Spring has sprung! The sun is (occasionally) peeking out from behind the clouds to thaw us from the winter chill, and, after months of being cooped up and bundled up indoors, we are all ready to get out into the wild, bare our skin, and …
Get bit by a tick?
Of course, no wants to bring a tick home with them from their outdoor adventuring, but, if you are living in Maine or other coastal areas of the United States, the likelihood is very high. According to the website Everythingticks.com, these minuscule insects thrive in warm, wooded and humid environments – which describes the Maine climate in the spring and summer to a T! Unfortunately, these creeping, crawling creatures can transmit serious diseases through their bites, including Lyme disease. The sooner ticks are found and (properly) removed, the lower the risk of becoming infected with Lyme disease or other infections, many of which have long-term side effects if left untreated.
Tick Checks Can Keep You Safe and Healthy
Performing a tick check as soon as you get back home from hiking or other outdoor activities can help keep you safe from ticks that carry disease. Follow the steps below on yourself and any friends or family members that were adventuring with you outside – even if you were just frolicking in a grassy backyard!
1. Remove Clothing – Try to remove most of the clothing you wore outside as soon as possible to avoid bringing ticks into your home on shirt sleeves, pant legs or socks. Leave the clothes outside until you are ready to put them in the dryer on high-heat to kill any ticks that might be lurking.
2. Check Hot Spots – Just as ticks like hot and humid external environments, they also gravitate to the hotter and sweatier areas of the human body before they latch on for a meal of blood. “Hot spots” are areas of the body to which ticks gravitate, such as the armpits, groin and hairline. Because ticks can be so small, it is important to look closely, especially in areas with dark hair. If you are on your own, you can use a mirror to check hard-to-see areas, or you can ask a friend or family member to double check spots that are difficult to reach on your own.
3. Remove any Ticks – If you do find any ticks, it is important to remove the tick properly and fully. For more information about how to do this, go here.
4. Monitor for Signs and Symptoms – After removing a tick from your body, monitor how you are feeling closely. If you come down with a fever or chills or notice any odd rashes, body aches or other strange symptoms, be sure to contact your doctor immediately to discuss treatment options.
5. Consider Getting Your Tick Checked for Diseases – Click here for more information about testing a tick for disease-causing pathogens.
Since I practice Traditional Chinese Medicine, my knowledge regarding treating Lyme disease is rooted within the world of acupuncture and herbal medicine. And though I’ve read a fair amount about the subject, I can’t say I have a nuanced understanding of the antibiotic approach to treating acute or chronic Lyme. Prescribing antibiotics isn’t something I do.
I have, however, worked with multitudes of patients who were/are undergoing treatment for chronic Lyme, and I’ve often been part of that treatment through prescribing herbs (Western and Chinese herbs, mostly) and providing acupuncture. Most often, if a patient comes to see me for herbs, it’s because the antibiotics haven’t worked for them.
Though I’ve already written about this in previous posts, this bears repeating: The conventional approach to treating acute Lyme is controversial. From the blog of Kristen McElveen, a local ND who treats Lyme and chronic Lyme:
Currently, the ILADS recommendation for acute Lyme is a minimum of 6-8 weeks of antimicrobial therapy, while the IDSA/CDC is now even recommending 14-21 days. Unfortunately, many doctors are still only prescribing a single dose of doxycycline, or up to a week’s worth, which is not sufficient treatment, even from an IDSA/CDC standpoint.
Antibiotics are considered by many physicians to be highly effective in treating both acute and chronic Lyme disease – and for many people they are. Depending on the particular case, some people take antibiotics for months, some years at a time. That being said, up to 40 percent of people do not respond to antibiotic treatment. In fact, a study from Johns Hopkins University found that six months after Lyme treatment, 36 percent of patients reported new-onset fatigue, 20 percent reported widespread pain, and 45 percent had neurocognitive difficulties
Antibiotics, also known as antibacterials, are medications that destroy or slow down the growth of bacteria. They include a range of powerful drugs and are used to treat diseases caused by bacteria. Antibiotics cannot treat viral infections, such as cold, flu, and most coughs. Learn more: antibioticstore
The predominant theory for this involves the spirochetes’ ability to encyst when under “threat” (in this case, antibiotics). In the encysted state, the spirochetes enter a state of lowered metabolism and essentially hiberate. Fascinatingly, they can still monitor the environment in this state of hibernation, and when the threat is withdrawn, they change into a more active form again. (If you think we’re smarter than bacteria…you’re most likely wrong).
