Gather and Post Here Your Medical Tests Results - Discussion Thread

[certainlypois2]

Right now
Testosterone serum 303           264-916 ng/dl
Free Testosterone     18.2         8.7-25.1 pg/ml

It's usually in the lower end of the range. But i did have a result that was 600 ng/dl.  I was feeling pretty good that day.

[BoneBroth]

Deficiencies of any theese hormones is a sign of comprimised function in the pitutary and hypothalamus:

Adrenocorticotrophic hormone (ACTH) (targets the Adrenals)
Thyroid-stimulating hormone (TSH) (targets the Thyroid, temperature controlling, heart rate)
Luteinising hormone (LH) (targets the testes)
Follicle-stimulating hormone (FSH) (targets the testes)
Prolactin (PRL)
Growth hormone (GH) (Stimulates growth and repair)
Melanocyte-stimulating hormone (MSH)
Antidiuretic hormone (ADH) (or Argenine Vasopressin, AVP) (Controls the blood fluid and mineral levels in the body by affecting water retention by the kidneys. Deficiency leads to dryeness, low blood pressure, varicose veins and slow bowel movements.
Oxytocin (anabolic hormone that heals osteoporosis)
Corticotropin-releasing hormone (helps regulate metabolism and immune response by working with the pituitary gland and adrenal gland to release certain steroids)
Gonadotropin-releasing hormone (instructs the pituitary gland to release more hormones that keep the sexual organs working)
Prolactin-controlling hormones
Thyrotropin-releasing hormone (activates the thyroid, which releases the hormones that regulate metabolism, energy levels, and developmental growth)

certainlypois2: Have you tested any of the other hormones on that list?

[Muon]

My endo says one adrenal gland is producing way too much aldosterone. She prescribed something similar to (but not the same as) spironalactone.

If I were younger, doc would recommend surgery to remove adrenal gland.

Steroid hormones during a flare:
CORTISOL *688.000 nmol/l 133.00 - 537.00
Aldosterone SERUM/PLASMA * 2210 pmol/l 61 - 970

Flare behaviour is typical for MCAD. Serotonin, locally released by intra-adrenal mast-like cells may be responsible for the increased values above, see articles below. And since we are talking about a flare it will probably normalize again.

Role of Mast Cells in the Control of Aldosterone Secretion

Serotonin-induced stimulation of cortisol secretion from human adrenocortical tissue is mediated through activation of a serotonin4 receptor subtype

Contributions of ACE and mast cell chymase to endogenous angiotensin II generation and leucocyte recruitment in vivo

Conclusion
"In vivo, Ang II is primarily generated by ACE under basal conditions, but in inflammatory conditions, the release of MCP amplifies local Ang II concentrations and the associated inflammatory process. Thus, AT1 receptor antagonists may be more effective than ACE inhibitors for treating ongoing Ang II-mediated vascular inflammation."

Demo had clogged arteries

https://poiscenter.com/forums/index.php?topic=2545.msg40222#msg40222

Interesting cortisol discussions. I just recently completed CT scans of my adrenal glands, found benign nodules/tumors which might explain my resistance to blood pressure control meds. Under supervision of a nephrologist. I also have high creatinine count. Kidney problems have been a mystery to me.

Ref

"Increase in mast cell population and upregulation of the 5-HT signaling pathway occur in aldosterone-producing adenomas. In particular, aldosterone-producing adenoma cells overexpress 5-HT4 receptors and are hyper-responsive to 5-HT4 receptor agonists. These data suggest that the intra-adrenal serotonergic regulatory system represents a potential target for development of both adrenal imaging methods to evaluate the lateralization of aldosterone production, and pharmacological treatments of primary aldosteronism." Role of Mast Cells in the Control of Aldosterone Secretion

Wiki: https://en.wikipedia.org/wiki/Aldosterone#Stimulation

What's going on here?

