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Brett Thurston said:
Oh dear ? I didn't mean to cause a family rift. I never knew frozen water could be so controversial
Worry not!
We are passionate here, and that is fine by me, as long as one remembers…?
Keith said:
Before I start, may I just say a huge thank you to Brett for adding to the gout debate in a constructive manner without abusing us with promotions for his own website. I know he is not alone in making real contributions, but he is the first website owner to start a discussion for it's own sake, and not for self-advancement.?
Well as much as I'd like to say that I am very surprised that I am the first, unfortunately I'm not surprised at all. It just seems to be the way things are on the net at the moment ? everybody looking out for themselves, and not respecting the work that others are already putting in. I don't have any right at all to come stomping in here all over Keith's work, and why others think they do is beyond me.
… Respect! All I ask really.
Keith also said:
All advisers fall into one of two camps. You either manage gout pain, or you manage it's cause ? uric acid.
I'm not quite sure that I agree with this. Mainly because I have one (gout-free) foot in each camp.
I take a view of short term pain relief, coupled with long-term uric acid reduction. Ice and NSAIDs did the trick for me during the worst times, but obviously reducing the UA levels was the chief thing I needed to do (and did do)
That is exactly correct. To be clear, I was talking about primary focus. Sensible people who believe uric acid management? is paramount, accept that pain relief is a necessary temporary measure. The other camp, and my soon-to-be-published research, suggests that it is strong and influential, regard pain relief as the only valid goal. I.e. they dismiss uric acid control as being too difficult (it's a bit more complicated than that, but that will do for now.
My conclusion on ice is that it would appear to be a serious risk factor for inducing urate deposits. As I cannot see how this would benefit a gout sufferer (beyond temporary pain relief) I cannot recommend it, especially since there are many more equally effective pain relief options. (If anyone wants to discuss these, please start new topics). I'm prepared to be open-minded about this, and would welcome more research. As I see it, the only way this research could be effective is to use DECT to measure the urate deposit effects, as no other technology can realistically assess the affect of ice within the joint.
Before I start, may I just say a huge thank you to Brett for adding to the gout debate in a constructive manner without abusing us with promotions for his own website. I know he is not alone in making real contributions, but he is the first website owner to start a discussion for it's own sake, and not for self-advancement.
Brett Thurston said:
?which is a fairly new site put up by the Arthritis Foundation, that
they mention ice as a potential treatment. I assume that they know their stuff.
I doubt that is a safe assumption. That organization serves us well in the fact that it seeks to raise the profile of gout, but we should never lose sight of the reason why it does it ? to sell more Uloric and Adenuric (febuxostat).
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However, there is no need for us to fall out about ice as a treatment for gout. All advisers fall into one of two camps. You either manage gout pain, or you manage it's cause ? uric acid.
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If your focus is on relieving gouty arthritis pain, then there is plenty of evidence, scientific and anecdotal, that ice works. Similarly, there is evidence that heat and other forms of nerve stimulation help. Distraction therapy is probably useful for many people, but amongst the best non-medical treatments for most types of pain (not just gout) is anxiety therapy. I'm still researching that one, but it seems that the thought of pain is much worse than pain itself.
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If you seek to manage uric acid, then ice is a poor choice, as it encourages uric acid to form crystals. Temperature is probably the single biggest factor in triggering gout attacks.
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Given the plethora of gout pain treatments, and my own conviction that managing uric acid is much more important than managing gout pain, then my choice is to avoid ice. Others can make there own choice, but it is vital that they understand their options, and not simply rely on Internet quotations which get repeated time and time again. It's an easy trap to fall into, and I used to list ice as a gout treatment based on the number of times it cropped up on other sites, and the Rheumatology research you mention. Thanks to the discussions in this forum, I now realize that only gout sufferers truly understand gout, so we have to try to train our doctors and other health advisers to think more clearly.
I worry a little that there might still be some under-researched information on GoutPal.com from the early days. If anyone spots anything, please let me know by starting a new discussion here.
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A final thought on the pain vs uric acid issue. I was chatting with my gouty brother-in-law over the holiday. He is firmly in the gout pain camp. “What's the point of taking a pill everyday, when I only need a few pain-killers once or twice a year?”
A perfectly valid point of view, and I imagine he'd welcome the ice pack.
