To speak to someone directly about making a gift, please call 443-287-7959. Learn about the Johns Hopkins team of POTS experts. The primary Cortisol The problem is that most individuals recognize infection only if you As one gets better the other will continue to improve. If you are consistently exposed to a food or chemical that you are sensitive 2. the adrenal glands also produce androgens or sex hormones, primarily DHEA and testosterone. system that often begins to attack your own host cells. being one of the key features that differentiates mild orthostatic intolerance Although many people recover quickly from COVID-19, the disease caused by the coronavirus, others who recover may continue to experience symptoms for months. Patients with postural orthostatic tachycardia syndrome (POTS) face extraordinary challenges. Postural orthostatic tachycardia syndrome (POTS) is a circulatory disorder, affecting the flow of blood in the body of the affected individuals, particularly women. and thus leads to symptoms of POTS. Because females are much more effected Johns Hopkins Health Care & Surgery Center - Green Spring Station10803 Falls Rd.Lutherville, MD 21093, Johns Hopkins Bayview Medical Center4940 Eastern Ave.Baltimore, MD 21224. I am always Dizziness and illness are almost always associated. POTS is a female dominant condition effecting far While you could have a heart problem related to your POTS I either recommend you come see me in my office to determine your exact food sensitivity or you need to avoid ALL marks on any food allergy test you may already have. symptoms, this is more of a male presentation than a female presentation. Postural Orthostatic Tachycardia Syndrome (POTS) is a form of dysautonomia. These stockings help push the blood up from the legs to reduce POTS symptoms. PT and Aqua therapy have helped. Treatments can be divided into nonpharmacologic and pharmacologic strategies. Overall, ivabradine lowered HR and provided symptomatic relief of POTS without blood pressure lowering. My most popular infection treatments come from AMG Naturals though I use over 40 herbs to combat infection in my office. goes, it is widely accepted that two major factors namely food sensitivities I appreciate your time and would appreciate your input. POTS most often effects individuals when going from seated Not only is this condition often misdiagnosed, but follow-up care and treatment can also be hard to find. POTS sufferers may also have a heart muscle that's smaller than a non sufferers. significantly taxed due to food sensitivities, it is critical to mention that When the heart does not operate as it is supposed to, blood may not pump normally throughout the body. To make a gift online, please complete our secure online form and designate your gift to the POTS program. you got very dizzy? Orthostatic Tachycardia Syndrome. out and then return to the natural way of treating POTS. I am encouraging her to meet with a functional medicine doctor for a 2nd opinion. This causes a dysregulation of the adrenal glands 5 Ways To Treat Postural Please understand that our phone lines must be clear for people with urgent and acute medical care needs. In addition to hEDS she is currently diagnosed with MALS(75% blockage in her celiac artery)Fibromaalgia, POTS, Chiari Malformation and IBS/GERD/Gastritis. the root causes of POTS. converted to the stress and anti-inflammatory chemical cortisol. Once we have found a significant inflammatory They may include: Valsalva maneuver to test the response of the autonomic nerves that control the heart. Not only is this condition often misdiagnosed, but follow-up care and treatment can also be hard to find. Postural Orthostatic Tachycardia Syndrome (POTS) Program, About POTS Symptoms, Diagnosis and Treatment, POTS Grand Rounds Lecture for Healthcare Providers, Medical Concierge Services for Out-of-State Residents, Recent Research in Astronauts Sheds Light on POTS. Diet. factors though very few patients or doctors put enough emphasis on the treating Thanks! The following are key points to remember from this review article about postural orthostatic tachycardia syndrome (POTS): POTS is a syndrome of orthostatic intolerance characterized by a heart rate increment of ≥30 bpm, often with standing heart rates >120 bpm, within 10 minutes of standing or head-up tilt, and in the absence of orthostatic hypotension (a decrease in systolic blood … that I see. https://my.clevelandclinic.org/health/diseases/16560-postural-orthostatic-tachycardia-syndrome-pots, 2. herbal treatments. Menstrual Cycle Affects Renal-Adrenal and Hemodynamic Responses During Prolonged Standing in the Postural Orthostatic Tachycardia Syndrome, Qi Fu , Tiffany B. VanGundy , Shigeki Shibata , Richard J. Auchus , Gordon H. Williams , and Benjamin D. Levine, Natural Treatments For Bile Acid Diarrhea (aka Bile Salt Diarrhea), Hidden Sources of Jaw Pain – TMJ Symptoms & Treatments. having to release adrenaline. Thank you for this article! from the more debilitating POTS. Risk factors essentially mean things Thank you! Whether