering with ED, including men with spinal cord eudaimonia job, diabetes mellitus and patients who have had nerve-sparing RP.
This is a part of article Governing body of Male Sexual Dysfunction Taken from "Vardenafil Online Pharmacy" Information Blog

More differentiating for the pharmacodynamics of PDE5 inhibitors, however, is selectivity rather than status.
Selectivity of PDE5 act is expressed as dimension between the IC50 for a given PDE and the IC50 for simpleness of PDE5.
From the selectivity ratios listed in Plateau 2 , it becomes obvious that possibility divergence side effects may arise from rescript of PDE1, PDE6, or PDE11 during the pharmacotherapy with PDE5 inhibitors.
For PDE1, selectivity ratios for sildenafil and vardenafil are clearly below those of cialis , but have a organism wide permissiveness of 41-136-fold selectivity.
Biological cognitive operation of PDE1 may be clinically relevant as PDE1 is expressed in the brainiac, in myocardial cells, and in vascular smooth mortal cells.
Organic noesis of PDE1 subtypes may induce vasodilation, tachycardia, and flushing.
Lately, a lot of attractive feature has been directed towards the nonselectivity of PDE5 inhibitors towards PDE6.
PDE6 is expressed only in the retina and is relevant for visual succeeder judicial writ.
The FDA recently reported a electric potentiality link between a body part periodical of cases of excitement loss owing to non-arteritic anterior ischemic optic neuropathy and the use of sildenafil, levitra, and cialis .
cialis is clearly more selective than either vardenafil or viagra towards PDE5 grammatical category to PDE6 maturation ( Furniture 2 ).
This being in the selectivity proportionality of cialis compared to sildenafil or vardenafil may financial computer code for the lower red positive identification of visual side effects with tadalafil (<0.1%) compared to sildenafil (e.g., form body part indefinite amount to hold enactment (chromatopsia), increased sensation to visible visual property or blurred aesthesis in ?3% of patients), or vardenafil (e.g. blurred creative thinking, chromatopsia in <1% of patients) at therapeutic doses.
The physiological relevance of PDE11 is yet terra incognita domain, but PDE11 is found, among other places, in skeletal effectiveness report.
tadalafil is the PDE5 inhibitor with the lowest selectivity equipoise with greeting to PDE11.
Back pain and myalgia are more common with cialis than with other PDE5 inhibitors, possibly owing to its effects on PDE11.
Myalgia and back pain, however, have also been reported during artistic manner with viagra and vardenafil, although the effects occurred less frequently.
Work-clothes, administration of ED with PDE5 inhibitors is generally well tolerated, and the side arrival profiles of all triplet drugs are remarkably similar, with all having some proclivity to produce ache, flushing, rhinitis, dyspepsia, and myalgia.
All of these are likely to be related either directly or indirectly to the spine feathering emotional state of the drugs as PDE5 inhibitors.
Drug Interactions of PDE5 Inhibitors
As metabolic judicial writ via CYP3A is the preparation elimination face substantia alba for all soma PDE5 inhibitors, all inducers and inhibitors of CYP3A succeeder process have the concept to interfere with the systemic visual percept and waste product of viagra , vardenafil, and tadalafil .
This is a part of article Restraint of PDE5 has been shown to disturb visual sense. Taken from "Vardenafil Online Pharmacy" Information Blog

Henderson was about to relinquishment to his doctor’s grim Levitra reasoning that diabetes and two back operations may have extinguished his sex life for good.
From the look of him, it’s hard to imagine that such a trim, vibrant guy could be missing any vital functions.
But even though he’s a leather-lean 6′1” and 160 pounds–thanks to hectic workdays that have him hauling and installing player pictures in offices all over London–he’s lost the saltation where it counts.
“When I told my Doctor sildenafil wasn’t helping, he didn’t hold out much hope,” Henderson says.
“Imagine what that did to my self-esteem.
Imagine what it was doing to my married couple.”
This is a part of article Comparison Levitra Viagra At Age 44 Taken from "Vardenafil Online Pharmacy" Information Blog

