Preponderance Of Evidence Research Articles

Skilled home healthcare utilization and outcomes for older adults with dementia: A scoping review.

This study aims to summarize the existing research literature examining Medicare-skilled home health (HH) utilization and clinical outcomes for persons with dementia (PwD). We sought to answer the following questions: (1) How is dementia defined and classified in the HH literature? (2) What associations have been observed between dementia status and patterns of HH utilization? (3) What associations have been observed between dementia status and HH outcomes? Using Arksey and O'Malley's framework for scoping reviews, we searched PubMed, Google Scholar, and select relevant journals for quantitative studies conducted in the United States between 2000 and 2023 examining Medicare HH use and outcomes for PwD. We describe and compare approaches to classify dementia, identify findings related to HH utilization and outcomes supported by the preponderance of evidence, and comment on existing gaps and areas of ambiguity in the literature. Thirty-two articles met the inclusion criteria. Most used claims-based data to classify dementia, leveraged national data, and were limited to traditional Medicare beneficiaries. Studies found meaningful differences in HH utilization by dementia status; most notably, PwD were more likely to access HH without a preceding hospitalization, had longer lengths of stay, and incurred higher HH costs. Literature relating to clinical outcomes was more difficult to interpret, due to significant variation in study objectives, samples, and outcome measures which prompted more nuanced and even contradictory conclusions. There is a dearth of research identifying how specific HH care pathways (e.g., service types, visit frequency) impact outcomes for this patient population. This review supports the understanding that PwD are a unique subpopulation of HH patients who require special attention in policy development and evaluation. Critical research is needed to examine clinical outcomes in PwD further to inform practice and improve care quality.

Finance and Output Volatity During The Global Financial Crisis

This paper assesses the effectiveness of financial depth and financial inclusion in the mitigation of output volatility during the 2008-2010 Global Financial Crisis. The paper also evaluates whether finance is more effective in countries with more developed financial systems, higher levels of economic developments, sounder banking systems, and better political stability. Employing a cross-sectional dataset covering more than 100 countries, our results indicate the ability of finance in subduing output volatility during the crisis. Our evidence is also concrete in suggesting the success of finance in reducing output volatility in more financially developed, advanced, and politically stable countries. However, the evidence is unclear on whether finance is beneficial for countries characterized by low, intermediate, or high banking stability. In addition to these findings, the preponderance of evidence tends to suggest the better ability of financial usage as compared to financial access in mitigating aggregate fluctuations during the crisis. Finally, our additional analysis reveals that finance functions well in stabilizing output when output volatility is high.

State fragility, violence and trade: Dangerous trade routes in Colombia

We investigate the effect of domestic armed violence brought about by insecurity on the geography of freight mobility and the resulting differential access of regions to global markets. There is a preponderance of evidence from the micro-level analysis of Colombia-U.S. export shipping records that export freight shipping from inland regions was re-routed to avoid exposure to domestic armed violence despite extended landside and maritime shipping distances. The discrete choice model shows that the shipping flow was curbed by the extended re-routing due to localized domestic armed violence. The results highlight that security must be accommodated for sustained freight mobility and export-oriented economic development in the Global South.

Walk This Way: How Weight Distorts Gender Identification of Point-Light Walkers

Extensive research in social perception and biological motion has converged on the finding that humans are particularly accurate in identifying gender from the gait of minimal visual conspecific stimuli (e.g., point-light walkers). Despite the preponderance of evidence in favor of this ability, we return to the original paradigm and vary a single parameter—weight. Across nine pre-registered studies, participants (N = 3,196) were assigned to view the gait of point-light walkers based on actual human motion patterns. We find a decline in the accuracy of identifying the gender of female point-light walkers as their weight increases. However, as the weight of female walkers decreases, gender identification accuracy is recovered. These findings carry implications for the gendered nature of weight bias and the role of weight in human perception.