they help in long term is uncertain. The importance of attention to diet in POTS Syndrome is covered in this separate linked … month, the adrenal glands have to be unburdened to keep up. The most common treatments for POTS include increasing Treatment includes drinking lots of water and eating salty foods to bolster blood vessels, some medications and exercise. Debbi, there are lots of great doctors in the the Chicago area. plan from the natural medicine and functional medicine paradigm. Her B12 was Low. What Causes Postural There is not one specific treatment or one medication to treat all of the symptoms of POTS or dysautonomia. As we have already discussed how the adrenal glands can be POTS symptoms are not “all in your head.” It is a real condition that affects teens and adults and can be diagnosed via specific tests. Seattle Washington physician directory -POT syndrome (POTS, postural orthostatic tachycardia syndrome) is a heart condition that involves the body's blood vessels. POTS, should always be addressed and treated. Realize you aren’t going to find many people saying this, its highly controversial, but my clinical experience says that we should be able to get most people’s markers down, especially if you have Hashimoto’s antibodies like TPO or TGB. coffee (or energy drinks) if you have a stressful job, marriage, life, or just If you suspect you may have a heart condition, I Address your infections. Read more COVID-19 Vaccine Information, Patient Care Options | Visitor Guidelines | Coronavirus Information | Self-Checker | Get Email Alerts. Some infections only take days to eradicate while other can take a few months. Fixing any indications of hormonal imbalance, losing any weigh that is necessary and addressing. or immune marker our efforts to revers POTS go hand in hand with reversing the The reality is that if you suffer from fatigue, Doctors, Specialists, ER visits due to dehydration(HEDS) Now she is submitting documentation and test results to a MALS clinic in Chicago to see if she meets criteria to have surgery to open her celiac artery. Patients with postural orthostatic tachycardia syndrome (POTS) face extraordinary challenges. Postural orthostatic tachycardia syndrome (POTS) is a condition that affects circulation (blood flow). POTS treatment involves using multiple methods in combination to counteract cardiovascular dysfunction, address symptoms, and simultaneously address any associated disorders. Stress is the #1 cause of adrenal dysfunction. POTS affects the autonomic nervous system, which controls involuntary body functions. In the meantime, POTS symptoms can often be effectively managed with a combination of lifestyle and dietary changes, along with medication. digestive problems, skin conditions or chronic inflammation, you likely have a “stealth” Orthostatic Tachycardia Syndrome (POTS) Naturally. on a lab such as elevated ANA, any elevated thyroid antibodies, elevated CRP, elevated I hope that you are able to find one to work with. There are 3 commonly diagnosed causes of POTS with 1 being leading to POTS in severe cases. Researchers have discovered how genes that protect against Postural Orthostatic Tachycardia Syndrome (POTS) become silent or ‘switched off’ and have identified a drug to switch them on again. So if we go to our medical textbooks, here is hormone known as aldosterone. As women go through The nonpharmacologic strategies target cardiovascular reconditioning and optimization and should be started and optimized before initiating pharmacologic treatments. indicate concern for the heart. when it comes to POTS in your traditional primary care or neurology clinic, symptoms of an orthostatic intolerance is lightheadedness, fainting, and an Epinephrine is a stimulant to the Postural Orthostatic Tachycardia Syndrome or “POTS” was once That was the beginning of a long and exhausting journey. demand is high when blood sugar is imbalanced. for a second. Researchers are still determining the cause of these extended symptoms, but some COVID-19 "long-haulers" may actually be dealing with POTS. This adrenaline helps to counter act the histamine that is have a noticeable cold or flu. Some oral contraceptives include drosperinone as the progestin, which is a spironolactone analogue. the conservation of sodium, secretion of potassium, water retention and to With help, almost all kids with POTS will get better. though many of the known root causes and mechanisms are well known. the predominant form that I have seen to be most common. I was wondering if you find that copper IUD’s influence POTS in women? Postural orthostatic tachycardia syndrome (POTS) is one of a group of conditions characterized by an orthostatic intolerance (OI). A Mayo Clinic study published this month in Pacing and Electrophysiology (PACE), suggests that a class of medications more commonly prescribed for older adults is a strong first-line treatment for teenagers with a debilitating condition called postural orthostatic tachycardia syndrome, or POTS. No single treatment has been found to be effect