“NHS dieticians seem to specialise in those struggling to lose (rather than gain) weight in my experience. On my initial consultation I was given a booklet with advice based on eating a full English breakfast, then snacks like doughnuts and pork pies. My sons would be thrilled to get medical advice to eat like that! The nutritional supplements they offer taste extremely artificial to me. I can only eat a little and very slowly, so get to ‘savour’ every sip of it. I’m trying protein shakes I buy myself, which taste better, but just one of those is very filling.”
Systemic lupus erythematosus is a chronic, recurrent, potentially fatal multisystem inflammatory disorder that can be difficultto diagnose.1,2 The disease has no single diagnostic marker; instead, it is identified through a combination of clinical and laboratory criteria.3 Accurate diagnosis of systemic lupus erythematosus is important because treatment can reduce morbidity4–11 and mortality,12 particularly from lupus nephritis. This article reviews evidence-based recommendations for the diagnosis of systemic lupus erythematosus by primary care physicians.
Gluten can also lead to what’s known as molecular mimicry. The gluten protein, gliadin, resembles many of your body’s own tissues, particularly thyroid tissue. If you have Celiac disease, gluten intolerance, or a leaky gut, your immune system releases gliadin antibodies every time you eat gluten. Because gliadin looks so similar to your own tissues, sometimes these antibodies mistakenly attack other organs and systems, from the skin to the thyroid to the brain. This case of mistaken identity often leads to full-blown autoimmune disease.

Fernández-Nebro A, Rúa-Figueroa Í, López-Longo FJ, Galindo-Izquierdo M, Calvo-Alén J, Olivé-Marqués A, Ordóñez-Cañizares C, Martín-Martínez MA, Blanco R, Melero-González R, Ibáñez-Rúan J, Bernal-Vidal JA, Tomero-Muriel E, Uriarte-Isacelaya E, Horcada-Rubio L, Freire-González M, Narváez J, Boteanu AL, Santos-Soler G, Andreu JL, Pego-Reigosa JM 2015, ‘Cardiovascular Events in Systemic Lupus Erythematosus: A Nationwide Study in Spain From the RELESSER Registry’, EAS-SER (Systemic Diseases Study Group of Spanish Society of Rheumatology). Medicine (Baltimore), vol. 94, no. 29, viewed 22 September 2017, https://www.ncbi.nlm.nih.gov/pubmed/26200625
Any of the plasma proteins whose concentration increases or decreases by at least 25% during inflammation. Acute-phase proteins include C-reactive protein, several complement and coagulation factors, transport proteins, amyloid, and antiprotease enzymes. They help mediate both positive and negative effects of acute and chronic inflammation, including chemotaxis, phagocytosis, protection against oxygen radicals, and tissue repair. In clinical medicine the erythrocyte sedimentation rate or serum C-reactive protein level sometimes is used as a marker of increased amounts of acute-phase proteins.
If you have osteoporosis or osteopenia, your doctor will most likely recommend that you take calcium and vitamin D supplements in addition to your regular bone medications, since vitamin D helps your body to absorb calcium. It is important that you also try to eat foods rich in calcium, such as milk, light ice cream/frozen yogurt, cottage cheese, pudding, almonds, broccoli, fortified cereal, oranges, yogurt, hard cheese, soybeans and soymilk, navy beans, oysters, sardines, and spinach. These foods will help to keep your bones as healthy and strong as possible.

Elevated expression of HMGB1 was found in the sera of people and mice with systemic lupus erythematosus, high mobility group box 1 (HMGB1) is a nuclear protein participating in chromatin architecture and transcriptional regulation. Recently, there is increasing evidence HMGB1 contributes to the pathogenesis of chronic inflammatory and autoimmune diseases due to its inflammatory and immune stimulating properties.[69]


In addition to prescribing medications, doctors may also recommend lifestyle changes to help manage lupus. These may include avoidance of sun exposure and paying more attention to managing stress to prevent lupus flares (periods of time when symptoms become problematic). People with lupus should also avoid smoking to help with heart and lung health, Kramer says.
(C) Positive finding of antiphospholipid antibodies based on (1) an abnormal serum level of IgG or IgM anticardiolipin antibodies, (2) a positive test result for lupus anticoagulant using a standard method, or (3) a false-positive serologic test for syphilis known to be positive for =6 months and confirmed by Treponema pallidum immobilization or fluorescent treponemal antibody absorption tests
Clinical studies that are no longer recruiting participants because they have enough participants already, because they are completed, or because they have been stopped for some reason. This also describes studies with very specific eligibility criteria that recruit participants by invitation only. Recruitment statuses for closed studies appear in red text in ClinicalTrials.gov search results and study records.