[LookingForACure]

Notable things in my blood tests

Antibodies:
:ENA Sm/RNP- Positive
ANA Tire - HEp2 Nuclear pattern - speckle - Second pattern : FND 1/640
Antinuclear antibodies titre - 1/640

Low serum folate - 2.6 ug/l in 2016 - 3.4 in 2018 - Normal ranges - 3.1-20.50 ug/l

EBV Virus
EBV capsid IgG level- Detected (Consistent with past not recent infection with EBV)
EB virus IgM antiobdy level - Not detected


Unsure if these mean anything:
Renal profile
Serum sodium - 146 mmol/L  Normal range : 135-145mmol/L

FBC Lymphocyte count - 1.2 - Normal range : 1.2-3.5

Tissue transglutaminase Abs - (DUFF) - 0.3 Normal range 0-7
(Serologically negative for coeliac disease)

Please let me know if you any thoughts on these as I don't really know what they mean. I am planning to get a lot more blood tests in specific things so please let me know the important ones I should get as I'm unsure what to get done. Do you think I should be in a POIS state when I have the tests done or not. I know for neurotransmitter ones it would make a big difference.

Iwillbeatthis, I would highly recommend seeing a rheumatologist. Your ANA titre (indicator of autoimmune disease) is substantially higher than almost all of the healthy population and you are positive for two antibodies associated with lupus.

[Iwillbeatthis]

Iwillbeatthis, I would highly recommend seeing a rheumatologist. Your ANA titre (indicator of autoimmune disease) is substantially higher than almost all of the healthy population and you are positive for two antibodies associated with lupus.

It was a private rheumatologist I saw four and a half years ago who ordered these tests, she said the results were unusual for my age, however when I tested for C3 and C4 they were normal (wasn't in POIS state but don't think it would have made a difference). The thing is if you have a condition they don't know about then they are no help to you even with things showing on tests.

I don't think typical specialists can help us, it needs to be a research specialist who is willing to make the effort to investigate further and work out what's going wrong rather than trying to find a specific condition.

[Iwillbeatthis]

Aminos Acids (No GABA detected and low in GABA precursors like Leucine, Glutamine, Valine, Serine)
_URINE AMINO ACIDS QUANTITATION_
Ref Range:
AMINO ACID Result (uM/mM Crea) Reference Range (uM/mM Crea)
~
Phosphoserine 4 Not Detected
Taurine 58 16-180
Phosphoethanolamine 3 Not Detected
Aspartic Acid 2 2-7
Hydroxyproline 1 <13
Threonine *6 7-29
Serine *16 21-50
Asparagine 4 <23
Glutamic Acid 1 <12
Glutamine 20 20-76
Sarcosine 0 Not Detected
Alpha Aminoadipic acid 1 Not Detected
Proline 0 <9
Glycine 46 43-173
Alanine 21 16-68
Citrulline 1 <4
Alpha Aminobutyric 0 <4
Valine 3 3-13
Cystine 3 3-17
Methionine *1 2-16
Isoleucine 1 <4
Leucine *1 2-11
Tyrosine 3 2-23
Phenylalanine 3 2-19
Beta Alanine 2 Not Detected
Beta Aminoisobutyric 2 <91
GABA 0 Not Detected
Ethanolamine 17 Not Detected
Tryptophan 0 Not Detected
Hydroxylysine 0 Not Detected
Ornithine 2 <5
Lysine 7 7-58
1-Methylhistidine 59 Not Detected
Histidine *25 26-153
3-Methylhistidine *14 19-47
Anserine 1 Not Detected
Carnosine 5 Not Detected
Arginine 1 <5
.

Low amino acids are common with those with a MTRR 11 mutation, low amino acids signify you need extra methylation support. So it makes sense how SAM E was helpful for you. Dr Amy Yasko uses the Urine Amino Acids Test as her main guide for treatments in her Methylation protocol.

"The newer SNP panel also looks at MTRR11. We have found that increased use of the Bowel formula seems to make a big difference for those who are MTRR11 ++ and who have low overall amino acids. Again this was information presented at Autism One last year and if you dont have those DVDs you might want to take a look at them."

They are talking about bowel support rna from holistic health, methyl max from holistic health would also be helpful but its recommended you do their step one before going for additional supports.

 I also have MTRR 11 mutation heterozygous so I'm interested to see what my UAA test shows when I do it soon.

[BoneBroth]

Blood test four weeks ago taken at 09:40 am (two days after nocturnal emission with associated normal POIS symptoms).
My GH (growth hormone) was 0.15 μg/L. There was no reference interval due to pulse secreation. The value seems to be fluctuating during the day and peaks at night. In the morning it should go down, but really as much as  0.15 μg/L? I read on a site that normal interval should be between 0.4 to 10 μg/L.