European Union civil liability frameworks in the age of artificial intelligence: Assessing current regimes and future prospects

This study intends to evaluate the suitability of the EU’s liability regimes in solving AI-related concerns by carefully examining the current legal environment. It also examines the consequences and viability of using these frameworks to consider the special features of AI technology. Furthermore, the article offers insight into the growing nature of AI liability inside the EU and its potential by thoroughly examining current regulations and evaluating the suggested revisions and proposals for prospects. Some of the questions that are the focus of the attention in the article are the burden of proof and its allocation in cases involving AI-caused damages, the standard of proof required to establish liability in AI-related cases, whether a preponderance of evidence, clear and convincing evidence, or a higher standard should be applied in different scenarios and the difficulties in establishing causation in AI-related damages. The method used in this paper will consist of conducting a comparative analysis based on the hypothesis (bearing in mind that there is no established court practice in the EU with regard to this matter) of how different jurisdictions in the EU handle liability and proof standards in AI-related cases, highlighting of any emerging trends or most suitable doctrines and practices. These questions certainly open a discussion of the potential future developments in AI liability law, considering the rapid advancements in AI technology and how legal standards might need to adapt as AI systems become more sophisticated. By focusing on these practical aspects of AI liability, this research can offer valuable insights into how the legal system can effectively address the challenges posed by AI technology and set the legal bases for fair and just outcomes for all parties involved.

Are manual therapies effective at reducing chronic tension headache frequency in adults?

MAYBE. Among patients with chronic tension headaches, manual therapies may reduce headache frequency more than sham manual therapy, usual care, or exercise treatments-by 1.5 to 4.2 headaches or days with headache per week (strength of recommendation, B; preponderance of evidence from primarily small, heterogeneous randomized controlled trials [RCTs]).

Perspective: A Research Roadmap about Ultra-Processed Foods and Human Health for the United States Food System: Proceedings from an Interdisciplinary, Multi-Stakeholder Workshop

Our objective was to convene interdisciplinary experts from government, academia, and industry to develop a Research Roadmap to identify research priorities about processed food intake and risk for obesity and cardiometabolic diseases (CMD) among United States populations. We convened attendees at various career stages with diverse viewpoints in the field. We held a “Food Processing Primer” to build foundational knowledge of how and why foods are processed, followed by presentations about how processed foods may affect energy intake, obesity, and CMD risk. Breakout groups discussed potential mechanistic and confounding explanations for associations between processed foods and obesity and CMD risk. Facilitators created research questions (RQs) based on key themes from discussions. Different breakout groups convened to discuss what is known and unknown for each RQ and to develop sub-RQs to address gaps. Workshop attendees focused on ultra-processed foods (UPFs; Nova Group 4) because the preponderance of evidence is based on this classification system. Yet, heterogeneity and subjectivity in UPF classification was a challenge for RQ development. The 6 RQs were: 1) What objective methods or measures could further categorize UPFs, considering food processing, formulation, and the interaction of the two? 2) How can exposure assessment of UPF intake be improved? 3) Does UPF intake influence risk for obesity or CMDs, independent of diet quality? 4) What, if any, attributes of UPFs influence ingestive behavior and contribute to excess energy intake? 5) What, if any, attributes of UPFs contribute to clinically meaningful metabolic responses? 6) What, if any, external environmental factors lead people to consume high amounts of UPFs? Uncertainty and complexity around UPF intake warrant further complementary and interdisciplinary causal, mechanistic, and methodological research related to obesity and CMD risk to understand the utility of applying classification by degree of processing to foods in the United States.

Melting curves of ice polymorphs in the vicinity of the liquid-liquid critical point.

The possible existence of a liquid-liquid critical point in deeply supercooled water has been a subject of debate due to the challenges associated with providing definitive experimental evidence. The pioneering work by Mishima and Stanley [Nature 392, 164-168 (1998)] sought to shed light on this problem by studying the melting curves of different ice polymorphs and their metastable continuation in the vicinity of the expected liquid-liquid transition and its associated critical point. Based on the continuous or discontinuous changes in the slope of the melting curves, Mishima [Phys. Rev. Lett. 85, 334 (2000)] suggested that the liquid-liquid critical point lies between the melting curves of ice III and ice V. We explore this conjecture using molecular dynamics simulations with a machine learning model based on abinitio quantum-mechanical calculations. We study the melting curves of ices III, IV, V, VI, and XIII and find that all of them are supercritical and do not intersect the liquid-liquid transition locus. We also find a pronounced, yet continuous, change in the slope of the melting lines upon crossing of the liquid locus of maximum compressibility. Finally, we analyze the literature in light of our findings and conclude that the scenario in which the melting curves are supercritical is favored by the most recent computational and experimental evidence. Although the preponderance of evidence is consistent with the existence of a second critical point in water, the behavior of ice polymorph melting lines does not provide strong evidence in support of this viewpoint, according to our calculations.