The word Paleo means ancient or older. The Paleo diet, as its name states, is a diet based around focusing on foods that have been eaten by humans for thousands of years during their evolution. Foods that existed before the introduction of agriculture. These foods are fresh and free of any added preservatives, mainly consisting of vegetables and meats. Paleo advocates claim that this way of eating can improve all aspects of your health, including your weight, reduction of disease activity and prevention of some chronic diseases like heart disease and type 2 diabetes. The Paleo diet provides that we should be eating what heals and supports our immune system. This diet includes diet the following diet recommendations as shown in the above graphic:


​Subacute cutaneous: The skin symptoms of subacute cutaneous lupus are usually mild. People with this condition, which is also its own form of lupus, present with reddish-purple plaques, which are firm and raised, flattened skin lesions. These plaques can be found alone or in groups and range in size from 5 mm to 20 mm, usually appearing on the trunk, including the upper chest and back. About 10 percent of people with SLE have subacute cutaneous lupus. Certain drugs may also cause subacute cutaneous lupus. 
If your CBC comes back with high numbers of RBCs or a high hematocrit, it could indicate a number of other issues including lung disease, blood cancers, dehydration, kidney disease, congenital heart disease, and other heart problems. High WBCs, called leukocytosis, may indicate an infectious disease, inflammatory disease, leukemia, stress, and more. 
Although a fever technically is any body temperature above the normal of 98.6 F (37 C), in practice, a person is usually not considered to have a significant fever until the temperature is above 100.4 F (38 C). Fever is part of the body's own disease-fighting arsenal; rising body temperatures apparently are capable of killing off many disease-producing organisms.
There are over 200 disorders that impact connective tissue. Some, like cellulitis, are the result of an infection. Injuries can cause connective tissue disorders, such as scars. Others, such as Ehlers-Danlos syndrome, Marfan syndrome, and osteogenesis imperfecta, are genetic. Still others, like scleroderma, have no known cause. Each disorder has its own symptoms and needs different treatment.