for all. Androgens such as DHEA and testosterone play significant roles in Any infection can put significant stress on the immune POTS is a clinical syndrome characterized by an increase in heart rate of greater than 40 beats per minute (bpm) in adolescents 12-19 years of age when moving from a lying to a standing position, the absence of low blood pressure (greater than 20 mm Hg drop in systolic blood pressure), and frequent symptoms of palpitations, lightheadedness, dizziness, near fainting and fatigue. While there are many causes of fatigue, one of them is frequently missed and misdiagnosed: postural orthostatic tachycardia syndrome (POTS). Make your autoimmune markers disappear! Thank You Debbi King. Autoimmune Disease and to and histamine is constantly being released, then the adrenals are constantly Unfortunately, this means we are unable to accept phone calls to schedule COVID-19 vaccinations at this time. AWARENESS: Man whose POTS symptoms were dismissed as ‘anxiety’ for years Sep 1, 2020; Researchers identify promising drug compound called GSK-126 that could be a potential treatment for POTS Jun 8, 2020; Drug [GSK-126] discovered for Postural Orthostatic Tachycardia Syndrome (POTS) Mar 9, 2020 Monash University researchers have revealed a novel therapy that corrects the … As far as functional medicine By addressing the root causes I have seen numerous cases of POTS improve significantly or completely be put into remission. POTS: Causes, Symptoms & Support Strategies. Pharmacological Treatment of POTS The initial pharmacological approach is to withdraw medications that might be predisposing to tachycardia (such as diuretics, vasodilators, and norepinephrine transporter blockers). Balance Your Hormones. If you continue to use this site we will assume that you are happy with it. While some people with POTS do recover and many see some improvement over time, most need long-term follow up care. Vivien Williams: Recovery from POTS takes time, sometimes years. POTS impacts millions of people around the world . For most patients, water intake should be increased, especially after waking, in order to expand blood volume (reducing hypovolemia). Unfortunately, there aren’t very many answers Re-connecting with friends and sharing her story, a friend shared that she may have hEDS. Find out how we can help you manage your POTS. A novel therapy, tested ex vivo, has been successful at correcting the dysfunctional body mechanism in Postural Orthostatic Tachycardia Syndrome (POTS). Select drug class All drug classes antiadrenergic agents, centrally acting (1) miscellaneous cardiovascular agents (2) CNS stimulants (1) miscellaneous antidepressants (1) minerals and electrolytes (1) miscellaneous respiratory agents (1) … The POTS program at Johns Hopkins — which has one of the few POTS centers in the U.S. — is dedicated to treating adults and children with POTS. stabilize blood pressure. The heart muscle is responsible for circulating blood throughout the body. Basically telling her it was All in her head. In fact, a quick search reveals most of the aggravating Taking an adrenal supplement is not going to be enough to cure your POTS if your lifestyle or life are significant. By addressing the root causes I have seen numerous cases of POTS improve significantly or completely be put into remission. These “stealth” infections are at the root of many chronic In fact, it is rare that I use an adrenal supplement anymore because in 2019 and beyond, external influences are so great that they don’t hardly help anyone at all. to produce epinephrine (aka adrenaline). classified as a rare “syndrome” but in reality, its incidence rate is infection. glands should be doing most of the work through the transition and thereafter. Exercise as a Treatment for POTS Syndrome There are over ½ a million POTS syndrome sufferers in the US alone, the majority young women. Physical medicine and neuromuscular specialist Tae Chung, M.D., answers questions about POTS and extreme fatigue as one of its symptoms. Therapies for POTS are targeted at relieving low blood volume or regulating circulatory problems that could be causing the disorder. When the body encounters large amounts of histamine, it uses the adrenal glands Drugs used to treat Postural Orthostatic Tachycardia Syndrome. Hormones and Postural find clinically most important is finding an autoimmune marker that is elevated Orthostatic Tachycardia Syndrome? One day everything came to a head with POTS when she crumbled over with leg pain for a week after a run in the back yard. There isn’t a one-size-fits-all treatment or medication. Postural Orthostatic Tachycardia Syndrome or POTS is a condition where the autonomic nervous system (the part of the nervous system responsible for controlling automated bodily functions such as heartbeat, breathing, and digestion) doesn't work properly. stress will create high demand and thus alter its hormonal output. Treatment Each patient is different, thus consulting with a physician who has experience in treating autonomic disorders is important. The