LH: 3.6 IE/L (1.7 - 8.6)
FSH: 4.0 IE/L (1.5 - 13)
Testosterone: 18.0 nmol/L (or 519 ng/dL) (Ref: 8.0 - 30)
SHBG: 45 nmol/L (10 - 80)
Testosterone/SHBG quota: 0.40 (0.3 - 1.1)
ACTH: 5.3 pmol/L (1,5 - 14 pmol/L morning)
Renin: 29 mIE/L (5 - 80 mIE/L in the morning after going up)
Chromogranin A: 1.6 nmol/L (< 2,0 nmol/L)
GH: 0.15 μg/L (No reference due to pulse secreation) (0.4 to 10 μg/L Googled)
IGF-1 : 149 μg/L (60 - 207)

Symptoms of GH deficiency at adults (I experience the symptoms in red colour) according to this site:

Anxiety and/or depression
Baldness (in men)
Decrease in sexual function and interest
Decreased muscle mass and strength
Difficult to concentration and lack of memory
Dry, thin skin
Elevated triglyceride levels
Fatigue and/or tiredness
Heart problems (only irregular heart beat, slow pulse)
High levels of LDL (the "bad") cholesterol
Insulin resistance
Lower tolerance to exercise
Reduced bone density (possible), making you more susceptible to developing osteoporosis
Sensitivity to heat and cold (sometimes)
Very low energy levels (not always, but regulary)
Weight gain, especially around the waist (on the contrary, weight loss)

The normal causes is a tumor or other damage to the pituitary gland. but then the IGF-1 should also be out of range, which it is not. But my everyday headache seems to be seated behind the eyes, where the pitutary is. However there is some days or even weeks where the pain is almost gone, thats when I havnt had a POIS for a longer time.

[Journey]

Blood test four weeks ago taken at 09:40 am (two days after nocturnal emission with associated normal POIS symptoms).

LH: 3.6 IE/L (1.7 - 8.6)
FSH: 4.0 IE/L (1.5 - 13)
Testosterone: 18.0 nmol/L (or 519 ng/dL) (Ref: 8.0 - 30)
SHBG: 45 nmol/L (10 - 80)
Testosterone/SHBG quota: 0.40 (0.3 - 1.1)
ACTH: 5.3 pmol/L (1,5 - 14 pmol/L morning)
Renin: 29 mIE/L (5 - 80 mIE/L in the morning after going up)
Chromogranin A: 1.6 nmol/L (< 2,0 nmol/L)
GH: 0.15 ?g/L (No reference due to pulse secreation) (0.4 to 10 ?g/L Googled)
IGF-1 : 149 ?g/L (60 - 207)

Update 2021-04-22: Oberon frequence scanner showed Hepatitis virus infection spread to many organs and thymus degeneration.

Try to get other tests for Thymus and hepatitis to confirm if that is the case and to get more information about those issues, it could be the inflammation degradating some organs if that is the case

[BoneBroth]

Blood test four weeks ago taken at 09:40 am (two days after nocturnal emission with associated normal POIS symptoms).

LH: 3.6 IE/L (1.7 - 8.6)
FSH: 4.0 IE/L (1.5 - 13)
Testosterone: 18.0 nmol/L (or 519 ng/dL) (Ref: 8.0 - 30)
SHBG: 45 nmol/L (10 - 80)
Testosterone/SHBG quota: 0.40 (0.3 - 1.1)
ACTH: 5.3 pmol/L (1,5 - 14 pmol/L morning)
Renin: 29 mIE/L (5 - 80 mIE/L in the morning after going up)
Chromogranin A: 1.6 nmol/L (< 2,0 nmol/L)
GH: 0.15 ?g/L (No reference due to pulse secreation) (0.4 to 10 ?g/L Googled)
IGF-1 : 149 ?g/L (60 - 207)

Update 2021-04-22: Oberon frequence scanner showed Hepatitis virus infection spread to many organs and thymus degeneration.