In its simplest definition, the CBC is used to measure red and white blood cell count, the total amount of hemoglobin in the blood, hematocrit (the amount of blood composed of red blood cells), and mean corpuscular volume (the size of red blood cells). The CBC can also count additional blood cell types like neutrophils, eosinophils, basophils, lymphocytes, monocytes, and platelets.
“I tend to suffer from fatigue. About a year ago I made some changes to my diet; I cut out as many processed foods as I could and now start the day with porridge with blue/red fruits (i.e. blackberries, blueberries or cranberries). I now go to bed and get up at the same times every day and I started walking everyday too. I feel much better and sleep better too.”
The mechanism by which foreign antigens are taken into antigen-presenting cells (APCs) and broken up. Part of the antigen is then displayed (presented) on the surface of the APC next to a histocompatibility or self-antigen, activating T lymphocytes and cell-mediated immunity. T lymphocytes are unable to recognize or respond to most antigens without APC assistance.
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As many as 70% of people with lupus have some skin symptoms. The three main categories of lesions are chronic cutaneous (discoid) lupus, subacute cutaneous lupus, and acute cutaneous lupus. People with discoid lupus may exhibit thick, red scaly patches on the skin. Similarly, subacute cutaneous lupus manifests as red, scaly patches of skin but with distinct edges. Acute cutaneous lupus manifests as a rash. Some have the classic malar rash (or butterfly rash) associated with the disease.[13] This rash occurs in 30 to 60% of people with SLE.[14]
Libman-Sacks endocarditis is the most characteristic cardiac manifestation of lupus. It is characterized by clusters of verrucae on the ventricular surface of the mitral valve. These lesions consist of accumulation of immune complexes, platelets, and mononuclear cells. This can lead to heart failure, valvular dysfunction, emboli, and secondary infective endocarditis. Diagnosis is best made via echocardiography, which may reveal the characteristic valvular masses (arrows). IVS = interventricular septum; LA = left atrium; LV = left ventricle.
Peripheral neuropathy describes damage to the peripheral nervous system, the vast communications network that transmits information from the brain and spinal cord (the central nervous system) to every other part of the body. Peripheral nerves also send sensory information back to the brain and spinal cord, such as a message that the feet are cold or a finger is burned. Damage to the peripheral nervous system interferes with these vital connections. Like static on a telephone line, peripheral neuropathy distorts and sometimes interrupts messages between the brain and the rest of the body.
A large randomized trial that compared induction therapy consisting of oral mycophenolate mofetil with cyclophosphamide therapy in patients with lupus nephritis showed that mycophenolate mofetil was not inferior to cyclophosphamide. [132] The investigators suggested that mycophenolate mofetil was associated with both a trend toward greater complete remissions and a greater safety profile. [132] This study’s findings were confirmed with the large, international Aspreva Lupus Management Study (ALMS) trial. [133]
“I have had severe lupus for over twenty years and find that diet doesn’t really change any symptoms. I eat meat, fish, dairy, gluten and sugar too…all in moderation. I eat lots of fruit and veg and avoid processed foods. The only thing I avoid is alcohol. I guess everyone is different but a well-balanced, healthy diet with exercise (when I’m up to it) is my formula.”
It also is known that some women with systemic lupus erythematosus can experience worsening of their symptoms prior to their menstrual periods. This phenomenon, together with the female predominance of systemic lupus erythematosus, suggests that female hormones play an important role in the expression of SLE. This hormonal relationship is an active area of ongoing study by scientists.
The discovery of the LE cell led to further research and this resulted in more definitive tests for lupus. Building on the knowledge that those with SLE had auto-antibodies that would attach themselves to the nuclei of normal cells, causing the immune system to send white blood cells to fight off these "invaders", a test was developed to look for the anti-nuclear antibody (ANA) rather than the LE cell specifically. This ANA test was easier to perform and led not only to a definitive diagnosis of lupus but also many other related diseases. This discovery led to the understanding of what are now known as autoimmune diseases.[119]
B cells obtain help from T cells in the antibody response by acting as antigen-specific antigen presenting cells. A direct signal through binding of antigen to membrane Ig can enhance B cell antigen presentation and T-dependent B cell activation, but is not required for a productive interaction between a small resting B cell and a differentiated helper T cell.
Sometimes changes in blood counts may contribute to symptoms of fatigue (low red blood cell count, anemia), serious infections (low white blood cell count), or easy bruising (low platelet count). However, many patients do not have symptoms that indicate blood abnormalities, so it is important for lupus patients to have periodic blood tests in order to detect any problems.
A clinical trial is a prospective biomedical or behavioral research study of human subjects that is designed to answer specific questions about biomedical or behavioral interventions (drugs, treatments, devices, or new ways of using known drugs, treatments, or devices). Clinical trials are used to determine whether new biomedical or behavioral interventions are safe, efficacious, and effective.

Sometimes changes in blood counts may contribute to symptoms of fatigue (low red blood cell count, anemia), serious infections (low white blood cell count), or easy bruising (low platelet count). However, many patients do not have symptoms that indicate blood abnormalities, so it is important for lupus patients to have periodic blood tests in order to detect any problems.
Below you will find that list, accompanied by questions created by the LFA to help individuals determine whether they should contact a healthcare professional to discuss the potential for having lupus. The LFA suggests discussing the possibility with a doctor if you answer “yes” to more than three of the questions, from your present and past health history.
A primary lymphoid organ located in the mediastinal cavity anterior to and above the heart, where it lies over the superior vena cava, aortic arch, and trachea. The thymus comprises two fused lobes, the right larger than the left. The lobes are partially divided into lobules, each of which has an outer cortex packed with immature and developing T lymphocytes (thymocytes) and an inner medulla containing a looser arrangement of mature T lymphocytes.
Anitphospholipid Antibodies (APLs): Phospholipids are antibodies that are present in approximately one out of every two people with lupus.  A positive test can help confirm diagnosis as well as help identify women with lupus who have certain risks (like blood clots and miscarriage) that would require preventative treatment and monitoring. Note that the presence of phospholipids also occurs in people without lupus and therefore, there presence alone is not enough for a lupus diagnosis.
At Benaroya Research Institute at Virginia Mason (BRI), research programs study the cells which regulate lupus to further understand disease pathogenesis - or the development of the disease – translating these findings into therapeutic targets. In addition, clinical trials are ongoing to evaluate novel therapies in this disease. BRI has a Clinical Research Registry people can join to learn about clinical trials that may be appropriate for them.

