injury was the onset of systemic juvenile idiopathic arthritis after vaccination with a gardasil vaccine and specifically we're only one of the issues that you have to the field or anything in his medical practice or anything like that he relied upon the pinto article as establishing the increase in sight and with exposure that's correct and let me just  clarify something he relied on his training experience in the measurement of cytokines but in terms of the pinto article what pinto was designed to do was to measure the increase in  and in the pinto experiment you have whole blood cells that are withdrawn from the twenty they're twenty four actually but twenty women in the study and then you put them in to her is from placebo versus vaccination and then you look at the vaccinated group and you say the median group versus those who got one microgram or ten micro rams and what dr mackay testified and we believe in the search for that special master miranda's completely disregarded is that in order to measure cytokine production at that point the cells have to be stimulated stimulated and into pacifically if you'll you'll look in dr mccabe discussed that and i maybe i'm wrong but my recollection was that pinto measured whether or not there was an increase doesn't establish that why was that he relied upon as the basis for his opinion that it did in fact cause an increase inside his viewpoint of the experiment was in there has to be a stimulant that's put into the assaye that's how dr mccabe explained the article in so that it's the conclusion of sin to us that they come to says that you would true that dr mckay that said there are almost too many variables to to say what exactly caused this injury he does say that but i do believe the president is that just because there are other things that could have caught that doesn't mean that the medical theory that is being proposed is not right but medical theory is one thing right so assuming you get passed from one because you've shown viable medic that period you look at the frazier article the stain li article you'll see that that's the point of this that three doses of the vexation so she is in that period in that period she manifest clinical symptoms that show up regulation of side kinds physically the ones implicated as j in those would be rash fever joint pain and what's that but with the impact of the fact that that her symptoms didn't worsen after the go in that specific instance she was on medication that would have hampered her symptoms at that point so she was on enbrel and she was going methotrexate so you would not expect to see the same up regulation of cytokines the same symptoms because she's on the very medications that are suppressing t n f alpha for example an eerily can wine and so for her she did have a flare the evidence shows she did go to physical therapy in the physical therapy records show she has a flare but is it to the degree no and the reason is because of the medication she's on her own at that time you know in terms of temporal association and i'll go back to the the the base is the seven month window is that is the time frame necessary according to the scientific literature for there to be seroconversion or immune immunogenicity after gardasil vaccination other words they have a continues on in so what you expected you would have what's called amplification dr mckay testified the amplification process during the three shot regimen so that is that process is ongoing during the timeframe process of a series of conversion it starts it at the point of vaccination or first second or third it first vaccination but it continues on in that amplification process or that as i understand it potential impact but i didn't because i didn't follow it as just saying that there could be a long time lag after one of the vaccinations and during that time link there was drop off immediately after vaccination in they don't activate again and told the next shot as i appreciate it the the immune response continues to build post shot  think is has money was that they were not done but that they in a clinical setting they are never done they're really isolated to a laboratory setting so he can see that he didn't actually have a hard evidence for creation process theory the only evidence in the record for the nessie experiencing amplification would be what what her clinical symptoms were at the time of her diagnosis in july of two thousand and eight and that would be her said rate  gathered and they rely upon things that were not supportable and yet it seems to me that the special master is going to so far out of his way to find again that kind of crime line rely upon a lot of ridiculous stuff like articles that had sample sizes that wouldn't give you any kind of typically significant results and and things that were completely irrelevant to the analysis so i think i just i just have a real hard time with the special masters that evidence that the special master found to be contradictory well the claim or the special master didn't exclude any evidence he considered everything that was submitted to him by the parties any evidence on that to analyze whether the evidence that was presented by the parties or particular petition in this case because they're trying to prove the theory was reliable and persuasive but he looked at all everything and submitted the only thinking what really exceedingly rare on a for the record it says it shows at the annual inches in range of this disease in children this is sixteen years of age if between zero point three and zero point eight out of every one hundred thousand people were children and it seems to me just to build any type of viable statistical analysis of this would involve hundreds and hundreds of thousands of individuals something that we don't have in fact the d in these cases especially the special master throw out over and over and over again because it's not statistically significant and then he somehow tries to say that comes the second time when double doubles almost nothing is still almost really the first of the bottom line in terms of if a if a certain type of condition or injury pops up after vaccination usually the first thing that comes to the mind is practitioners focus reports and in this case in the time this case tried great deal of literature the support including ten thousand other things but you know the special master in his role is the fact finder look through all the evidence didn't exclude any evidence considered everything and determined that in this case at this point in time while it's not possible we're talking about here then that would make sense but in terms of cytokines there is no indication that there was any type of ongoing elevation of cytokines to the point time when she became systemic either two or four months later after the vaccination from d that was discussed by miss o'dell that the in the pinto article it was dr a safe view that actually the vaccinated group of the of the twenty four women before there were received the c about twenty to receive vaccination months and that really was the basis i think for dr caves testimony about the time in the seven months being appropriate there is really nothing to support what he was talking about in terms of amplification his question dr became that hearing about where is the evidence to support some type of application because you know that she didn't have the symptoms immediately after vaccination and it was really no elevation of so many months after she got the second vaccination how does the claimant deal with the fact that even though there are certain tasks that to be taken to determine whether amplification is occurring because of the nature of our health care process those tests are not going to be given in a clinical sense no you almost never well i mean people go to the doctor because they have symptoms and that's the first thing you go to the doctor but that hurts the right thing doesn't help you answer her question or her seat because there's no reason this particular petition would have on of the doctor to have the cytokines tested theory until after the symptoms so it's too late rather than what their argument is their argument that there is nothing in the medical literature anywhere that would support the notion that amplification could otherwise be occurring and there's nothing in the medical literature that his case caused her adaptive innate immune systems to become just regulated in other words to get out of balance like a normal individual would after vaccination with gardasil and as a result she had this regulation that was perpetual post vaccination and that's what resulted in her development of the s j so in terms of some other points that were raised by  respondent let me just focus for a moment on the epidemiological evidence that was really required by the special master and in follow up on your comments about the specific stud increased rate or a increased rate and shae i a e a and for those reasons and for the emphasis the court placed on those we believe that they raise the burden of proof that was required by partition as a result erd and that finding deserves no deference by this court let me go on to talk to a little bit more about temple association into in just a few seconds i have left to say that