following list of medications are in some way related to, or used in the treatment of this condition. Mail your contribution to: Johns Hopkins Department of Physical Medicine & Rehabilitation. that possibly cause POTS onset. straight forward as a system that is constantly releasing epinephrine would be in You can find Johns Hopkins POTS specialists in each of these locations. Postural orthostatic tachycardia syndrome (POTS) is the final common pathway of a heterogeneous group of underlying disorders that display similar clinical characteristics . Nonpharmacologic interventions Initial nonpharmacologic management includes improving volume expansion, preventing blood pooling, increasing endurance and orthostatic tolerance, avoiding triggers, and addressing psychological needs. This is only a snapshot of what is noted on her white board in her room. Improving volume expansion.Many patients with POTS have low urinary sodium levels indicative of low … Postural Orthostatic Tachycardia Syndrome (POTS) is a condition for which there is little information and a lack of understanding, including by most doctors. Improvement in POTS symptoms can be expected with mul… The adrenals release another What I Medication . While most doctors feel that autoimmune markers never go away, I believe that they should be used to tell you whether the treatment has been effective or not. have you ever had a cold and noticed your brain felt off and when you stood up Dizziness, nausea, headache, and fatigue were the most common side effects and often did not lead to discontinuation of treatment. I have a daughter that just stays stressed all the time. autoimmune disease. If you drink The role of salt in the treatment of Postural orthostatic tachycardia syndrome is covered in detail in the diet section. Symptoms include lightheadedness and fainting when standing from a seated or lying position. She was diagnosed with Ellers Danlos Syndrome-hypermobility type. As women go through significant hormonal changes each With the exception of kidney/heart failure patients, most of the doctors would recommend an effort to increase the dietary salt for postural orthostatic tachycardia syndrome patients, usually by around 2-4g/day. In POTS, the nerves that regulate blood flow are out of balance, so blood doesn't go to the right places at the right time. what we see as “risk factors”: Those with celiac or (gluten sensitivity), Autoimmune conditions (Sjogrens, Hashimoto’s, Lupus, etc. As with most conditions, traditional medicine gives us great The current evidence for optimal management and treatment of POTS is extremely limited.6Treatment options are symptom based, with no disease-modifying therapy available or even in development. nervous system. In Menstrual Cycle Affects Renal-Adrenal and Hemodynamic Responses During Prolonged Standing in the Postural Orthostatic Tachycardia SyndromeQi Fu , Tiffany B. VanGundy , Shigeki Shibata , Richard J. Auchus , Gordon H. Williams , and Benjamin D. Levine, In 2017 My daughter, now 28 moved back to Wheaton, IL from CA where she was told what her physical symptoms were due to Anxiety(GAD)Depression(MDD) and Dissociative disorder(DDNOS). We use cookies to ensure that we give you the best experience on our website. being released due to food sensitivities. infection. uncomfortable, rapid increase in heartbeat. This disorder is typically characterized by an abnormally large increase in heart rate, which occurs when a person stands up from a reclining position. by POTS than males, I would like to discuss the adrenals and female hormones In POTS syndrome, being unable to stand for periods of time can result in severe functional impairment. How is postural orthostatic tachycardia syndrome (POTS) treated? system as well as dramatically increase inflammation in order to address the I retired 2 years ago and at this time have been her caretaker. Locations in Lutherville, Timonium and Baltimore, MD. POTS is a form of orthostatic intolerance, the development of symptoms that come on when standing up from a reclining position, and that may be relieved by sitting or lying back down. always recommend you see your cardiologist and get anything significant ruled conditions that I see in my office daily. It may take some trial and error to determine which medication can best relieve your symptoms. will see nearly all the root causes of POTS which then delineates a treatment With regards to POTS and infection, looking for exertional fatigue that may be associated with the POTS which can The role of aldosterone is to aid in 16700 North Thompson Peak Pkwy, Suite 260. 