Ultraprocessed Foods and Obesity Risk: A Critical Review of Reported Mechanisms.

Epidemiologic evidence supports a positive association between ultraprocessed food (UPF) consumption and body mass index. This has led to recommendations to avoid UPFs despite very limited evidence establishing causality. Many mechanisms have been proposed, and this review critically aimed to evaluate selected possibilities for specificity, clarity, and consistency related to food choice (i.e., low cost, shelf-life, food packaging, hyperpalatability, and stimulation of hunger/suppression of fullness); food composition (i.e., macronutrients, food texture, added sugar, fat and salt, energy density, low-calorie sweeteners, and additives); and digestive processes (i.e., oral processing/eating rate, gastric emptying time, gastrointestinal transit time, and microbiome). For some purported mechanisms (e.g., fiber content, texture, gastric emptying, and intestinal transit time), data directly contrasting the effects of UPF and non-UPF intake on the indices of appetite, food intake, and adiposity are available and do not support a unique contribution of UPFs. In other instances, data are not available (e.g., microbiome and food additives) or are insufficient (e.g., packaging, food cost, shelf-life, macronutrient intake, and appetite stimulation) to judge the benefits versus the risks of UPF avoidance. There are yet other evoked mechanisms in which the preponderance of evidence indicates ingredients in UPFs actually moderate body weight (e.g., low-calorie sweetener use for weight management; beverage consumption as it dilutes energy density; and higher fat content because it reduces glycemic responses). Because avoidance of UPFs holds potential adverse effects (e.g., reduced diet quality, increased risk of food poisoning, and food wastage), it is imprudent to make recommendations regarding their role in diets before causality and plausible mechanisms have been verified.

Oxytocin's Regulation of Thermogenesis May Be the Link to Prader-Willi Syndrome.

Prader-Willi Syndrome (PWS) is a genetic neurodevelopmental disorder that is caused by either the deletion of the paternal allele of 15q11-q13, maternal uniparental disomy of chromosome 15 or defects in the chromosome 15 imprinting centre and is characterized by cognitive impairment, hyperphagia and low metabolic rate with significant risk of obesity, as well as a variety of other maladaptive behaviours and autistic spectrum disorder (ASD). Many of the features seen in PWS are thought to be due to hypothalamic dysfunction resulting in hormonal abnormalities and impaired social functioning. The preponderance of evidence indicates that the Oxytocin system is dysregulated in PWS individuals and that this neuropeptide pathways may provide promising targets for therapeutic intervention although the process by which this dysregulation occurs in PWS awaits mechanistic investigation. PWS individuals present abnormalities in thermoregulation an impaired detection for temperature change and altered perception of pain indicating an altered autonomic nervous system. Recent studies indicate that Oxytocin is involved in thermoregulation and pain perception. This review will describe the update on PWS and the recent discoveries on Oxytocin regulation of thermogenesis together with the potential link between Oxytocin regulation of thermogenesis and PWS to create a new groundwork for the treatment of this condition.

Vaccine Decision-making in a Time of Conflicting Recommendations: A Call to Go Beyond Politics.

Vaccine Decision-making in a Time of Conflicting Recommendations: A Call to Go Beyond Politics.

Effect of NAM on Nasal Symmetry and Proportions in Patients with UCLP: A Systematic Review

Introduction : Nasal reconstruction presents a challenge in case of patients with unilateral cleft lip and palate (UCLP). Correction of the nasal deformity to achieve a symmetrical nose from the deficient columella and malformed nasal cartilage in cleft patients presents a great challenge. Nasoalveolar molding (NAM) was developed as a neoadjuvant therapy for patients with cleft lip and palate to improve nasal deformity before surgical intervention. The aim of this systematic review was to understand more about the effect of NAM on nasal symmetry and proportions in patients with UCLP. Method : We searched for manuscripts involving patients with UCLP who received NAM prior to cleft lip repair. Electronic literature searching of the PubMed, Scopus, Cochrane and Google scholar databases was conducted for the studies that had been published up to December 2021. Result : Presurgical NAM demonstrated benefits in nasolabial form when compared with patients who did not receive any presurgical infant orthopaedic appliances (PSIO). The use of presurgical NAM helps to achieve favourable reshaping of the nose and decrease the severity of the initial cleft deformity, resulting in improvement on nasolabial form. These changes lead to improved nasal symmetry and proportions in UCLP patients. Conclusion: The preponderance of evidence in this review suggests that presurgical NAM is a beneficial adjuvant therapy for nasal deformity correction and helps achieve nasal symmetry in patients with UCLP. However, there is insufficient evidence to conclude whether presurgical NAM produces these benefits at the time of nasal maturity.