The big problem with “gout diet,” and the reason for my scathing remarks about your GP, is that, once you understand gout, you realize there is no such thing. Especially in your case, where gout is likely to be hereditary. It's like referring to a “tallness diet” or a “blonde diet”.
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Gout diet usually refers to low purines, but dietary purines have a marginal? effect on gout. Most purines come from our own cell breakdown, so the main dietary effect is from excess weight, especially muscle mass.? Also excess iron is a considerable risk for gout.
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The professional response should be to engage the services of a qualified nutritionist who can assess current diet and make proper recommendations about improving diet in respect to gout. Unfortunately, nutritionists who understand gout are rare, but they should be able to come up with something if the risk factors are explained properly. In my view, advising a patient to Google “gout diet” is negligent, incompetent and ignorant.
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It is a good idea to consult a rheumatologist if there is doubt about the diagnosis, but best to insist on one with recent experience of gout, as some rheumatologists are simply not up-to-speed with current gout management, or may not have the necessary joint aspiration experience. The only pain from a joint aspiration (other than from incompetence) is the anxiety of expectation.
Thank you for your comments, and continuing support, metamorph.
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I haven't put much effort into promoting the QOL site, as I want to focus on completing the improvements to this site and GoutPal.com. I also have other projects, in various stages of completion, with a common factor being my intent to expose myths and explain facts in many areas where I find the BS to CS ratio unacceptable. (bull shit to common sense).
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I plan to summarize the most popular topics from the old Water Cooler forum on the new QOL site. I like your idea of summarizing recent discussions from that site here, so I'll add a 'Latest QOL Discussions' section similar to the 'Latest Gout Discussions' on the right.
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I'm still not 100% convinced that Quality Of Life is the best title for the kind of interesting non-gout discussions that have taken place here, but as I cannot think of anything better, it will continue as QOL.
woodster said:
?he told me it was gout as I had high uric acid levels and perhaps this would be my only flare due to my lifestyle change and I shouldn't worry about it too much, then said Google the gout diet
Google “medical negligence”
Seeing a rheumatologist might help, but you really need to sign on to a new GP. If anyone suggests Internet searching for medical advice they are a fool. If they purport to be a doctor, they are certifiable. Please post the nutter's name and location so that others in the land of cricket can avoid him.
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Uric acid control – the key to fixing gout – is not that difficult. Measure it regularly. Reduce it to safe levels with allopurinol. Simples.
jamespond said:
Sorry if what i'm asking is already in these forums – i can;t access “goutpal.com” pages, only “gout-pal.com” ones…
Sorry – now fixed.
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As for the stones, without an analysis, it's hard to know the best treatment. One reason why DECT technology is so welcome is that it allows hospitals to check stone composition in order to determine best treatment. Bicarbonate is good for urate stones, but ineffective on calcium stones.
jamespond said:
8 days continous testing – same time of day (9.00am) gives me…
7.3
7.6
6.7
7.0
8.8
6.7
4.7
6.0
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i never realised that it would vary so much !? Anyone else have the same kinda readings?
The meters do seem sensitive to droplet size – a fairly common problem until one gets totally familiar with the testing routine. Look carefully at the test strip after surprisingly low or high readings, then retest if the test area looks sparsely covered or overfilled.
jamespond said:
I decided to start at 300mg….
My first 2 readings before starting (1 week after a BAD attack and foot still feeling bruised) was 7.3, 7.6…. not bad, i thought.
Started taking Allo, then got the following daily readings (all taken 1st thing in morning).. 6.7, 7.0, 8.8, 6.7
The 8.8 threw me a little, and i wondred if taking the Allo would increase my levels in the blood, but it's back down to 6.7 this morning??
I havn't calibrated the meter yet, but took the wife's as a control test and she was 4.7 the first day, and also 4.7 the day i got my high reading… ?
Allopurinol will not increase uric acid levels in your blood, but results will vary due to many factors. Best to look at weekly averages if taken daily, monthly averages if taken weekly, etc.
I didn't realize calibrating the meter was an option. Is it necessary?
hansinnm said:
zip2play said:
…
I am going to disagree with Keith on the issue of allopurinol and body size. It seems logical to me that dosing?should depend on body mass, at least LEAN body mass.
…
Zip, I think, both, you and Keith are correct.