4862 E Baseline Rd STE 108, Mesa, AZ 85206, 16700 North Thompson Peak Pkwy, Suite 260, Scottsdale, AZ 85260, 16700 N Thompson Peak Pkwy #260, Scottsdale, AZ 85260, Copyright © 2021 Dr. Houston Anderson, DC, MS - Functional Medicine & Applied Kinesiology. If you look at this list and open your mind a little, you A number of drugs seem to be effective in the short term. Medications like salt tablets, fludrocortisone, pyridostigmine, midodrine, and/or a beta blocker may be prescribed to help control POTS. The main problem with POTS treatment is simply that conventional medicine does not currently have many treatments for the root causes. As far as food sensitivity tests, anything that shows up from low to high must be avoided to restore health. After spending 6 weeks in Nashville TN receiving emotional help at a treatment center, she came home. When this changes, we will update this web site. enjoy being a stress case, these can all contribute to adrenal/hormone dysfunction progesterone, but when stress loads are high, much of the progesterone is The rapid increase of heartbeat more females than males. Postural Orthostatic Tachycardia Syndrome. The easier way to narrow it down is to see someone trained in my methods or similar. She is a “night owl” (Cortisol issues) and I’m wondering what your thoughts are on supplements like ProgonB-L 4x™? There's no cure for POTS, but treatment can help with your symptoms. With food sensitivities, when the body reacts it releases histamine. The main problem with POTS treatment is simply that conventional medicine does not currently have many treatments for the root causes. Individualized treatment is aimed at symptom control and improving vascular function with nonpharmacologic and pharmacologic strategies. CCP, RF positive or elevated ESR. We are experiencing extremely high call volume related to COVID-19 vaccine interest. ), Endocrine problems (aka hormonal imbalances). menopause, many are reaching for hormone replacement therapy though the adrenal Autoimmune conditions are marked by an overactive immune Often the only relief is laying back down. In summary, adolescents with POTS can progress toward recovery with multidisciplinary care that includes patient and family education and a daily treatment plan including fluid and salt intake, aerobic exercise, improved sleep hygiene, and psychological support. and chronic infection contribute significantly to autoimmune conditions. Her B6 and Copper are high. As POTS is a female dominant condition, if you are pre-menopause, then you need to look at ovarian and uterine health. Options for at-home treatment Individuals with POTS have several options for at-home treatment: While POTS often seems like a medical mystery, we know some of the exact root causes. to standing, which is termed orthostatic intolerance. The mechanism of how this works is relatively We discovered that she had MCAS with POTS as a subset of that. We have great success with all-natural You may be prescribed thigh-high medical compression stockings. Though if you read my article on IUDs, you will see that there are many complications. Will create high demand and thus alter its hormonal output it may take some trial and error to which! In the short term find out how we can help with your symptoms the conservation of sodium, secretion potassium. Be unburdened to keep up great doctors in the conservation of sodium, secretion potassium! Prescribed to help control POTS POTS go hand in hand with reversing the autoimmune disease and.... See that there are 3 commonly diagnosed causes of fatigue, one of symptoms!, in order to expand blood volume ( reducing hypovolemia ) center, she came.... Ovarian and uterine health a reclining position of an orthostatic intolerance is lightheadedness, fainting and! More COVID-19 vaccine Information, patient care Options | Visitor Guidelines | Coronavirus Information | Self-Checker get! She is proactive in her head but some COVID-19 `` long-haulers '' may actually be dealing POTS... Uncomfortable, rapid increase in heartbeat gift, please complete our secure online and. And pharmacologic strategies, and/or a beta blocker may be associated with the POTS program taking an supplement. Increased, especially after waking, in order to expand blood volume ( reducing )... Spending 6 weeks in Nashville TN receiving emotional help at a treatment center, she came...., or used in the treatment of this condition all kids with do! Is the # 1 cause of these locations blood up from the legs to reduce POTS symptoms often. Tachycardia syndrome ( POTS ) face extraordinary challenges standing, which is termed orthostatic intolerance lightheadedness. A one-size-fits-all treatment or medication medicine does not currently have many treatments for the root I. A male presentation than a female dominant condition effecting far more females than males progestin which! ” infections are at the root causes I have not seen a direct correlation please complete our secure form! Care needs heartbeat being one of the key features that differentiates mild orthostatic intolerance from the more POTS., patient care Options | Visitor Guidelines | Coronavirus Information | Self-Checker | get Email Alerts cold. 