Try to get other tests for Thymus and hepatitis to confirm if that is the case and to get more information about those issues, it could be the inflammation degradating some organs if that is the case

My private clinic said they would only test me for Hepatitis B if "my eyes were yellow" because it was soooo expensive ($200) and the cost of my health must not jeopardize the doctors golf club membership card (my thoughts). So I will now try the more uneconomical public health care (otherwise I have to pay for it myself). Yes, I read that the thymus is involved with formation of T-cells and a low T cell response might give room for Hepatitis B, but I also read that the thymus is degenerated before your 20 years old (!?).  I have a family doctor who recommended me to also ask for the following tests:

Liver: EBV, Hepatitis B/C, Cytomegalovirus (CMV), Albumin
Immue system: Trombocytes (TPK), White blood cells (LPK), HIV, Auto-immunity test, Connective tissue disease (SLE),
Gut: Gluten intolerance test (again)
Other: Folacin, B12/Zink/Mg/So/Po/Iron (Iron was of great importance), Migrain (visit a neurologist)

At least three members (Bizzy 2016, Iwillbeatthis 2018 and Vandermolen 2019) have reported signs of auto-immunity (abnormal levels of auto nuclear antibodies (ANA)).  (And Iwillbeatthis report EBV). If any of you three read this, have you made any follow up on these tests or any test that indicate leaky gut?

"There are currently over 100 recognized autoimmune diseases [5], including autoimmune liver diseases. One hypothesis suggests that a condition known as "leaky gut" may play a significant role in the development of all autoimmune diseases"

https://drruscio.com/autoimmune-liver-disease/

Today I started a 2-3 days bone broth fast to see if it has some beneficial healing effects of my intestines (according to Dr Axe). Here is an experience from someone else who did it.

[Hopeoneday]

Member Bulbo - elevated immunoglobulins:

I checked my IgE level and it was 350 IU/ml ( normal value for adults is <190 IU/ml ).
Posible causes
https://www.healthline.com/health/hypergammaglobulinemia#takeaway

[Iwillbeatthis]

Got my Urine Amino Acid test results back attached bellow , Carnosine and Beta Alanine are crazy elevated indicating gut dysboisis, I will now run a 360 GI stool test and a h pylori test.

I guess these are why meat was causing me so much issues and not the phenylalanine...

Beta-alanine (high)
Beta-alanine, a nonessential intermediary amino acid, is abnormally elevated in this urine
specimen. Normally beta-alanine is near completely deaminated to alpha-ketoglutarate
(B-6 dependent). Beta-alanine is derived from: (1) the breakdown of DNA/RNA (yeast,
pyrimidine, uracil), (2) activity of unusual bacteria on aspartic acid and, (3) the
hydrolysis of anserine and carnosine, which are peptides found in beef, pork, poultry,
salmon, and tuna. Elevated beta-alanine inhibits the breakdown of anserine and carnosine,
and impairs the renal conservation of taurine and beta-aminoisobutyric acid; taurine is an
important antioxidant, neurotransmitter and essential for the retention and homeostasis of
intracellular magnesium and potassium. Beta-alanine is a neurotoxic substance that
suppresses development in the brain and spinal cord. Beta-alanine also interferes with the
metabolism of the neuroinhibitory neurotransmitter gamma-aminobutyric acid.
Hyper-B- alaninurea has been associated with seizures and somnolence.Patients exhibiting
elevated urinary B-alanine should be retested after given a trial on a low-protein,
low-pyrimidine diet and high B-6 (P-5-P). Elevated levels of B-alanine are highly correlated
with gastrointestinal and genitourinary infections in patients with Chronic Fatigue
Syndrome. Intestinal dysbiosis, especially candidiasis, should be evaluated via a
Comprehensive Stool Analysis.

The levels of one or both dietary peptides anserine and/or carnosine are markedly elevated in this urine specimen, indicating incomplete digestion of anserine-containing meats(chicken, turkey, duck, rabbit, tuna and salmon) and/or carnosine-containing meats (beef, pork, tuna and salmon).
Zinc status should be checked (RBC Elements) since the peptidase activity is zinc dependent. The peptidase activity can also be inhibited by high levels of Beta-alanine, which can result from B-6 insufficiency, or abnormal intestinal flora.