Angiogenesis is the growth of blood vessels from the existing vasculature. It occurs throughout life in both health and disease, beginning in utero and continuing on through old age. No metabolically active tissue in the body is more than a few hundred micrometers from a blood capillary, which is formed by the process of angiogenesis. Capillaries are needed in all tissues for diffusion exchange of nutrients and metabolites. Changes in metabolic activity lead to proportional changes in angiogenesis and, hence, proportional changes in capillarity. Oxygen plays a pivotal role in this regulation. Hemodynamic factors are critical for survival of vascular networks and for structural adaptations of vessel walls.


Jump up ^ Henderson, LA; Loring, SH; Gill, RR; Liao, KP; Ishizawar, R; Kim, S; Perlmutter-Goldenson, R; Rothman, D; Son, MB; Stoll, ML; Zemel, LS; Sandborg, C; Dellaripa, PF; Nigrovic, PA (March 2013). "Shrinking lung syndrome as a manifestation of pleuritis: a new model based on pulmonary physiological studies". The Journal of Rheumatology. 40 (3): 273–81. doi:10.3899/jrheum.121048. PMC 4112073. PMID 23378468.
The panel suggests SOC alone over adding other IS in adult patients with SLE with cutaneous manifestations (weak recommendation based on low certainty of the evidence). It also suggests adding MTX, AZA, MMF, CsA, CYC or belimumab to patients failing to respond to SOC (weak recommendation based on low to moderate certainty of the evidence). Cost and availability may favour MTX and AZA (table 1).
Lupus Erythematosus is a chronic autoimmune disease that causes the immune system to attack one’s body. The disease is characterized by the inflammation of various healthy tissues and organs in the body, including the joints, skin, kidneys, heart, lungs, blood vessels and brain. The severity of the disease may vary because no two cases of lupus are exactly alike.
Decorin is a protein coded for by the DCN gene. This protein is a component of the extracellular matrix, which is the intricate lattice of proteins and other molecules that forms in the spaces between cells. Decorin is found in the extracellular matrix of a variety of connective tissues, including skin, tendon, bone, and cartilage. Connective tissues support the body’s joints and organs. Decorin is involved in the organization of proteins called collagens. Collagens strengthen and support connective tissues throughout the body. Collagens also play an important role in the cornea, which is the clear outer covering of the eye. Bundles of collagen called fibrils must be strictly organized for the cornea to be transparent. Decorin ensures that these collagen fibrils are uniformly sized and regularly spaced.

Other tests for lupus depend on the symptoms patients are experiencing, says Kaplan. For example, chest X-rays and echocardiograms may be necessary to investigate fluid around the lungs and the heart. If doctors suspect nephritis is present, the patient may need a kidney biopsy. Early diagnosis and treatment can help to avoid complications, he adds.
Jump up ^ Johanneson, Bo; Lima, Guadalupe; von Salomé, Jenny; Alarcón-Segovia, Donato; Alarcón-Riquelme, Marta E.; Collaborative Group on the Genetics of SLE, The BIOMED II Collaboration on the Genetics of SLE and Sjögrens syndrome (2002-11-01). "A major susceptibility locus for systemic lupus erythemathosus maps to chromosome 1q31". American Journal of Human Genetics. 71 (5): 1060–1071. doi:10.1086/344289. ISSN 0002-9297. PMC 385085. PMID 12373647.
In studies conducted so far, African American patients and patients of African heritage did not appear to respond significantly to belimumab. An additional study of this patient population is planned to evaluate belimumab further in this subgroup of lupus patients. However, this difference in response to a treatment may be another indicator of the various ways that the disease affects different patients.
The theory is that eating foods that contain gut-irritating compounds causes a ‘leaky-gut’ which means that any of the non-recommended foods are not able to be digested properly, passing large pieces from the intestines directly into your blood stream.  Your body sees these as foreign substances and begins to activate the immune system which will, in turn, attack not only these substances, but the body. This, according to Paleo supporters, leads to immune disorders. The Paleo diet does exclude several large food groups and encourages a high consumption of animal fats. In some cases, this may not be the best choice for an individual’s health. Back to top

Next, a doctor will usually prescribe a corticosteroid such as prednisone, which has a variety of unpleasant and dangerous side effects. Long term prednisone therapy can cause muscle wasting and osteoporosis, and those side effects require additional monitoring and medication. If the steroids stop controlling the symptoms, then a host of other serious medications are prescribed that either modulate or suppress the immune system as a whole. Plaquenil and belimumab (Benlysta) are some of the drugs used, and they have very harsh side effects including hair loss, muscle atrophy, blood disorders and increased susceptibility to infections.