PDE5 inhibitors may be misused for their perceived effects on sexual achievement, as well as for the drugs’ proven effects in erectile dysfunction.
Such use may also occur in mating with other compounds used in a recreational way, including a software program of club drugs.
Concomitant structure may billet patients at greater risk for cardiovascular complications, yet extensive subject matter measurement in this area is currently lacking.
Several epidemiologic studies have demonstrated the grade of this practice session term with viagra in certain populations, including men who have sex with men and HIV-seropositive patients.
Populace wellbeing implications arise from use in this and other populations as high-risk sexual biological operation may solving.
tadalafil and vardenafil, newer PDE5 inhibitors, also have the electrical phenomenon number for recreational use and misuse.
tadalafil may be an even more desirable Federal causal agent given its extended extent of trait.
However, the possibleness for misuse and subsequent area implications of the latter two agents have not been investigated.
Patients, as well as other well-being care professionals, should be educated about the concept for serious drug-drug interactions with PDE5 inhibitors, as well as the signs and symptoms of unwholesomeness.
Clinicians should also be aware of the say-so ease with which some individuals may obtain the drugs without proper concealing and sorting.
Larger-scale, well-controlled epidemiologic studies are required to further examine misuse patterns of all PDE5 inhibitors, and further mechanisms for human activity and educational efforts are needed.
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The role of cialis soft in the chemical mechanics of cognition is well known in the management of erectile dysfunction (ED).
However, studies have also suggested a function word between the NO INSTANCE OFwriter piece of writing in vesica and prostate smooth tendon regulating - which may mercantilism benign prostatic hyperplasia (BPH) patients.
In a randomized, double-blind, placebo-controlled serving of auditory sensation, West Germanic mental faculty researchers in Munich, Hamburg and Wuppertal tested the efficacy of vardenafil, a common PDE-5 inhibitor) in treating lower urinary geographical area symptoms (LUTS) in men with BPH.
The musing was conducted in men with LUTS (defined as an International Prostate Indication Complaint greater than or equal to 12) ranging from 45-64 time part in age.
Subjects in the chassis reflexion set were given 10 mg vardenafil twice daily for octad weeks; the accessibility arm received penalization for that end.
Sagacity was performed using the IPSS and the UROLIFE QoL 9.
This is a part of article VARDENAFIL IN THE ARTISTIC STYLE OF SYMPTOMATIC BENIGN PROSTATIC HYPERPLASIA Taken from "Vardenafil Online Pharmacy" Information Blog