?You said: “Thus the bigger man>> the more food he eats>> the more purines he eats>> the more nucleic acids he breaks down>> the greater the need for allopurinol to control to safe levels.”?
I agree with you on that point. ?
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Keith said: “The correct way to use allopurinol is a 3 phase dosage, based only on uric acid numbers.”?
I agree with Keith on his point.
And I don't believe that there is much of a disagreement that the SUA level?must?be below 5 in order to live a care/flare/attack-free gouty life, regardless of weighing a 100 pounds or three hundred pounds.
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I hope the Wise One has clarified this for all allopurinol takers.
Weight is a factor.
Height is a factor.
Diet is a factor.
Climate is a factor.
Parents are a factor.
etc.
But the only way to control allopurinol dose is by uric acid test. It's only my opinion, but those that try to control dose by the weighing scale, and not the uric acid test result, are negligent.
rdavisiii said:
Short story long, cannabis is not going to help your attacks, only?controlling?your Uric Acid will do that. ?But when you have a handle on that spark it up and act like your 19 again, you will be dead before you know it and why have a bunch of hypocrites run the life you have left. ? This time is special enjoy it as much as you can. ??
Excellent advice
I've emboldened the bit you need to focus on, Green Toe.Until you control uric acid properly, there will always be times when the pain hits. Some authorities believe in just treating the pain, as it does not seem worth taking urate lowering drugs every day, when gout is only going to hurt a few days a year. I disagree strongly with this, because treating the inflammation from a gout attack just allows the underlying problem to build. Left untreated, uric acid crystals will spread throughout your body, increasing the frequency and intensity of gout attacks. The internal tophi grow into bone, tendon, and cartilage, adding osteoarthritis into the mix.
So if cannabis masks the pain and delays you from properly treating uric acid it's A Bad Thing. If it helps you get over the few months of pain that remains a risk during the early months of urate lowering therapy then it's A Good Thing.
Hi jamespond, (some type of 007 fish?
?)You are doing everything right with the gradual weight loss, the allopurinol and the meter.
Though at least 80% of doctors don't seem to get it, allopurinol is one drug at least that should never be dose adjusted based on weight.
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The correct way to use allopurinol is a 3 phase dosage, based only on uric acid numbers.
1. Target setting (titration) phase. You start with 100mg to ensure you are not in that tiny minority who are allergic ? signified by rash. Up the dosage in-line with tests every one or two weeks until you reach well below 6mg/dL. The exact number will vary from person to person according to how they react to the drug. Ideally you get down to the 2 to 3 range for a few months, but anything below 6 is OK.
2. Urate debulking phase. You maintain the uric acid level from phase 1 until you have gone 6 months without a gout flare. Tests only need to be done every 1 to 3 months, though as you have your own meter, you'll probably do more. The only thing certain about this period is that it will fix your gout, and the lower your target level is, the quicker it will happen. You cannot be certain about gout flares except to say that they may not happen, but if they do, they will get less intense and less frequent as the weeks pass. You cannot be certain about how long this debulking will take. In theory it is a product of how long you have had gout, and how low you maintain uric acid levels. Significant improvement in the first month, with a lingering tail of indeterminate length is the best guess.
3. Maintenance phase. If you managed a uric acid level of 2 to 3, then you can relax allopurinol very gradually (say 50mg between tests with at least one week between tests). Settle on a dose that keeps you between 5 and 6 for the rest of your life. With careful monitoring, studies have shown that is possible to take a 'alopurinol holiday', but this is only if you get frequent tests to make sure you never go over 6mg/dL.
As for your trip, you can see that there are no certainties. Based on percentages, you will have less chance of a gout flare in January if you start allopurinol than if you do nothing. You have to accept that, whatever you do, there is a risk of a flare for a few months. Be prepared with colchicine, or tough it out.
Like any natural source, there are many different compounds that can be extracted. The report I quoted mentions 2, and some product descriptions focus on another. Natural xanthine oxidase inhibitors are all around us in many plants, but the difficulty lies in extracting a controlled dose.
Plant extracts are a huge industry with massive investment in quality control procedures. Boiling a kettle and splashing it on a few leaves cannot come close to achieving a reliable, medical quality product. My earlier post was a tongue-in-cheek 'procedure' for the type of things that you would have to consider before attempting to use Banaba Leaf as a serious uric acid reducing tool. Surely nobody would consider this when allopurinol is so cheap, reliable and effective (when managed by the 20% of healthcare professionals who know what they are doing).
