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According to researchers at the Mayo Clinic in Rochester, Minnesota, rheumatoid arthritis (RA) appears to be increasing in women after 40 years of decline. In a report that was published earlier this year, researchers from the National Arthritis Data Workgroup stated that an estimated 1.3 million adults in the U.S. are affected by RA. This compares to the estimate of 2.1 million in 1995. However, the group decided to take a look at more recent data than that used for the Workgroup study. To this end, they recruited 350 patients with RA in Olmstead County, Minnesota that were diagnosed between…

Rheumatoid arthritis (RA) is an autoimmune disease that causes the body’s immune system to attack itself. Many treatments have been investigated that would control or suppress the body’s immune system. Anti tumor necrosis factor (TNF) drugs are immune system suppressants that are widely used to treat RA. A new study conducted by researchers at the Medical Research Council’s Laboratory of Molecular Biology in Cambridge has resulted in a breakthrough in the understanding of how autoimmune responses can be controlled. In a normal immune system, the body develops immune cells to recognize…

Many in the medical community still believe that fibromyalgia is a psychological condition since there have been no distinct causes found for the condition. In fact it has been called the “invisible syndrome” because it cannot be diagnosed using X-ray or lab tests. But a new brain scan study has found a common factor in fibromyalgia patients. Researchers from the Centre Hospitalo-Universitaire de la Timone, in Marseille, France, took brain scans of 20 female fibromyalgia patients and 10 without the condition. They also had the participants provide information to measure anxiety,…

On Wednesday’s post I reported on a study that indicated that people with rheumatoid arthritis (RA) were more likely to have cardiac problems that people without RA. In that study the researchers believed the increased cardiac risk was related to a condition known as diastolic dysfunction. Diastolic dysfunction is a condition where the there is stiffening in the heart which leads to problems with proper circulation of blood. Blood can actually spill backwards through the heart and into the lungs. In a third study reported on at last week’s American College of Rheumatology’s (ACR) annual…

I wrote on Monday about a study presented at the American College of Rheumatology’s (ACR) annual meeting in San Francisco. In that research study, a graduate student from Sweden found that people with rheumatoid arthritis (RA) had nearly twice the risk of heart attack and death from heart attack of those without RA. Another research study presented at ACR meeting also indicates that people with RA have an increased risk of heart problems as those without RA. The researchers in this study, led by Dr. Hilal Maradit Kremers, found that a condition known as diastolic dysfunction can lead to…

Title: Panel: Toughen Dermal Filler WarningsCategory: Health NewsCreated: 11/19/2008Last Editorial Review: 11/19/2008

Title: Rheumatoid Arthritis Exercises SlideshowCategory: SlideshowsCreated: 11/13/2008Last Editorial Review: 11/14/2008

Title: New Therapy Could Transform Arthritis TreatmentCategory: Health NewsCreated: 11/14/2008 2:00:00 AMLast Editorial Review: 11/14/2008

Title: Rheumatoid Arthritis Pictures SlideshowCategory: SlideshowsCreated: 11/10/2008Last Editorial Review: 11/13/2008

Title: Health Tip: Exercise to Beat Arthritis PainCategory: Health NewsCreated: 11/13/2008 2:00:00 AMLast Editorial Review: 11/13/2008

The University of Alabama at Birmingham (UAB) Center for Education and Research on Therapeutics (CERTs) has won a $2.2 million federal grant to study the risks and benefits of a newer class of medicines called biologics. These are genetically engineered therapies that target the immune system of patients who have rheumatoid arthritis, Crohn's disease, psoriasis and other autoimmune disorders.

Johns Hopkins Researchers at Neuroscience 2008 - Table grapes are high in flavonoids, which are thought to have strong antioxidant and anti-inflammatory properties. Now, researchers at the Johns Hopkins University School of Medicine have shown that powdered grapes appear to reduce pain and inflammation in a rat model of arthritis, where rats knees are inflamed using a chemical injection.

UCB today announced the results of two phase III studies, published in the Annals of the Rheumatic Diseases Online, showing Cimzia® (certolizumab pegol), the only PEGylated anti-TNFalpha (Tumour Necrosis Factor alpha), provided significant clinical benefits as monotherapy, and in combination with methotrexate, in adults with active rheumatoid arthritis (RA).