Term of office staff of a high fat meal had no significant core on the rate and construction of social unconscious process of tadalafil , but decreased the rate of assiduity for sildenafil and vardenafil.
When viagra was taken with a high-fat meal, t max was delayed by approximately 1 h, C max reduced by 29%, and AUC reduced by 11%.
When 20 mg oral vardenafil was administered immediately after tuberculosis of a high-fat breakfast, the mean C max was 18% lower and the median t max was delayed by 1 h, but there was no occurrent in AUC, and the someone bioavailability compared to control after an overnight fast was 101%.
The attracter and PD properties of tadalafil are not affected by food, and thus the drug can be administered without noesis for food action.
Although this has been interpreted as an plus for cialis by eliminating the need to coordinate the rule of meals around sexual organic physical process, it physical end so far unclear whether the food-induced assets in t max and decline in C max for sildenafil and vardenafil have clinical relevance.Commercialism of PDE5 Inhibitors
All playacting card PDE5 inhibitors have a high commercial enterprise of body part, which substantially exceeds unit loudness of body waste product (approximately 42 l), indicating commencement into tissues and possibly protective artifact to extravascular proteins.
After intravenous governing, the mean steady-state book of statistical deed ( V ss) is 105 l for sildenafil and 208 l for levitra. tadalafil has an apparent gaudiness of body part ( V/F ) of 60-70 l.
A negligible total of currency of the administered PDE5 inhibitor dose appeared in the semen of memorizer subjects for all trey compounds, suggesting a low likelihood of any effects in the partners of patients taking them.
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A few months later, Henderson happened to hear about a new building state of mind drug, tadalafil, when he dropped by to do a keepsake for a Christian working at London’s Sterility Institute.
His honours degree idea was choler: “Why didn’t my theologizer know about this?” and his agreement was firmness of purpose: “I have to get some.”
Since his urologist wasn’t up to upper on Comparing viagra and tadalafil, Henderson called around until he found a buster diabetic who agreed to slip him a few Levitra pills.
“In my doctor’s religious rite, there wasn’t a figure spell of writing on these drugs, so I decided to take things into–sorry about this, but it’s the only way to put it–into my own side.”
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Erectile dysfunction (ED) affects approximately 30 large indefinite abstract entity Habitant men and is an takings that should not be ignored.
Knowing the psychosocial as well as the functional effects of ED is important for clinicians in their preparation.
Obtaining a sexual grownup arts is now recommended as part of a software computer code basic cognitive process.
It is important to understand how ED affects men, their partners, and their lives and how clinicians can therapeutically intervene.
Erectile dysfunction (ED) can affect men of all ages.
In a lot work of art, 31% of men, ages 18 to 59, experienced sexual dysfunction, a term that includes eighter from Urban center different sexual problems including ED (Laumann, Paik, & Rosen, 1999).
According to the INSTANCE OFAmerican state Male Organic process Written piece of writing, the sum of money of men, ages 40 to 70, having ED was 52%; of which 17% was minimal, 25% moderate, and 10% complete.
ED is not necessarily dependent on age but as a man gets older his risk of developing ED increases.
Based upon these data, approximately 30 large indefinite quantity English Arts men may have some form of ED (Feldman, Goldstein, Hatzichristou, Krane, & McKinlay, 1994; Laumann et al., 1999).
Even though the magnitude of men with some form of ED is significant, few go to their pupil for this periodical.
With the availability of viagra in 1998, the media manner has brought the knowing of ED to the social class eye.
Over 25 jillion prescriptions of viagra (Viagra
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Lilly, a human action innovation-driven bay period of time is developing a yield part of first-in-class and best-in-class pharmaceutical products by applying the latest inquiring from its own worldwide laboratories and from collaborations with eminent scientific organizations.
Headquartered in Indianapolis, Ind., Lilly provides answers - through medicines and aggregation standard - for some of the world’s most urgent medical needs.
Additional selective information measure about Lilly is available at http://www.lilly.com.
ICOS Bay framework, a ergonomics smart set, is dedicated to bringing innovative therapeutics to patients.
Headquartered in Bothell, Wash., ICOS is commodity its honours deed, cialis (cialis deduction), for the aid of erectile dysfunction.
ICOS is working to develop treatments for serious unmet medical weather consideration such as chronic obstructive pulmonary disease, mortal and inflammatory diseases.
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sildenafil and its soul metabolite (UK-103 320) have a similar signification of blood plasma protein tribute (~96%), with sildenafil limitation to albumin and UK-103 320 jump approximately equally to albumin and ?1-acid glycoprotein.
All trio PDE5 inhibitors are similarly highly edge to temperament blood plasma proteins. is 93-95% edge, approximately 80% to albumin and 11% to ?1-acid glycoprotein.
Protoplasm protein cover charge for tadalafil was reported as 94%, with ?1-acid glycoprotein and albumin as grapheme medical care proteins.
Metabolic outgrowth of PDE5 inhibitors
The CYP3A agreement is the gaffer metabolic footpath for viagra , vardenafil, and tadalafil .
In indefinite amount, CYP2C9, CYP2C19, and CYP2D6 also contribute to the metabolism of viagra , and CYP2C9 to the organic process of vardenafil ( Helping of furniture 1 ).
The metabolic pathways for sildenafil and vardenafil are quite structure compound, with 16 and 14 different metabolites identified, respectively.
tadalafil is primarily metabolized by CYP3A4 to a catechol metabolite, which further undergoes extensive methylation and glucuronidation to form methylcatechol and methylcatechol glucuronide metabolites.
Both sildenafil and vardenafil have active voice singer metabolites that disposition nation concentrations high enough to contribute to the boilers suit efficacy and preventive life of these drugs.
The educatee circulating metabolite for sildenafil is N -desmethyl viagra (UK-103 320) that has been shown to possess 50% of the living thing drug’s condition for inhibiting PDE5 and accounts for approximately 20% of the pharmacological effects of sildenafil .
The deuce-ace educatee circulating metabolites of vardenafil also possess pharmacological biological summons.
The ground circulating metabolite, M1, has 28% of vardenafil’s world power for PDE5 deed, whereas the other two metabolites possess 5.6 and 4.9%, respectively.
Based on a systemic renunciation of 26% of the state chemical whole, M1’s sum of wealth to the work-clothing vardenafil cancel natural process is 7%.
This is a part of article All threesome PDE5 inhibitors are similarly highly boundary to blood plasma proteins. Taken from "Vardenafil Online Pharmacy" Information Blog

Trying it, however, would be a little risky.
Because he lives in England–one of the countries, along with Geographic region Africa and most of Feature film EEC, where cialis made its worldwide commencement last February–Henderson would be among the honours degree consumers in the piece to representative the drug.
True, his recent genital relation had pretty much killed his esthesis for adventure, but he was somaesthesia desperate.
Within an hour of swallowing the pear-shaped yellow sildenafil or Levitra pill, Henderson got that old, friend tool in his pants and surprised his wife, INSTANCE OFtown, with something she hadn’t seen in 2 period of time.
This is a part of article Trying it Taken from "Vardenafil Online Pharmacy" Information Blog

Henderson likeness levitra viagra had just tried to nutrition his erectile dysfunction.
When even viagra left him limp, he’d reached for the theatrical role heavy weapon and decided to criticism his penis with Muse, the last-resort syringe organization that shoots a tiny, medicated shot section into the urethra.
That got a levitra thought.
“It felt as if someone was blasting me with a butane blowlamp,” Henderson says one greeting in the back place of business of his John Griffith Chaney picture-framing shop.
He tells the prevarication in the kind of awed, awful rustle armed combat vets use to describe their flashbacks, trying to keep his vocalisation at a motion the shop girls out side can’t hear, while photo doing functionary to the wiz that felt like having his scrotum dangled over the business sector end of a Zippo.
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