Having said that, a significant number of our visitors live in the Philippines, and may have access to banaba leaf based treatments. I must stress that it's usefulness can only be judged by it's effect on uric acid. If it is effective, then it may actually induce gout attacks in the early stages, just as Western medicine drugs like allopurinol often do. The thought of people experimenting with urate lowering preparations without realizing that lowering uric acid can cause gout flares scares me.
OK, for anyone who wants a little self-experimentation, here we go?
First, unless you have access to weekly uric acid tests from your doctor, you'll need a uric acid monitor.
Second, you need your banaba.
Amazon sell a range of banaba products.
Third, you'll need a plan. This needs to be a personalised plan to manage the 3 phases of urate lowering therapy. It's the type of thing you'd get from a caring doctor prescribing allopurinol, but if you're getting that level of care, you're unlikely to be coming here for advice. I'm sure by now that everyone knows my general approach to this 3 phase uric acid management plan, so I wont bore you again here. Once you've got the first two items, come back and we'll thrash out the numbers for the plan.
I take no responsibility if it doesn't work, or if you die.
There are lots of natural xanthine oxidase inhibitors, as a thorough search of PubMed will reveal. However, the fact that your source confuses allopurinol (uric acid lowering) with colchichine (anti-inflammatory pain relief) should set alarm bells ringing.
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The relevant research is:
J Ethnopharmacol. 2004 Aug;93(2-3):391-5.
Xanthine oxidase inhibitors from the leaves of Lagerstroemia speciosa (L.) Pers.
Unno T, Sugimoto A, Kakuda T.
Central Research Institute, ITO EN Ltd. 21 Mekami, Sagara-cho, Haibara-gun, Shizuoka 421-0516, Japan.Abstract:
Xanthine oxidase (XOD) is a key enzyme playing a role in hyperuricemia, catalyzing the oxidation of hypoxanthine to xanthine and then to uric acid. This study aimed to identify the XOD inhibitors from the leaves of Lagerstroemia speciosa (L.) Pers. (Lythraceae), which was traditionally used as a folk medicine in the Philippines. Using a bioassay-guided fractionation technique, two active compounds were isolated from the aqueous extracts of the Lagerstroemia speciosa leaves, namely valoneic acid dilactone (VAD) and ellagic acid (EA).The result demonstrated that the XOD-inhibitory effect of VAD was a stronger than that of allopurinol, a clinical drug used for XOD inhibitor, with a non-competitive mode for the enzyme with respect to xanthine as the substrate. These results may explain and support the dietary use of the aqueous extracts from Lagerstroemia speciosa leaves for the prevention and treatment of hyperuricemia.
PMID: 15234783 [PubMed – indexed for MEDLINE]
But that refers to extracts prepared in lab conditions. The practical considerations seem overwhelming to me:
- How do you control dosage?
- How do you know it is safe?
- Are there any long term health risks?
- What are the costs compared to proven uric acid lowering medications.
Having said all that, you only have a 20% chance of proper gout care at the doctors, and I know a reputable supplier, so I'll be back soon with some costings.
This topic has got too confusing. I cannot see if there are outstanding questions, or who they might belong to.
If anyone has outstanding questions, please start a new thread. If this forum is still locked due to my upgrade efforts, use the Emergency Gout Support Forum referred to in my sig below.
Before posting, please read the forum guidelines.
Please stop using the phrase “normal uric acid”
Please stop listening to doctors who use that phrase. If you have paid them money, ask for it back.
newman said:
I just drove thinking all was well …about 1400 miles. I went to sleep woke up with major pain in my knee. Drank only water and ate yogurt on the trip to avoid problems? I am new to this I had blood tests last month after similar flair from a long drive? all normal?
There is no such thing as a normal uric acid level (except in the minds of lazy incompetent medics). During early allopurinol treatment you need a target uric acid level – more below.
I had been taking alliprinol and indomecin. The pain was so bad kept me in bed for 5 days? Any ideas? 53 and not drinking booze 20 lbs overweight? High stress lately from last flair.
A water and yoghurt diet leaves you malnourished, which might cause a high enough cell turnover to raise uric acid.
Driving 1400 miles, without regular breaks to stretch the legs puts the knees and ankles at high risk of uric acid collecting and crystals forming (if uric acid is raised).