LED Technologies, LLC announced today that the U.S. Food and Drug Administration (FDA) cleared their DPL™ Therapy System for the relaxation of muscles and relief of muscle spasms, temporary relief of minor muscle and joint aches, pains and stiffness; temporary relief of minor pain and stiffness associated with arthritis; and to temporarily increase local blood circulation.

Diabetes Mellitus is one of the most common chronic disorders in the population, affecting some 2 million people in the UK. Patients with diabetes (both Type 1 and 2) suffer an array of rheumatic complaints which are wide-ranging in nature and are often complex in management.

A group of leading European hand surgeons will tomorrow view 'live' an arthroscopic surgical procedure to implant a biodegradable thumb joint resurfacing material called a 'spacer'. The procedure will be ...

Main Category: Medical Devices / Diagnostics Also Included In: Bones / Orthopaedics Article Date: 21 Nov 2008 A live surgical webcast of MAKOplasty robotic arm partial knee resurfacing will be presented by ...

TULSA A Tulsa-based researcher believes a failed cancer drug could be the answer for sufferers of chronic pain.

Taking vitamin E supplements does not reduce a woman's risk of rheumatoid arthritis , an analysis of data from the Women's Health Study indicates.

This week's Elder Connection is published in larger type for the benefit of our senior readers.

Rheumatoid arthritis is a painful, inflammatory type of arthritis that occurs when the body's immune system attacks itself. A new article in PLoS Biology, reports a breakthrough in the understanding of how autoimmune responses can be controlled, offering a promising new strategy for therapy development for rheumatoid arthritis.

Pycnodysostosis, a condition from which the painter Henri de Toulouse-Lautrec suffered, is a genetic disease characterized by short stature. This rare disease, surprisingly, provides a window into how joints are destroyed by arthritis.

Researchers have identified a potential new therapeutic target that could be used to treat inflammatory disorders, such as rheumatoid arthritis. Drugs that hit this new target are actually in trials for the treatment of another disease, leukemia.

Using single photon emission computed tomography, researchers in France were able to detect functional abnormalities in certain regions in the brains of patients diagnosed with fibromyalgia, reinforcing the idea that symptoms of the disorder are related to a dysfunction in those parts of the brain where pain is processed.

Rheumatologists, dermatologists and patient advocates have come together to publish the first-ever international guidelines for the treatment of psoriatic arthritis, a disease that mainly affects people who have psoriasis but also some people without it.

Patients with early rheumatoid arthritis (diagnosed with the disease for less than 3 years) who were treated with a combination of methotrexate and Humira had less progression of joint damage...

TNF blockers (e.g., Enbrel, Remicade, and Humira) target and block inflammation associated with rheumatoid arthritis. In patients who respond to the drugs, there can be a significant reduction in: chronic...

Arthritis signs should not be ignored. Having joint pain or joint stiffness? You may be inclined to shake it off, disregard, or minimize the importance of the arthritis signs...

Psoriatic arthritis treatment is complicated. Since there is a wide array of symptoms and various levels of severity associated with psoriatic arthritis, treatment guidelines have been needed. The Group for...

It's probably the one bit of advice for living well with arthritis that is repeated over and over. The advice -- to pace your activities -- is easy to understand...

SEATTLE (MedPage Today) -- Hereditary angioedema can be treated with the same biologic that was approved last month for preventing attacks, a researcher said here.

CHRISTCHURCH, New Zealand (MedPage Today) -- Wide variability in the way oral methotrexate accumulates and is eliminated makes monitoring and dosing decisions for rheumatoid arthritis patients difficult, a pharmacokinetic study found.

SEATTLE (MedPage Today) -- The severity of acute attacks of hereditary angioedema was significantly reduced with an investigational kallikrein inhibitor, a phase III study showed.

VANCOUVER, British Columbia (MedPage Today) -- Patients with gout were less likely to develop Parkinson's disease, a cohort study found, supporting the purported protective role of uric acid.

BOSTON (MedPage Today) -- Medicaid programs differ broadly from state to state in their efforts to save money with prior-authorization policies that limit the use of disease-modifying anti-rheumatic drugs (DMARDs), a study here found.