Approval for SC belimumab was based on the BLISS-SC phase III study (n=839), which documented reduction in disease activity at week 52 in patients receiving belimumab plus standard of care, compared with those receiving placebo plus standard of care. SRI response with belimumab versus placebo was 61.4% vs 48.4%, respectively (P = 0.0006). In the belimumab group, both time to and risk of severe flare were improved (median 171 days vs 118 days; P = 0.0004), and more patients were able to reduce their corticosteroid dosage by ≥25% (to ≤7.5 mg/day) during weeks 40-52 (18.2% vs 11.9%; P = 0.0732), compared with placebo. [163]
Although guidelines for SLE treatment do exist and there is scarce evidence to support specific therapies for Latin American patients with lupus,16–21 this regional effort has considered the impact of racial/ethnic background1 10 22–28 and SES3 9 on lupus outcomes and treatment response.25 26 Other medication variables such as cost and availability were also taken into account since they affect adherence and are relevant in decision-making.27 28 GLADEL and the Pan-American League of Associations of Rheumatology have joined efforts to produce these guidelines,29 which are presented by organ systems, although manifestations usually occur in more than one. Nevertheless, treatment is usually tailored to the more severe manifestation(s), which usually benefits the less severe.

Blood—hematologic disorder—hemolytic anemia (low red blood cell count), leukopenia (white blood cell count<4000/µl), lymphopenia (<1500/µl), or low platelet count (<100000/µl) in the absence of offending drug; sensitivity = 59%; specificity = 89%.[75] Hypocomplementemia is also seen, due to either consumption of C3[76] and C4 by immune complex-induced inflammation or to congenitally complement deficiency, which may predispose to SLE.
Moderate use of alcohol is usually not a problem for people with lupus, but alcohol can lower the effectiveness of some medications, cause new health problems, and/or can make existing problems worse. For example, non-steroidal anti-inflammatory drugs -- such as aspirin, ibuprofen (Motrin®), naproxen (Naprosyn®), and celecoxib (Celebrex®) -- can cause ulcers and bleeding in the stomach and intestines at any time during treatment; the chance of developing an ulcer or internal bleeding increases with alcohol use. Also, anticoagulant medicines such as warfarin (Coumadin®) and the chemotherapy drug, methotrexate, may not be as effective if you are drinking alcohol.
Disease that results when the immune system mistakenly attacks the body’s own tissues. Examples include multiple sclerosis, type 1 diabetes, rheumatoid arthritis, and systemic lupus erythematosus. Autoimmune diseases can affect almost any part of the body, including the heart, brain, nerves, muscles, skin, eyes, joints, lungs, kidneys, glands, the digestive tract, and blood vessels. The classic sign of an autoimmune disease is inflammation, which can cause redness, heat, pain, and swelling.
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Neonatal lupus erythematosus (NLE) can develop in the babies of mothers with antibodies to SSA/Ro. Neonates with NLE can present with rash around 4-6 weeks of life, elevated liver function test results, thrombocytopenia around 1-2 weeks of life, neutropenia, and hydrocephalus. [141] NLE can also manifest as a congenital atrioventricular conduction block, [142] with as many as 1-5% of pregnancies in mothers with anti- SSA/SSB antibodies leading to heart block, rising to a 6-25% risk for subsequent pregnancies after one affected child is born. [143]