Providence and the Invention of American History by Sarah Koenig

Reviewed by: Providence and the Invention of American History by Sarah Koenig Marc James Carpenter PROVIDENCE AND THE INVENTION OF AMERICAN HISTORY by Sarah Koenig Yale University Press, New Haven and London, 2021. Photographs, notes, index. 296 pages. $45.00 cloth. In Providence and the Invention of American History, Sarah Koenig usefully brings the lens of church history to bear on early struggles over the legacy of Oregon’s pioneer past, focusing on the rise and partial fall of patriotic legends related to a particularly unsuccessful and racist missionary, Marcus Whitman. His execution by a small band of Cayuse in 1847 was used as an excuse for American settlers’ first war on Native people in Oregon; after his death, pioneers and proselytizers turned Whitman into a martyr, “a God-ordained hero of both Christianity and American expansion” (p. 13). Providential historians seeking to “envision the West as a Christian region, despite ample evidence to the contrary,” bolted increasingly unlikely patriotic deeds onto Whitman’s legacy, eventually crediting the failed missionary with having single-handedly “saved” Oregon from falling into the hands of the British (p. 15). The myths they created were subsequently disassembled by historians more reliant on documentary evidence (first regionally, then nationally), but the myth maintained as part of popular history and memory. Koenig’s book is a tightly focused monograph on the “creation, growth, and eventual disproving of the Whitman story,” framed as emblematic of “divides still present in American historical consciousness” (p. 4–5). This book is vital reading for scholars focusing on memory and historians specializing in [End Page 402] nineteenth century Oregon. The Whitman killings themselves are among the most trodden fields of historical debate in the Northwest, but Koenig breaks new ground examining the nonprofessional historians who developed, curated, and defended mythic histories of the missionary, particularly his fellow missionaries, conspiracy theorist Henry Harmon Spalding and peripatetic politician William Henry Gray. Koenig argues that Gray’s “pioneer providentialism” — the notion that Oregon was divinely ordained to be peopled by “rugged, determined individuals [who] triumph over both foreign influences and complacent structures of authority for the good of the nation and Protestant Christianity” — was influential not only in the 1860s, when Gray was a leader in setting up the earliest Pacific Northwest pioneer societies, but for decades afterwards (p. 103). Her chapter on “Selling Providence” shows how this mythmaking was adapted to popular imperial ends by the 1890s, with Whitman transformed (first by Gray and then by journalist Oliver Wood-son Nixon) from a besuited missionary martyr to a buckskin-clad rough-and-ready. Koenig traces a parallel story of Whitman debunkers, discussing a long line of scholars employing objectivity as a stance and a weapon in battles over the assertions and distortions regarding Whitman. Long before formal professionalization of American history, Koenig demonstrates, would-be historians such as Oregon Catholic missionary Jean-Baptiste Brouillet used objectivity as a “deft rhetorical move” to illuminate (or imply) the biases of critics and frame one’s own arguments as neutral (p. 72). This set of tools was available to all — the most compelling chapter of the book, “Debunking Providence,” shows how providentialists, too, used “objectivity as a matter of public performance as well as of unbiased inquiry” (p. 182). Early attackers of Whitman myths, such as local historian Francis Fuller Victor and public speaker William Isaac Marshall, had a preponderance of evidence on their side but were unable to break through until Yale historian Edward Gaylord Bourne made their research part of his definitive debunking in 1900, from a position of professional privilege. Even after being conclusively disproven, Koenig shows, the Whitman-Saved-Oregon myth and the broader practice of “pioneer providentialism” held on in popular history — preserved in local pioneer tales, regional monuments, and nationally in the speeches of President Warren Harding in the 1920s and the writings of Newt Gingrich and Pat Buchanan into the 1990s and beyond. Koenig notes that “religion is curiously absent” from many studies of Western mythology and Western history, using battles over the Whitman myths to argue that “providentialism was as significant as European intellectual currents in shaping historians’ moral visions of the American West” (p. 11). She effectively...