WEDNESDAY, Nov. 19 (HealthDay News) -- The dietary supplement beta-alanine (BA) -- widely used by athletes and body builders -- improves muscle endurance in the elderly, according to U.S. researchers.The finding "could have importance in the prevention of falls, and the maintenance of health and independent living in elderly men and women," said study author Jeffrey Stout of the University of Oklahoma.

THURSDAY, Nov. 13 (HealthDay News) -- New understanding about how to control autoimmune responses offers promise in efforts to develop treatments for rheumatoid arthritis (RA), British researchers say.

(HealthDay News) -- Arthritis is a rheumatic disease that affects the body's joints and connective tissues. Exercise is a relatively easy way to help control its symptoms.The University of Virginia Health System lists the benefits of exercise for people with rheumatic disease:

By Ed EdelsonHealthDay ReporterMONDAY, Nov. 3 (HealthDay News) -- The increased risk of heart attack that comes with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) to treat arthritis pain is directly related to the specific pain-causing molecule they act against, a new study finds.

TUESDAY, Oct. 28 (HealthDay News) -- TNF-antagonists, drugs widely used to treat rheumatoid arthritis (RA), don't appear to cause cancer, say Spanish researchers who analyzed data on more than 4,000 RA patients treated with the biologics.

According to experts, one in four people who suffer from such chronic health conditions as backache, heart disease, or multiple sclerosis become so worried about their health that they develop health anxiety.

Doctors from the University of Virginia Health System offer a list of the benefits of exercise for people who suffer from arthritis.

Call for people ages 51 years to 80 years who have osteoarthritis of the knee to participate in a study.

Experts say the Internet may offer patients an easier way to have doctors review their case and provide advice.

Keeping physically active may help to tackle health threats, study says

Pilates is a great form of exercise for arthritis patients who tend to shy away from exercise which they feel they cannot do. Pilates, named after its creator Joseph Pilates,...

Most osteoarthritis patients who respond well to a cyclooxygenase-2 selective NSAID (also known as COX-2 inhibitors) do so by the second week of taking the drug. The conclusion, drawn from...

In clinical trials, potentially new treatments are compared to placebo. If the new or active treatment elicits a superior response to placebo that shows it's effective. But the placebo itself...

Vitamin K has previously been recognized as having bone and cartilage effects and has been shown to be associated with osteoarthritis that is observable on x-ray. To confirm the...

Management of your osteoarthritis doesn't just lie in the hands of your doctor. In fact, there are self-management programs specifically designed to help you manage your osteoarthritis. Sound interesting to...

Maria Karris was only 60 when she noticed her legs beginning to swell. Gradually, they got bigger until the pain was excruciating.

Taking vitamin E supplements does not reduce a woman's risk of rheumatoid arthritis , an analysis of data from the Women's Health Study indicates.

The University of Alabama at Birmingham Center for Education and Research on Therapeutics has won a $2.2 million federal grant to study the risks and benefits of a newer class of medicines called biologics.

Social Science & Medicine , Vol. 17, No. 16. , pp. 1107-1123. Abstract This paper reviews current research and presents new evidence concerning sex differences in morbility and mortality.

BRUSSELS, BELGIUM, Nov 18, 2008 -- * FAST 4WARD showed monotherapy Cimzia 400 mg, dosed every four weeks, provided significant and effective clinical benefits compared to placebo * RAPID 2 trial showed Cimzia , ...

Research shows that being in a good mood helps you appreciate the bigger picture of life (and health) and helps you make smarter decisions, according to WebMD. We know, easier said than done, right? Start here.

With the holidays fast approaching, I know some of you are worrying about how you'll handle traditional meals and other food-focused gatherings. To help ease your mind, I've collected some reliable resources on healthy holiday eating. If you'd like to add to the list, please shoot me an email and I'll update as necessary!» Read the full article

It's the Great American Smokeout, and if they're quitting, your favorite smoker is going to need some support. Here are some stop-smoking tips to get them started.

Feeling a little tired, or maybe just lazy? Want to have new ChronicBabe content fed straight to you? Follow us on Twitter...and starting today, links to new stories will show up magically. Yay!

There's been a recall of Lean Cuisine meals containing chicken.