If you are dealing with Lyme, acute or chronic, here is a link to find a Lyme-literate doctor. Consulting a Lyme-literate practitioner, whether you have early or late stage Lyme disease, may be the right choice for you. In our clinic, Dr. Renee Lang is our Lyme-literate naturopath. Dr. Sasha Rose, Daniel Katz, and myself also have extensive experience treating Lyme with acupuncture and herbs (see below for more on this).
Naturally, this would be my favorite topic to write about when exploring approaches to treating Lyme. However, it’s already been done in such an eloquent and informative manner that I’m simply going to share with you an incredible piece on treating Lyme disease with Traditional Chinese Medicine. See it here.
Our most-often used brand for treating Lyme and co-infections are Classical Pearls. We have a variety of Pearls in stock at all times, but our most used are Lightening, Thunder, and Bamboo Pearls.
Of note, Andrew Weil suggests that patients seek out a practitioner of Traditional Chinese Medicine if they suspect chronic Lyme.
Cure Unknown, Inside the Lyme Epidemic: Written by Pamela Weintraub, Executive Editor at Discover magazine and science journalist, whose son became ill with Lyme and was the catalyst into her exploration of Lyme disease. This book is renown for impeccable research and captivating investigative journalism.
Healing Lyme: Easily my favorite. So densely packed with information and research that you wonder if Buhner is a Cylon. A wicked sense of humor, and a no-bullshit attitude when it comes to the kind of nasty politics that can drive medical ineptitude. An advocate for patients. An incredible herbalist with a healthy respect for research.
ILADS International Lyme and Associated Diseases Society: Through education, awareness, and action, ILADS promotes understanding of Lyme and its associated diseases and strongly supports physicians and other health care professionals dedicated to advancing the standard of care for Lyme and its associated diseases.
Summary: Effective diagnostic testing for Lyme has never been reliable. In the absence of an EM rash, there is no way to reliably and consistently diagnose Lyme disease , acute or chronic, using serological testing (testing the blood). Beyond this, Lyme is difficult to diagnose because fewer than half of all patients recall a tick bite or develop the signature bulls-eye (EM) rash, and routine Lyme ELISA screening test has up to a 60% false negativity. Coinfections also have a high rate of false negativity. Overall, the medical literature on diagnostic testing highlight the need for both and improvement and standardization in blood tests for Lyme disease and coinfections.
If you find a tick on your body or attached to you, REMOVE IT PROPERLY and SAVE THE TICK. Testing the tick for Lyme (and co-infections) is much easier than testing your blood later on. More on this below.
Instead, put the tick into a small plastic Ziploc bag with with a moist cotton ball or piece of wet paper towel.
You have the option to send this sample in for diagnostic testing. Remember, it’s much easier and much more accurate to test the tick itself. Here is the company we use:
Ticknology: They’re not free, but they’re affordable.
Diagnosing Lyme: Overview of Blood Tests…And A Litany of Problems
Clinically, Lyme disease is diagnosed based on symptoms: objective physical findings such as EM (erythema migrans, also know as the bulls-eye rash), facial palsy, or arthritis. Lyme can sometimes be diagnosed using serological blood tests. A serological blood test measures levels of specific antibodies in a patient’s blood. The most commonly used serological tests available for Lyme are referred to as a two-tiered test; typically, doctors will order an ELISA antibody test first, and if results are positive, a western blot test will be ordered. Research shows that the ELISA and the western blot are NOT reliable tests; if you look at the research literature on this methodology, the false negative rate is anywhere from 33% to 75%.
This being said, the ELISA and the western blot are still considered the “gold-standard” for diagnosing Lyme disease.
Let’s take a closer look. But first – if you’re simply not in the mood for the following dry-as-hell details about testing, and the problems inherent to the testing available, just read this succinct overview of current testing, from Columbia University Medical Center.
Below, I’ve listed out the detailed reasons why the “gold-standard” testing for Lyme is inadequate.
Measurable amounts of antibodies will not show up for 2-4 weeks after exposure, so if testing happens too quickly after infection, it’s possible to test (falsely) negative.
Spirochete levels tend to peak at 60 days after infection and then drop to low levels in the system. If tested when they are at low levels, many tests may not detect their presence.