Does an early COPD diagnosis improve long-term outcomes?

It depends. A diagnosis of chronic obstructive pulmonary disease (COPD) made using screening spirometry in patients without symptoms does not change the course of the disease or alter smoking rates (strength of recommendation [SOR]: A, preponderance of evidence from multiple randomized controlled trials [RCTs]). However, once a patient develops symptoms of lung disease, a delayed diagnosis is associated with poorer outcomes (SOR: B, cohort studies). Active case finding (including the use of spirometry) is recommended for patients with risk factors for COPD who present with consistent symptoms (SOR: C, expert opinion).

Statistical Analysis Methods Applied to Early Outpatient COVID-19 Treatment Case Series Data

When confronted with a public health emergency, significant innovative treatment protocols can sometimes be discovered by medical doctors at the front lines based on repurposed medications. We propose a statistical framework for analyzing the case series of patients treated with such new protocols, that enables a comparison with our prior knowledge of expected outcomes, in the absence of treatment. The goal of the proposed methodology is not to provide a precise measurement of treatment efficacy, but to establish the existence of treatment efficacy, in order to facilitate the binary decision of whether the treatment protocol should be adopted on an emergency basis. The methodology consists of a frequentist component that compares a treatment group against the probability of an adverse outcome in the absence of treatment, and calculates an efficacy threshold that has to be exceeded by this probability, in order to control the corresponding p-value and reject the null hypothesis. The efficacy threshold is further adjusted with a Bayesian technique, in order to also control the false positive rate. A random selection bias threshold is then calculated from the efficacy threshold to control for random selection bias. Exceeding the efficacy threshold establishes the existence of treatment efficacy by the preponderance of evidence, and exceeding the more demanding random selection bias threshold establishes the existence of treatment efficacy by the clear and convincing evidentiary standard. The combined techniques are applied to case series of high-risk COVID-19 outpatients that were treated using the early Zelenko protocol and the more enhanced McCullough protocol.

Face Mask - Benefits and Risks during the COVID 19 among Outpatients

The public is quickly becoming more aware of the fact that wearing a face mask prevents the spread of the SARS-CoV-2 virus. The use of a mask alone is insufficient to provide an effective level of protection against COVID-19; masks should be used as part of a complete strategy of actions to suppress transmission and save lives. Keep yourself safe if COVID-19 is spreading in your neighbourhood by following a few easy safety steps, including as keeping a physical distance, donning a mask, keeping rooms well-ventilated, avoiding crowds, washing your hands, and coughing into a bent elbow or tissue. The research around the general public's usage of masks to prevent COVID-19 transmission is developing quickly. In the course of this narrative review, we create an analytical framework to understand the use of masks, synthesising the pertinent literature to provide information on a number of topics, including population impact, transmission characteristics, source control, wearer protection, sociological considerations, and implementation considerations. COVID-19 is known to spread mostly through respiratory particles, and it can spread from presymptomatic, paucisymptomatic, and asymptomatic people. Limiting connections with sick individuals by physical separation and other precautions, as well as lowering the risk of transmission per encounter, are necessary for preventing the spread of disease. The preponderance of evidence indicates that mask wearing reduces transmissibility per contact by reducing transmission of infected respiratory particles in both laboratory and clinical contexts. When compliance is high, wearing a mask in public helps to stop the infection from spreading. Given these shortages of medical masks, we recommend the adoption of public cloth mask wearing, as an efficient kind of source control, in conjunction with existing hygiene, distancing, and obtained in-tuned with tracing strategies. The aim of this paper is to analyze and critically discuss the regulations, which require protective masks in public to conform to similar regulations already in place in other countries.Self structured questionnaire was prepared and circulated among a sample size of 100 adults and the result was analysed using software IBM SPSS.

Cardiovascular Considerations for Stimulant Class Medications.