Reminder:  November Pain-Blog Carnival submissions due today. For many of us, chronic pain is exactly that - chronic.  Meaning it’s here to stay, it’s settled in - it’s not going away.  What changes when you can’t be cured? “Settled in” I recently heard William Breitbart, Chief of Psychiatric Services at the world-famous Memorial Sloan-Kettering Cancer Center, speak about “Pain and End of Life.”  He spoke about changes that occur when someone is given a terminal cancer diagnosis.  He presented 10 items people wanted when…

I’m honored to be given the Kreativ Blogger Award, passed on to me by one of my favorite bloggers, Jeisea, at CRPS/RSD A Better Life. Unfortunately, I could find absolutely nothing about the origins of this award.  I found several different pictures of it on different sites, so my guess is it’s been around for a long while, and has changed as it’s meandered around the internet. Each winner gets to name 6 things she or he is happy about.  Given that there seems to be much flexibility with this award, I’m going to bend these guidelines a bit and say: 1-6.  Not…

Two of the most interesting new treatments for chronic pain are graded motor imagery and mirror therapy.  A related experimental treatment which is being studied as we speak is called “tactile discrimination.”  What’s this about? Chronic pain creates changes in your brain.  We think that these brain changes cause other functions to become impaired as well, for example, right-side and left-side discrimination.  Right-side and left-side discrimination is simply knowing your left side from your right side.  If you have chronic pain in your right hand, your brain will…

The American Pain Foundation has a great list of 10 ways to get better medical care on its website.  Here’s a preview: Identify your top concerns, questions, and symptoms. Manage expectations; most pain issues will not be resolved in a single visit. Keep follow up appointments. Continued at APF…  Readers, what other tips do you have? Reminder:  November Pain-Blog Carnival submissions due by Friday, 11/21.

On Monday, I looked at the many reasons why people with pain might have sleep problems.  Today, let’s look at what you can do to help yourself get better sleep! Fix What’s Causing Your Sleep Problems For most people, poor sleep is due to several issues.  If you have pain, any of these might make it difficult to get good sleep: pain decreased activity anxiety and worry depression sleep problems as part of your medical disorder medication If you can, fix - or at least improve - these issues.  Of course, some you might not be able to change.  For example, you may not be able to…

Taking vitamin E supplements does not reduce a woman's risk of rheumatoid arthritis (RA), an analysis of data from the Women's Health Study indicates.

Doctors from the University of Virginia Health System offer a list of the benefits of exercise for people who suffer from arthritis.

Call for people ages 51 years to 80 years who have osteoarthritis of the knee to participate in a study.

Middle-aged men who take aspirin or other "nonsteroidal anti-inflammatory drug" (NSAID) have significantly lower levels of a blood protein used to spot prostate cancer than men who don't take these widely used drugs, a study shows.

Modifying gene called Foxp3 may develop cells capable of suppressing immune response

Hi there.  If you are new to my blog please visit the about page.  This site was created by me (sasha)  because I have RA and chronic pancreatitis (CP).  Some blog posts are more about RA, others are more about CP.  The ones in between are about living with a chronic disease and the journey it takes us on.  A portion of this site is about the caretaker/caregivers journey. PAINS MEDS  - Chronic Pancreatitis - The Definitive Sasha Story. Many readers write to me about their pain med routine and how to resolve this anguishing battle.  I have luckily come out on the other side of pain…

I realized that I’ve written 3 blogs in a row about pain & depression.  I’d love to write about cheery happy-go-lucky stuff, but that is simply not the reality of my perception right now.  In “real life” I have to pretend all the time that things are fine and that i feel fine. I spend quite a bit of energy hiding my pain and/or depression which is right now the larger issue.  Frankly, if I was honest with anyone but my blog about where my head is at then I might be committed to some mental ward.  I don’t feel deathly or like being dead or anything, but I…

CHRONIC PAIN & DEPRESSION Part II - SWOLLEN BLOB/RA Please read Chronic Pain & Depression Part I to get my full background if you are new to the site.  It’s focus is about my other autoimmune disease chronic pancreatitis (CP). BACKGROUND/So getting you quickly up to speed: It’s been 6 long weeks since Jax split up with me and moved 2 doors down.  It has really shaken me up.  It is not the core reason I am so severely depressed, but it was certainly the catalyst for my deep depression.  Clinical depression is a pretty serious issue as I am coming to learn.  If I…