Spirochetes can encyst, alter their genetic makeup, and alter their form. This makes testing for Lyme disease difficult. (I know – it sounds like I’m making this up. Spirochetes are creepy and smart. For more on this, see here.)
…a certain percentage of people are lucky enough to mount a robust antibody response and then that shows up on the blood test. A significant amount of people are not. And it also has been shown that the longer you’re sick with this and the longer it’s been since you were actually exposed, you’re actually less likely to show an antibody response because of the way the bacteria can evade the immune system. These are what are called stealth pathogens, and they’re actually remarkably well designed to persist and to hide from the immune system. So after a while, your body kind of gives up and stops making antibodies…
So the two-tiered testing has a pretty high false-negative rate. And if you do sort of make it through the first gate and you have a positive ELISA and then you do the Western blot, the CDC has set up this criteria wherein certain antibodies that you’re making are considered specific, and certain other ones are not, and they require that you have a certain pattern and a specific number of these different antibodies in order to qualify for a positive test. And there’s a lot of controversy about which ones they chose and which ones they didn’t. Back in the ’80s, they had developed a Lyme vaccine, which has been since taken off the market because of some fairly severe side effects that people were developing, but they changed the test once they did that, and they excluded certain bands which would have been positive as a result of the vaccine.
…And the other problem with the test is that there’s one kit that’s used that has been approved by the FDA and the CDC, and that kit has one strain of the bacteria, and it is the Lyme Connecticut strain. Worldwide, there are probably 300 different strains of this bacteria, and some really interesting cutting-edge research is coming out of California as we’re seeing what were thought to be only European strains. We’re seeing them showing up here. So Borrelia bissettii, Borrelia miyamotoi, and all sorts of other Borrelia bacteria, like Borrelia hermsii, which causes more of a tick-borne relapsing fever picture, which we’re seeing if we know to look for them. However, that one test kit is not going to pick those up because those antibodies are different. So there are a number of reasons why the testing is problematic. Sunjya Schweig, MD, from this interview
5. The ELISA test tests blood serum for the presence of Borrelia antibodies. Lyme ELISA testing is useless as a screening tool because of its high incidence false negativity. From Harrod’s book, Healing Lyme: “…a significant number of studies have found, and continue to find, that the ELISA test is not all that effective in diagnosing Lyme disease. In general, some 40 percent of people known to have Lyme (because of EM rash) test negative for Lyme infection with ELISA. To make this statistic worse, studies have found ELISA to be negative in 35 percent of people in whom a skin biopsy found cultivatable spirochetes.”
6. The Western blot looks for either IgG or IgM, two different antibodies that are produced in response to infection. Western blot evaluation is the best first step in lab evaluation, but it requires knowledge of which bands are reasonably specific for Lyme.
However, it should be noted that “IgM antibodies rise during the third week, peak after four to six weeks and then disappear by week eight – so if you tested after this, they may not show at all. IgG antibodies, which appear between six weeks and three months of infection, can persist for years or decades after successful treatment, and so when tested, people will be found to be positive for the disease even if they do not have it.” -Buhner, Healing Lyme (all of the journal articles are listed at the end of this book)
7. Borgermans et al. (2014) sums up the reliance on two tiered-tested: “There is consistent evidence that the two-tier testing lacks sensitivity, cannot distinguish between current and past infection, cannot be used as a marker for treatment, is often dependent on subjectively scored immunoblots, and is considered expensive.”
8. Given the unreliability of testing, it’s recommended that when diagnosing Lyme disease, practitioners should AT LEAST use a checklist of symptoms along with the western blot assay with at minimum two bands.
“Bands” are borrelial proteins of the same molecular size against which the patient’s blood is tested; the more bands, the more specific the diagnosis. Patients should consider, if not offered, requesting results that include all bands. They should also consider requesting antibody testing for some of the common co-infections like Bartonella and Babesia and Ehrlichia.
9. If you’re being tested with the western blot, have your doctor request a complete list of the bands that react with your blood (many labs simple report “negative” or “positive” and do not provide a list of the bands). In some circles, two bands are considered enough to diagnose Lyme: 41kd and another Lyme-specific band.
10. Borrelia bacteria are very, very slow growing (which is why treatment can take so long). That being said, borrelial organisms are best treated when they’re actively replicating. On average, they replicate once a month, which is different than “normal” bacterial infections.