Carnosine (high)
Carnosine, a dietary peptide, is high in this urine specimen. Carnosine is an incompletely
digested peptide that is derived primarily from beef and pork. Carnosine consists of
histidine and beta-alanine. Breakdown of the peptide requires a zinc dependent
peptidase, which can be inhibited by high levels of the ”end product” beta-alanine. Betaalanine can accumulate if deamination of beta-alanine to alpha-ketoglutarate is impaired
due to B-6 insufficiency. Therefore, carnosine can accumulate as a result of high intake
of carnosine containing meats with insufficient zinc and/or B-6 availability. Beta-alanine
can also be elevated as a product of gastrointestinal bacterial conversion of aspartate
and/or breakdown of pyrimidines that are high in yeast. Thus beta-alanine can
accumulate and inhibit hydrolysis of carnosine as a result of significant dysbiosis, or
deficiencies of B-6 and/or zinc. Beta-alanine can have adverse effects in the central
nervous system, but more commonly elevated levels of beta-alanine inhibit renal
conservation of the amino acid taurine which is an important antioxidant,
neurotransmitter and essential for the retention and metabolism of intracellular
magnesium and potassium. If urinary taurine is either low or high, magnesium deficiency
is likely or pending. Comprehensive Stool Analysis (yeast/bacteria), Red Blood Cell
Elements Analysis (zinc, potassium, and magnesium) and assessment of B-6 status are
useful to identify the cause and potential consequences of the inability to break down this
dietary peptide.

[Iwillbeatthis]

1 methylhistidine  was also elevated which means muscle fatigue and tight muscles. Potassium and calcium were low which is probably why. H pylori can also cause low potassium, rubidium and other minerals.

[Iwillbeatthis]

UTEE showed Copper, sodium, selenium, zinc and phosphorus were low, Vanadium was slightly high.

Hair showed low: copper, calcium, sodium, potassium, chromium, boron, lithium, selenium, rubidium,


A high level of Vanadium (V) was found in this urine sample. Increased V, especially in an unprovoked urine sample, reflects recent
excessive exposure/intake and absorption to V. Vanadium can be highly toxic. Excess levels of V can result from over-zealous V supplementation.
It may also results from exccessive consumption of fish, shrimp, crabs, and oysters that have been harvested near offshore oil rigs. Industrial/environmental sources of V include: processing of mineral ores, phosphate fertilizers, combustion of oil and coal, production of steel, and chemicals used in the fixation of dyes and print (Metals in Clinical and Analytical Chemistry, 1994). V is used in producing rust-resistant, spring and high speed tool steels. Vanadium pentoxide and other vanadates are used as catalysts in the production of sulfuric acid and formaldehyde. Urban air in industrialized areas may have higher levels of V than in rural areas.

Symptoms of V toxicity vary with chemical form and route of assimilation. Inhalation of excess V may produce respiratory irritation and
bronchitis. Excess ingestion of V can result in decreased appetite, depressed growth, diarrhea/gastrointestinal disturbances,
nephrotoxic and hematotoxic effects. Pallor, diarrhea, and green tongue are early signs of excess V and have been reported in human
subjects consuming about 20 mg V/day (Modern Nutrition in Health and Disease, 8th edition, eds. Shils, M., Olson, J., and Mosha, S.,
1994).

[Iwillbeatthis]

Berlin had high copper on his hair test results:

"Copper Ideally, your copper levels should be lower than zinc to favor a higher zinc to copper ratio. High copper has been implicated in ADD. Copper is the cofactor that works with the enzymes MAO A and MAO B to break down dopamine and serotonin, so high copper may engender a higher degree of degradation of these two neurotransmitters.

 Excess copper has also been reported to cause fearful thoughts. If copper replaces zinc in your brain, it may be a factor in migraines, so zinc support may help you with this, as well as bring your copper into better balance."

I also read somewhere high copper lowers GABA too.

[BoneBroth]

Prospero writes:

But what is puzzling is the result for amino acids. They're almost all under the reference range. Extremely strange.

Another sign of a damaged gut that fails in breaking down protein or absorbing amino acids?

[BoneBroth]

I'm going to get another full spectra blood analysis but I'm not sure what analyse plan to take.

What markers are of importace for the POIS / inflammation / hormones  / leaky gut? Are there a thread for this?

[Muon]

Yes it's in the comments of the laboratory thread. People can dump their thoughts about parameters in there. Scroll through the pages.
https://poiscenter.com/forums/index.php?topic=3207.0

[BoneBroth]

Prosperos result
Low amino acids might be a sign that you are not absorping those, maybe because of gut inflammation/SIBO. Amino acids are the building blocks for many hormones.