The cardiovascular (CV) impact of stimulants has been examined for decades, with investigations ranging from small sample targeted studies of heart rate (HR) and blood pressure (BP), to large scale epidemiologic investigations. The preponderance of evidence is reassuring, albeit generally based on healthy samples using variable methodology, excluding those at theoretic high risk (eg, comorbid cardiac illness). Screening for theoretically vulnerable patients are recommended, as well as monitoring for CV symptoms and BP/HR, with shared inquiry/further evaluation if concerned. Future investigations to support the identification of risk are needed, while attention to stimulant-associated CV risk is an opportunity for clinicians to engage in general CV risk identification and intervention.

Gain in quantity and novelty of work in intermittent task switching

The preponderance of evidence in the literature suggests that intermittent tasks reduce productivity and quality of work. In a task switching study, with intermittent tasks appearing once a minute or once every three minutes, we examined attention allocation and the effect of switching on the quantity and novelty of work. Self-reported estimates matched attention allocation obtained from eye fixations, indicating awareness and volitional control of attention. Arousal, quantity, and novelty of work were higher in the switching conditions in comparison to the single task condition. The findings point to the possibility of a quickening effect induced by switching that may be beneficial for work under specific task conditions.

Hypoglossal Motoneuron (XII MN) Survival Over the Lifespan in Pompe Disease

Glycogen Storage Disease II, more commonly known as Pompe disease, is a lysosomal storage disease characterized by a partial or complete loss of acid α‐glucosidase (GAA) activity. Lingual impairment and sleep disordered breathing are common symptoms of Pompe disease with a potential role of XII MN dysfunction in both cases. Through innervation of the tongue muscles, XII MNs contribute to swallowing, speech, and maintenance of upper airway patency. Studies of Pompe (Gaa‐/‐) mice have found molecular and histological markers of neurodegeneration, and a recent case study of a patient with late‐onset Pompe disease revealed atrophied and possible degenerating XII MNs. However, whether the absence of GAA activity in Pompe disease directly leads to death of XII MNs is not definitively established. Because the preponderance of evidence indicates progressive neurodegeneration in Pompe disease, here we tested the hypothesis that when XII MNs do not express GAA activity, there will be a progressive loss of these cells over the lifespan. A novel transgenic mouse model (ChAT‐cre+/+●Gaa+/‐●eYFP+/+●Flox‐Gaa+/+) was generated in which GAA activity is absent in ChAT positive neurons, which also carry a yellow fluorescent protein (YFP) marker. Thus MNs in this mouse model do not express GAA, but skeletal myofibers have normal GAA expression. Brainstem tissue was harvested in young (1‐3 months of age) and advanced age mice (21‐24 months). Tissues were cryosectioned at 20 μm increments across the entire XII motor nucleus. Sections were slide mounted and visualized under fluorescence microscopy to detect YFP. The XII motor nucleus was identified based on anatomical landmarks and MNs were identified based on location, size, morphology, and YFP fluorescence. Preliminary MN counts across the rostral‐caudal extent of the XII nucleus (n=3 per group) indicate an approximately 7% decline in detectable YFP‐positive XII MNs over the age span (young: 658±19; old 617±28). Further, the histological appearance of XII MNs showed striking differences between the two age groups. The MNs from older mice showed the prototypical hallmarks of neuronal lysosomal storage disease including a markedly enlarged soma and extensive vacuolization. These preliminary findings are consistent with the hypothesis that absence of GAA in XII MNs leads to a histopathological appearance and neurodegeneration. Ongoing studies are evaluating XII MNs in age matched wild type mice.

Transforming growth factor-β1 in regulatory T cell biology.

Transforming growth factor-β1 (TGF-β1) is inextricably linked to regulatory T cell (Treg) biology. However, precisely untangling the role for TGF-β1 in Treg differentiation and function is complicated by the pleiotropic and context-dependent activity of this cytokine and the multifaceted biology of Tregs. Among CD4+ T cells, Tregs are the major producers of latent TGF-β1 and are uniquely able to activate this cytokine via expression of cell surface docking receptor glycoprotein A repetitions predominant (GARP) and αv integrins. Although a preponderance of evidence indicates no essential roles for Treg-derived TGF-β1 in Treg immunosuppression, TGF-β1 signaling is crucial for Treg development in the thymus and periphery. Furthermore, active TGF-β1 instructs the differentiation of other T cell subsets, including TH17 cells. Here, we will review TGF-β1 signaling in Treg development and function and discuss knowledge gaps, future research, and the TGF-β1/Treg axis in the context of cancer immunotherapy and fibrosis.