11. IgeneX, Clongen Laboratories, Advanced Testing Laboratories, and Medical Diagnostics Laboratory are preferred labs for Lyme-literate doctors when ordering a western blot, as they test more bands including bands 31 and 34, which are specific to Borrelia burgdorferi (and are the actual bands the vaccine was made from).
12. This post isn’t definitive in regards to the tests available – there are many. The point of this was to review the most common tests used in attempt to diagnose Lyme disease. Some tests, notably a blood culture that, so far, seems promising, is still being researched.
13. Chronic Lyme and other tick-borne illness is a clinical diagnosis, meaning it is most often diagnosed by a Lyme literate physician based on history, physical exam, and laboratory testing. Because there is no one perfect test for this condition, and the currently available tests each have their own limitations, practitioners must pull all of the information together – history, exam and testing – to make a clinical diagnosis. You can see ILADS treatment guidelines here.
This is the 3rd post in a 4-series piece on Lyme disease. See the last post here.
This is the second post in a four part series. If you haven’t read the first post, The Lyme Wars, I’d suggest you start there.
This post gets into the details of Lyme disease. During my research on Lyme, it became obvious to me that understanding Lyme requires embracing complexity. Many people out there, patients and practitioners alike, shy away from a delving into Lyme because it feels overwhelming (and it feels overwhelming because it absolutely IS). This is an attempt to make the info out there more condensed and accessible, but also an attempt to leave no rock unturned. I urge you to take your time with this series of posts. Click on the links and read the research, understand the arguments and the treatment options.
Also, before getting into the details, I want to say one very important thing.
If you find a tick on your body, or on someone else, REMOVE IT PROPERLY and SAVE THE TICK!!! Put the tick in a small plastic bag with a small piece of wet paper towel. Testing the tick is way easier (and way more accurate) than getting tested for Lyme with blood work. However if you start to see the symptoms of lyme disease, its best to get tested to be sure you haven’t caught the disease. See Testing and Diagnosis for more information on this.
Lyme Disease (NOT “Lyme’s” Disease) is a bacterial infection caused by Borrelia burgdorferi that can be transmitted to humans and pets by ticks when they bite you (if they are infected). Not all ticks are infected, and even if they are infected, that doesn’t mean they will infect you if they bite you.
There are other tick-borne illnesses that can be transmitted with Lyme, like Babesia, Bartonella and Erlichia, which is why all of the illnesses together are referred to as “tick-borne illness,” because there are more than one. These are also often referred to as “co-infections.” You can have Lyme and not have any of the co-infections, but it is not uncommon to see people with at least one co-infection.
This is from one of my favorite local-to-Maine resources on Lyme, Dr. Kristen McElveen, ND. Her post on Lyme is practical, informative, and simple. See it here.
Borrelia burgdorferi: What’s in a Name?
Borrelia burgdorferi is the name of a particular spirochete; a spirochete is a particular type of bacteria. The word spirochete means “coiled hair” and describes the shape of this bacteria. Spirochetes have been around millions of years longer than humans; in fact, the more you learn about them, you may feel similarly to me, and wonder if they’re more intelligent than humans. (Read on, if you just rolled your eyes.)
There are 15 spirochetal genera and 300 (if not more) different species of spirochetes. Four of the fifteen spirochetal genera have been found to cause human disease: Leptospira and Brachyspira, as well as Treponema (famously, syphilis), and Borrelia (famously, burgdorferi).
Borrelia burgdorferi is the species of spirochete most talked about when discussing Lyme disease.
A quick overview.
Borrelia is the genus, and burgdorferi, the species.
Often Borrelia burgdorferi is written, or referred to as Bb, because who wants to say Borrelia burgdorferi over and over again?
You’ll come across the term ‘borreliosis,’ which means a disease caused by Borrelia bacteria. (‘Lyme borreliosis’ is a more specific term than ‘borreliosis.’)
But wait! It’s important to understand that different species, subspecies, and strains are commonly lumped within Borrelia burgdorferi.
It’s why you often see this bacteria referred to asBorrelia burgdorferi sensu lato (sensu lato means “in the broad sense”). In other words, Borrelia burgdorferi sensu lato refers to all the Borrelia that cause Lyme-like disease. Why am I getting into all this detail, you ask?
Stephen Buhner, of the fastidiously-researched, Healing Lyme, makes some compelling points on this taxonomic confusion.