You are going to hate me for the next point (and it is something of a personal experience rather than something I've learned from gout research). Lying in bed, with affected joints immobile often extends the normal 2 to 3 days of an acute attack.
The most likely explanation however is that your attack is a perfectly normal reaction to lowering uric acid with allopurinol or other urate lowering therapies. As old urate deposits dissolve, they can cause a gout flare if partially dissolved crystals linger long enough.
The good news is that allopurinol will eventually get rid of the old crystals and gout flares will cease forever. But only if you get uric acid tested every 2 to 4 weeks for a few months to make sure your dose keeps uric acid well below 6mg/dL. Stay on that dose until you go for 6 months without a flare, then carefully relax dose to keep around 5 to 6 mg/dL.
After that, long drives should not be an issue. In the meantime, consider the following:
A well balanced, calorie controlled diet is the best thing for gout. When driving long distances, your calorie intake might need lowering slightly to reflect the lack of exercise. Do not make huge changes in diet, as these invariably cause uric acid to change suddenly. Sudden changes up or down are what usually causes a gout attack. Take a large bottle of water and drink regularly. This should induce frequent pee stops, where you must park as far away from the rest room as you can safely. Walk to the rest room, deliberately forgetting your water bottle. Walk back for your water bottle and refill it. OK, I'm rambling here, but just think of ways that suit you to incorporate as much fluid and exercise as you can.
On a final note. I know that indomethacin, or other pain relief, is quite rightly prescribed for the first few months of allopurinol. Some doctors prescribe daily use in the hope that it will prevent gout flares from old crystals dissolving. Others prefer a 'use as required' policy. Personally, I believe the second approach is best because doses that are high enough to kill gout pain in 1 or 2 days are not desirable for everyday use over several months. Discuss the dosage (and alternatives if indomethacin is not working) with your doctor to ensure that you are getting the best solution for you.
More details of numbers will allow contributors to give you better advice. In particular, I'm thinking:
- Uric acid number
- Exact weight and height
- Allopurinol dose
- Indomethacin dose
After a few weeks here, you'll wonder what all the fuss was about (and hopefully help some other gouties with your experience of how you won the gout war)
P.S. trev posted as I was writing this. Sorry for some duplication, but I guess it emphasizes the importance of numbers.
The only way to determine the acceptability of blood donations is to contact the nearest blood transfusion service.
All have different policies about what health conditions and treatments are notifiable. They also have different policies on what conditions or treatments will disbar donation.
In the interests of our collective gout knowledge, does anyone have the time to contact transfusion services and get official attitudes on the acceptability, or otherwise of gouty blood?
burgeszz said:
I am seriously considering losing weight. It's easier said than done I know first hand. I am going to stay on my Alp now and hopefully I can manage my ua level
This is exactly the best way to go, Burgess.
I sympathize with the weight loss. Very difficult, but well worth it. In the unlikely event that weight loss does not lower your uric acid, you will still gain massive benefits, as the strain on gouty knees and ankles is reduced. However, it is most likely that gradual weight loss will allow you to reduce your allopurinol dosage. For now, it gives you your best chance to get rid of the uric acid buildup whilst you find ways to lose weight.
Find a way to convince yourself that weight loss is more important to you than the next calorie. Then take it slow. Gradual weight loss is always the best way for gout sufferers, as fast weight loss generates excess uric acid. Slow and steady reductions in calorie intake coupled with slow and steady increases in gentle exercise such as walking or swimming will change your life for the better.
As a fat, lazy, beer monster, I know how hard it can be. I also know how much better you feel when there is 30 pounds less of you. Yes, it is hard to change habits of a lifetime, but changing your mindset is the start to improving your quality of life. And there are lots of very nice people round here to encourage and help you.
zip2play said:
Odo,
Thanks for filling out the Lancet reference. Good stuff. I'll bet it pissed off Takeda Pharmaceutical to read that.
I don't think it's anything new to Takeda. They are absolutely aware of the negligent way that allopurinol is prescribed. That's why they are spending $millions on flashy websites, advertising campaigns, medical seminars, etc, etc. If febuxostat isn't pushed properly, it will suffer the same fate as allopurinol – untrusted through misunderstanding and mismanagement – and the $trillions potential is lost.