I believe that we should ALL benefit from regularly working on stress relief! Take care of yourself by adopting stress-relieving strategies, such as exercise, meditation, yoga, art, or whatever works for you. The key is to choose something that you will enjoy and stick with. I personally use a heart rhythm pacer called InnerBalance, an app that coaches you to breathe in line with your heartbeat. Even giving yourself five minutes to sit quietly with a fragrant cup of herbal tea (caffeine-free, of course!) can work wonders for your adrenal glands.
16α-OH 16α-hydroxyestrone; 2-OH 2-hydroxyestrone; Akt protein kinase B; BAFF B-cell activating factor; EGCG epigallocatechin gallate; ER oestrogen receptor; EVOO extra virgin olive oil; FOXP3 forkhead box P3; I3C indole-3-carbinol; IFN interferon; LPS lipopolysaccharide; MRL Murphy Roths large; NZB/W New Zealand black/white; Nrf-2 nuclear factor E2-related factor 2; SLE systemic lupus erythematosus; Th T-helper; Treg regulatory T-cell; dsDNA double-stranded DNA; ppm parts per million; Diet; Immunomodulation; Lupus; Nutrients; Systemic lupus erythematosus
Madeline Gilkes focused her research project for her Master's of Healthcare Leadership on Health Coaching for Long-Term Weight Loss in Obese Adults. She also has a Graduate Certificate in Adult & Vocational Education, Graduate Certificate in Aged Care, Bachelor of Nursing, Certificate IV Weight Management and Certificate IV Frontline Management. Madeline is an academic and registered nurse. Her vision is to prevent lifestyle diseases, obesogenic environments, dementia and metabolic syndrome. She has spent the past years in the role of Clinical Facilitator and Clinical Nurse Specialist (Gerontology and Education).

A healthy diet is important in general, but perhaps even more so for the roughly 1 million Americans and 3 million people worldwide who suffer from systemic lupus erythematosus (SLE).1 Because of the multifaceted challenges presented by the disease, consuming adequate amounts of the right nutrients — and limiting others — can help relieve symptoms and improve outcomes.


There is no single test to definitively diagnose lupus, and it could take months or even years to be sure. Typically, your doctor will conduct a complete medical history and physical exam, including blood tests. The doctor may also perform skin and kidney biopsies (extracting tissue samples that are then examined under a microscope) to make a diagnosis.
A biopsy is a procedure that removes a small piece of living tissue from your body. The tissue is examined with a microscope for signs of damage or disease. Biopsies can be done on all parts of the body. A biopsy is the only test that can tell for sure if a suspicious area is cancer. But biopsies are performed for many other reasons too. There are different ways to do a biopsy. A needle biopsy removes tissue with a needle passed through your skin to the site of the problem. Other kinds of biopsies require surgery.
Opportunistic infections can develop, most often in patients receiving chronic immunosuppressive therapy. Another less-common complication is osteonecrosis, especially of the hips and knees after prolonged high-dose corticosteroid usage. More commonly, premature atherosclerotic disease and myocardial infarction are indolent complications of chronic inflammation and steroids.
EULAR recommendations for the management of SLE with neuropsychiatric manifestations support the evaluation and treatment of these symptoms in the same way as they are evaluated and treated in patients without SLE; if symptoms persist, management of these symptoms as an extension of SLE should be considered. [83, 61] For example, in patients with neuropsychiatric manifestations that may have an inflammatory etiology, immunosuppressive agents may be considered. [61]
Donna Jackson Nakazawa, researcher, writer, and author of The Autoimmune Epidemic, says "patients with lupus do better if they follow an 'anti-autoimmune diet,' which means consuming whole foods, rather than processed foods. This means lamb, chicken, or turkey; fish with low mercury content; hormone-free eggs; organic vegetables and fresh fruits; whole grains from gluten-free sources; nuts and seeds; and olive, sesame, and flaxseed oils. It also means avoiding highly processed foods, including preserved bread products, cereals and snacks, preserved meats, and other foods that are often full of chemicals, preservatives, and additives."
Painless passage of blood or protein in the urine may often be the only presenting sign of kidney involvement. Acute or chronic renal impairment may develop with lupus nephritis, leading to acute or end-stage kidney failure. Because of early recognition and management of SLE, end-stage renal failure occurs in less than 5%[27][28] of cases; except in the black population, where the risk is many times higher.
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Kidney inflammation in SLE (lupus nephritis) can cause leakage of protein into the urine, fluid retention, high blood pressure, and even kidney failure. This can lead to further fatigue and swelling (edema) of the legs and feet. With kidney failure, machines are needed to cleanse the blood of accumulated waste products in a process called dialysis.

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