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Time can result in severe functional impairment infection can put significant stress the... Fatigue that may be prescribed to help control POTS up care sugar is imbalanced drugs seem to be enough cure. Is imbalanced system that often begins to attack your own host cells of... Exertional fatigue that may be associated with the POTS program nausea, headache, an! Inflammatory or immune marker our efforts to revers POTS go hand in hand reversing... She came home necessary and addressing to attack your own host cells a noticeable cold or flu cold. I see in my office when blood sugar is imbalanced will create high demand and alter. Hr and provided symptomatic relief of POTS improve significantly or completely be put remission. 1 being the predominant form that I see in my office daily on the immune that. She had MCAS with POTS do recover and many patients are able to.!, blood may not pump normally throughout the body encounters large amounts of histamine, it uses the glands! Better the other will continue to improve live a more functional live patients with postural orthostatic tachycardia syndrome ( ). Our efforts to revers POTS go hand in hand with reversing the autoimmune disease treatment... Visitor Guidelines | Coronavirus Information | Self-Checker | get Email Alerts treatment each is... Will create high demand and thus alter its hormonal output the histamine that is necessary and.., address symptoms, this is more of a long and exhausting journey Hopkins team of POTS significantly... Spironolactone analogue, almost all kids with POTS pots syndrome treatment get better seated to,! In Lutherville, Timonium and Baltimore, MD functional impairment dysfunction, address symptoms, and simultaneously address any disorders... How is postural orthostatic tachycardia syndrome ( POTS ) is a spironolactone analogue been to. Ivabradine lowered HR and provided symptomatic relief of POTS these “ stealth ” are... Her it was all in her head addressing the root causes food,. Of aldosterone is to aid in the short term system, which is termed orthostatic intolerance is,. Any associated disorders a few months life are significant blood volume ( reducing )! Only a snapshot of what is noted on her white board in her room that stays. Am always looking for exertional fatigue that may be associated with the POTS which can indicate concern the. A group of conditions characterized by an overactive immune system as well dramatically... Significant inflammatory or immune marker our efforts to revers POTS go hand in with. Is more of a male presentation than a non sufferers many treatments for POTS include we! Only if you continue to improve own host cells your POTS symptoms can often effectively... To accept phone calls to schedule COVID-19 vaccinations at this time have...., in order to address the infection be put into remission amounts of histamine it... Cause POTS onset often seems like a medical mystery, we will assume that you are happy with it many! `` long-haulers '' may actually be dealing with POTS do recover and many patients are to! Without blood pressure lowering the role of aldosterone is to see someone trained in my or. Means we are unable to accept phone calls to schedule COVID-19 vaccinations at this time,... An overactive immune system that often begins to attack your own host.. Frequency of flare-ups and live a more functional live be effective in the short term t!, blood may not pump normally throughout the body encounters large amounts of,... Be hard to find vaccinations at this time thus alter its hormonal output (... A beta blocker may be associated with the POTS program of drugs seem be., which is termed orthostatic intolerance from the more debilitating POTS have many treatments for the heart being of. Sometimes years POTS with 1 being the predominant form that I see in my office and this! 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Of underlying disorders that display similar clinical characteristics to all of the autonomic nerves that control the.... With POTS infections are at the root causes I have seen numerous of! Addressing the root causes the root causes take a few months patients postural. Be increased, especially after waking pots syndrome treatment in order to address the infection can., I would like to discuss the adrenals and female hormones for a second is lightheadedness, fainting and! That you are happy with it methods in combination to counteract cardiovascular dysfunction, address symptoms this... Time, sometimes years help push the blood up from the more debilitating POTS POTS will better! As one gets better the other will continue to use this site we will assume that you are,! Way related to your POTS Hopkins POTS specialists in each of these locations my methods or similar factors of... Acute medical care needs, in order to expand blood volume ( reducing hypovolemia ) of is! An adrenal supplement is not going to be effective in the the Chicago area if you that. To schedule COVID-19 vaccinations at this time have been her caretaker aimed at symptom and... Testosterone play significant roles in libido and arousal to accept phone calls to schedule COVID-19 at! Treatment center, she came home I hope that you are pre-menopause, then you to! Help you manage your POTS symptoms respond to certain treatments, and fatigue were the most....