They'll be pretty relaxed in the knowledge that no other dealer will have the funds to push generics in the same way. It's a mindset that's almost impossible to beat, as where we see offensive marketing strategies, they simply see any publicity as an opportunity for more deals. They also monitor this forum, so they're probably meeting now to plan more spin on this issue.
odo said:
It's an interesting, although highly technical article, which survrys recent trials and the results of new approaches to gout treatment. I think it would be worth adding to the GoutPal data base.
IF ONLY SOMEBODY WOULD TELL ME HOW!
From the other thread:
odo said:
Anyway, I have just downloaded a PDF of the latest Lancet article on new gout drugs (mainly febuxostat). I will post it if I can remember how (clues please)
Sorry, odo the method you used last time no longer works, but I'll introduce a new method soon.
In the meantime, the best way is to use a free online storage facility, upload to your public area, and link here.
@everyone: This is also great for automatic backups. I link my data storage folders to DropBox, so files are automatically backed up remotely whenever I save them. It also means I can access them from any where I can get an Internet connection.
Sorry, I sat on the pointy hat
Yes, but why can't you just set a normal scanner at 80 kiilovolts and see uric acid crystals, or the absence of them? More significantly, why can't this be applied to the decrease or increase in urate deposits as a result of treatment or lack of it? After all, I don't need a scanner to tell me I have bones.
One thing puzzles me about the DECT scan for gout. If the software depends on using different frequencies to detect uric acid, why can't a normal scanner be set to that frequency, and show the urate deposits without the contrasting bone images?
Lyndak said:
Thanks Zip, but I'm still curious about how much your UA increases during an attack. I have read in here somewhere that it does go up. If that's true, my UA may have started out nearer to 8 and the 100mg of allo hasn't helped at all….get my meaning?
I truely appreciate all the great advice I have read and received on this forum. Keep up the great work! Lynda
Lynda, there is no definite answer to this. Studies may say that uric acid levels are usually lower during an attack, as they compare the uric acid level a few days after an attack with the reading at the time of the attack. On average it tends to be lower during the attack as during that time, uric acid that would have been in the blood was busy crystalizing in your joints, therefore lowering the blood concentration.
But many other factors come into play that cause changes to uric acid test results.
Only an average of a few tests, and analysis of the trend can determine what your true dose should be. As zip2play says, it is too important to be directed by Internet chatter, though we will all welcome a report back on what your nephrologist recommends, and more impotrantly, why.
I quite understand. I first tried this a couple of years ago, but got a little fed up with the archaic interface, and the quality of the discussions. As I was browsing through my website referrals, I noticed these old answers are still sending visitors, so I took a quick look. Needless to say, I couldn't resist adding my $0.02 to some recent questions that had less than perfect answers.
I might do more from time to time, but I admit that this is driven as much by a desire to send gout sufferers in this direction as it is by altruistic desires to spread knowledge.
Yes, caveman38, you (almost certainly*) have gout.
Yes, an acute attack can stem from heavy exercise or trauma. Also cold is another common trigger.
Colchicine is an inflammatory that is fairly specific to gout and some other autoimmune inflammatory diseases. NSAIDs like ibuprofen & naproxen are also commonly used. There is no 'best' choice other than what works best for you. The inflammation will pass by itself within a few days, but new gout attacks in the meantime can prolong this.
* 'almost certainly' means you should get this confirmed by a joint fluid examination by a rheumatologist with plenty of experience. It's painless, but don't be a guineau pig for a doctor who hasn't been doing this every month for a few years. Many doctors skip this test if the diagnosis is pretty obvious, which I suspect from your description is your situation.
You should also arrange for a 24 hour urine test to measure your uric acid excretion rate. That will determine which treatment is best for you, and your doctor may consider liver test results when setting your dosage. Ideally, you aim for a few months with very low uric acid levels to flush out all the old uric acid crystals, but liver or kidney issues might regulate the speed you can do this. As long as you keep on the right side of 350, all will be well.
The real doubts begin when it comes to treatment options. Some doctors consider that you should just treat the pain, and wait until you've had years of crippling misery before prescribing uric acid lowering treatment. They are best avoided, or better still, culled.
On the uricase / pegloticase issue – Krystexxa has now been approved.
Please add your questions, experiences and opinions, on the febuxostat debate page, after reading the gout debate guidelines.