CHRONIC PAIN & DEPRESSION part I - Fighting Death and Pancreatitis After reading this go to Pain and Depression Part II - Swollen Blob I’ve given this blog post an incredibly dull title on purpose.  It is an awful subject to be forced to write about. In many ways they go hand in hand.  Some days this is not true, but others it is so dreadfully true.  It seems to come and go in waves. If you are new to this blog, my name is Sasha.  I live in Los Angeles (but everyone thinks I am from NYC since all my family lives there) and have been a professional business woman &…

If you’ve been reading any of my posts the past 5 weeks then you’ll know that I’ve been severely depressed. I’ve also been looking for work because all of my clients and company work literally dried up the minute the economy started to become terribly worrisome.  All my company contacts have told me that they are being forced to scale back and no longer use contractors.  This is one of the toughest times I have ever gone through that is non-medical. In addition, the love of my life, Jax, split up with me because he could no longer deal with the stresses in my life…

The pharmacist had a phone number to an actual person who worked the weekends and knew something at my insurance company. He was able to discover the insurance had approved the prescription but had not entered it into the system. That makes sense, because when you approve something you should just keep it to yourself!Anyway, they were able to fill it at the local pharmacy today. So I am officially on Humira weekly instead of bi-weekly, I'll let you know how it goes.

This is the biggest run around I've gone through in a long time, if ever.My doctor gave me a script for weekly Humira, I gave that to my pharmacist, who submitted it to my insurance, where it was denied. Pharmacist called me, I called doctor, doctor called insurance, insurance asked for more info, doctor submitted more info, insurance asked for even more info, doctor submitted even more info.... That's all normal and expected, it's expensive and I don't blame the insurance for having a rigorous approval process.Then it gets ridiculous.The insurance company's mail-order pharmacy group called…

It took the insurance company several weeks to approve my prescription for weekly Humira, but they finally did. I have to wait a few more weeks and I can call to discuss decreasing my prednisone dose!I haven't been posting much, life has gotten so busy. There is a lot more chasing the twins around now that one is walking, we've had a lot more activities to attend for the older kids this Fall, plus school now. One thing about being busy, you don't have as much time to worry about your pain, you just have to go, go, go. But the weather change to cold, rainy and even snow yesterday, has hit me…

The insurance has not approved my prescription for weekly Humira yet. I don't blame them for resisting it. It's darned expensive medication! Hopefully we'll find out tomorrow if it's been approved.

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Here's a comment I'm posting from one of my readers, gary Presley, announcing the recent publication of his book, Seven Wheelchairs: A Life beyond Polio. I apologize for not writing an actual post, Gary, but I'm tired and my hands hurt, so I'm just reposting your comment in its entirety. I hope that's OK!Seven Wheelchairs: A Life beyond Polio was recently released by The University of Iowa Press.The memoir is a history -- an American tale -- of my fifty year wheelchair journey after being struck by both bulbar and lumbar poliomyelitis after a vaccine accident in 1959. The Press says Seven…

I'm so tired I want to cry right now. That's one of the worst things about fibromyalgia, the kind of soul-crushing fatigue that blackens your mood. I haven't been sleeping well lately, and sleep is crucial for people with FM, as one of the root problems for people with FM is having a sleep disturbance. I actually had to miss a physio appointment because of the lack of sleep. I have bronchitis and the hacking has kept me awake for the last one and a half nights. I hate FM fatigue. Sometimes I get so tired I can literally feel the chemicals in my brain switch from happy to sad. It's pretty…

On November 4, 2008, millions of people with disabilities across the United States and around the world joined our non-disabled peers in watching the United States election results. Obama supporters cheered or wept to learn that the next US president would be Obama. Then we cheered or wept again when Obama mentioned people with disabilities in his acceptance speech. History was made–not only for America, not only for Black people, not only for Kenya and all of Africa, not only for Indigenous peoples, but also for people with disabilities.But we cannot afford to allow the moment to end here.