Journeys result
Journeys cortisol was over reference range (633.0 - nmol / L). I've also had cortisol over reference range at two blood tests in the morning. When I'm in a POIS state I see how my blood vessels on my hands constrict in the morning more than when I'm not in a POIS state. Thats an effect of cortisol. It is vasoconstricting. There are users who claimes that cortisol lowering methods has a profound effect on POIS (Yoga, meditation etcetera).

Hight cortisol might both aggravate POIS symptoms, but also be a direct cause of POIS. Long term stress cause hight cortisol which is shutting down the stommach/intestines and absorption of nutrients important for hormons (fat soluble vitamins, B-vitamins, A-vitamins). Probably the anabolic hormones (testosterone, oxytocin etc) are the first who become deficient since all building materials are used for cortisol/histamin/adrenalin (tahts why some users get well on testosterone therapy). And the POIS inflammation itself will produce high cortisol so the process becomes a vicious circle.

Lowering cortisol levels means lowering stress and that means improving the gut health which in turn improves absorbtion of fat solluble vitamins that are important for hormonal balances, and thats why POIS gets better if you "lower cortisol levels".

Berlin1984's result
A gene that reduce the breakdown of histamine could be a key. There are users who report quick relief upon high intensive training. Last week my therapest said that when you exercise hard, or run fast, your body will burn (break down) cortisol/adrenalin/histamin quicker and leave less in the blood circulation. In the stone age we used to run fast when we were "chased by a lion", but now we are handeling the stress by watching a movie - not unlikely a horror/thiller/action movie that stimulate even more cortisol, when we need it at least - in the night when the body is regenerating our hormonal systems.

Coming up: I just got the results from a big blood test and all values were within range, but the all the diffrent kinds of white blood cells were near the lowest range which according to the analyse indicate low B12, low folic acid (bad absorption?) and celiac disease/gluten intolerance (inflamed/leaky gut?).

[BoneBroth]

My two new blood analyses doesnt show much but might indicate two things:

1. Slitgtly elevated cortisol as in my previous tests
2. The lower range for white blood cells, might indicate an exhausted immune system and according to the interpretation, low on B12/folic acid and possible celiac disease or chrons.

My comment: Very likely that the gut dysbiotic that I belive I have (ballon stommach, positive SIBO test, skin rashes, smelly gas, diarrhea/constipation ) is causing this. After those blood test I had a better period and stool became better in color and texture on my adjusted SIBO diet.

Then, I accidently got the worst food poisoning in my life (after a sandwich with sallad at a caf?) and vomited 20 times. The last 10 times, when there were no more things to empty in the stommach, there were only green bile coming up (I never thought that bile could go backwards up in the stommach, but a doctor said it could). 30 minutes before I throwed up I also had a glass of ascorbic acid mixed with sodium bicarbonate and liquid B-vitamin complex. I think the sudden pH increase from possibly too much bicarbonate might have made it easy for the bacteria to survive in the stommach, witch made it worse.

Anyway. After 3 days in horizontal position and the worst tension headache I had for a very long time (I guess the muscles were tense after the throw-ups) and loosing two more kilos because of the vomiting/not eating (I weight only 63 kg now) I had yellowish stools, ballon stommach and dry, cold eyes without any NE/O happening last week. This after trying to gain the lost kilos. But my stommach apperantly want to take things in a slower pace.   (2021-11-19 update: Stools starts to regain color/consistence)

I believe the intestinal situation is the main culprit here and in before the end of november I will recive the result of an advanced poop-analyse, just as user Clues latest attribution.

[BoneBroth]

It's starting to build up a hughe amount of interesting test results here. It would be great to see a compilation of off-the-chart-values that POIS'ers have in common, but also values that are near the endpoints of the normal range (for example the beginning/end quartiles). Since the data is so huge, we should organise a group of members to split the job. Some could focus on vitamin status, other on hormonal values, and other on psychological results etcetera.

It's also interesting to see what members that has normal values, or the percentual diffrence between the normals and off-the-chart members. This should have a new thread called something like "Test Result Compilation" with an intro post that specifies the diffrent analyse classes and then one post for each type of value. We would need a common method to work after. To classify the diffrent analyse values might be a starting point. Anyone interested to be a part of such a "analyse compilation" group?

Some questions to be answered:
How to handle values that changes over time (sometimes within range, sometimes outside)