Ongoing conflicts in Iraq and Afghanistan are creating a generation of veterans in the United States from all branches of the armed services and all 50 states who are struggling to overcome physical and psychosocial injuries. Most combat veterans convalescing in military hospitals across the country will survive physically, but getting on with their lives after returning home to their families and communities is proving a significant challenge for hundreds of thousands. Among the 1.6 million who have served since 2001, suicide is on the rise, as is unemployment and incidents of substance…

Roche today announced that the European Committee on Human Medicinal Products (CHMP) has given a positive recommendation for RoActemra (tocilizumab, known as Actemra outside of the EU), in combination with methotrexate (MTX), for the treatment of adult patients with moderate to severe rheumatoid arthritis (RA) who have either responded inadequately to, or who were intolerant to, previous therapy with one or more disease modifying anti-rheumatic drugs (DMARDs) or tumour necrosis factor (TNF) antagonists. (Source: Roche Media News) MedWorm Sponsored Message: Find out how you can get your…

CONCLUSION: Anti-TNF alpha therapy showed to be effective, safe and well tolerated in the setting of HCV infection. PMID: 19014870 [PubMed - in process] (Source: Autoimmunity Reviews)

DMARDS and infections in rheumatoid arthritis. Autoimmun Rev. 2008 Dec;8(2):139-43 Authors: Caporali R, Caprioli M, Bobbio-Pallavicini F, Montecucco C Patients with rheumatoid arthritis (RA) has an increased infections risk and morbidity and mortality related to infections. This increased risk may occur due to the disease itself with intrinsic cellular immunity alterations or as a results of drugs used to control the disease. The potential risk of infections related to conventional disease modifying anti-rheumatic drugs (DMARDs) is not completely clarified. Methotrexate (MTX) may increase the…

Conclusions: We found the prevalence of 2 important cutaneous manifestations to be 9.3% in IBD in Turkish patients. EN was found to be more common in Crohn's disease and is associated with an active episode of bowel disease and peripheral arthritis. In addition, PG was connected with uveitis and peripheral arthritis.(Inflamm Bowel Dis 2009) (Source: Inflammatory Bowel Diseases)

Syk kinase inhibitors show good outcomes in rheumatoid arthritis (RA) patients after 12 weeks, a new study in the journal Arthritis and Rheumatism has suggested. (Source: Arthritis Research Campaign)

so i finally was able to meet with my Rheumatologist the other day.  I never know what to expect, since the last time I met with him, he made it sound like I was deteriorating fast and that I should switch from methotrexate (MTX) to enbrel/etanercept pretty quickly.  this time, he made it seem like i was doing great, and even emphasizing it by pumping his arm when he said it. “you’re doing great!” *arm pump* i think he just forgot how our last meeting went.  that happens when you don’t see your patients for months and months at a time.  my previous rheumatologist…

Welcome to my blog!  I hope you can find  rheum[atoid arthritis] here as well as share your RA story, the good, the bad, and my favorite, the UGLY-  as I set my sights on sanity, despite the fact that I feel like Wiley hanging on a ledge having just noticed  Roadrunner (beep!  beep!) is about to drop that anvil on his burning fingertips.   Can you relate to THAT?   I am trying desperately to find a way to look at my lumpy and crooked hands, knees and shoulders and see the humor.  And yes, there *is* humor there!   I have had this beast of a diagnosis for almost 6 months, but…

THURSDAY, Nov. 13 (HealthDay News) — New understanding about how to control autoimmune responses offers promise in efforts to develop treatments for rheumatoid arthritis (RA), British researchers say. RA — a painful, inflammatory form of arthritis — occurs when the body’s immune system attacks itself. A molecule called Foxp3 plays an important role in immune system regulation. People who lack or have mutated versions of the Foxp3 gene lack or have dysfunctional immune system regulation. Scientists at the Medical Research Council’s Laboratory of Molecular Biology in Cambridge…

I realized that I’ve written 3 blogs in a row about pain & depression.  I’d love to write about cheery happy-go-lucky stuff, but that is simply not the reality of my perception right now.  In “real life” I have to pretend all the time that things are fine and that i feel fine. I spend quite a bit of energy hiding my pain and/or depression which is right now the larger issue.  Frankly, if I was honest with anyone but my blog about where my head is at then I might be committed to some mental ward.  I don’t feel deathly or like being dead or anything, but I…

“Happiness is nothing more than good health and a bad memory” Albert Schweitzer French philosopher and physician (1875-1965) As I stated in my introductory post, I’m kind of behind the curve when it comes to utilizing new media.I surf the Internet and watched one of the presidential debates on my cell phone. However, from an advertising standpoint I don’t feel competent about being effectively able to reach consumers using new media.So while I’m able to use new media I don’t feel as if I know enough about it yet to utilize it to its fullest extent in a marketing…