They should more properly be called borreliosis, which simply means a disease caused by Borrelia bacteria…Each of these subspecies and strains possess slight variations on the core genome; all cause slightly or very different symptom pictures…each borrelial species, during infection, produces offspring that have slightly to very different genetic structures. In other words, when you get Lyme disease, you don’t just have one bacterial species in your body making you sick but rather an infectious swarm of similar but not identical genetic variants. This is one of the reasons why antibiotics are less than perfectly successful at treating Lyme infections.
-from Healing Lyme (2nd edition)
The Black Legged Tick: The Most Common Vector of Bb
The best documented route of Bb transmission is by a tick bite, and usually it’s the black-legged tick of the Ixodes genus (Ixodes scapularis and Ixodes pacificus are the most common). For a great resource, see these vibrant photos of different species of ticks. Proper identification is always helpful.
Nymph and adult black-legged ticks can transmit Lyme bacteria. Nymphs, the most likely to transmit Lyme disease, are about the size of a poppy seed. Upon attaching to a host, the tick releases a series of anti-inflammatory chemicals and antihistamines to numb the skin, and secretes a glue-like compound called cementum which helps it stay stuck to the host. After inserting its mouthparts into the host to feed, an infected tick can inject borrelia, and other pathogens, into the bloodstream. For a delightful illustration of this (blech!), see here.
As I alluded to previously, borrelial organisms are clever, and apparently I’m not alone in thinking this. In an article in the New Yorker, journalist Michael Specter interviews Richard Otsfeld, a senior scientist at the Cary Institute of Ecosystem Studies, who has studied Ixodes for over 10 years.
Ostfeld is a thoughtful, soft-spoken man, not unduly excitable. But when he talks about the Lyme bacterium he sounds like a proud parent. “Borrelia is a remarkable creature,” he told me. “It has all my respect.” He went on to explain that the bacterium, after slipping through the tick’s mouthparts, can change its form, cloaking itself in the surface proteins of the tick’s saliva. Then, much like H.I.V., the bacterium hijacks the immune system. “It doesn’t stay in the bloodstream for long,” he said. “Instead, borrelia manages to insinuate itself into parts of the body that have fewer circulating antibodies, where it is harder for antibiotics to reach.”
Nazzzty little things. NAZZZTY!
Lastly – it’s common knowledge that the transmission time from an infected (attached) tick is about 2 days. However, when existing research on this was reviewed, it showed that many factors were involved that affected transmission time, and transmission of bacteria can occur with tick attachment anywhere between 10 minutes and 72 hours.
The Bulls-Eye Rash That May Never Appear: KNOW WHAT’S UP
If you are infected, symptoms appear anywhere from 2 to 30 days after you’re bitten. Early symptoms are flu-like (fatigue, aches, fever, etc.) Some people develop a distinctive bulls-eye rash (erythema migrans, often referred to as EM), but some studies show that this occurs in less than half of infected people.
In addition, the rash may not look like a typical bulls-eye rash and may be in an area on your body that you can’t see; an atypical rash, if you have one, will usually occur around the place you were bitten and will often expand over time.
A bulls-eye rash is diagnostic of Lyme disease. Period. Blood testing, in this case, is not required for diagnosis. If you have a bulls-eye rash, anywhere on your body, you have Lyme disease. Treatment should start immediately.
Acute and Chronic Lyme: Symptoms
I got this handout at the 2016 MidCoast Lyme Conference in Wiscasset, Maine; I wish I knew who put it together so I could give that person or organization credit (let me know if it was you!). MidCoast Lyme Disease Support and Education is a great resource, btw. See their website here.
Prevalence and Geography
Borrelial organisms have been around longer than humans. In other words, they ain’t new (and neither are borrelial infections). In the U.S., Lyme has been reported in all 50 states, though it’s most prevalent in the Northeast, Northwest, and Great Lakes area. It’s theorized that the disease has captured our attention more now than ever because of the spike in numbers of people infected.
But why are more people getting infected?
Spikes in infection rates are attributed to population increase and resulting alterations to the physical environment. Climate change, too. From Specter’s article on Lyme in the New Yorker:
Deer are not Ixodes’s most important host, but they have come to symbolize the spread of Lyme, and represent an ecology that has changed dramatically in the past thirty-five years. “Once you have Lyme disease in the area, and once you start to carve up the forest into little bits, and especially when the fragmentation is done by suburban development, you get an increase in Lyme risk,” Richard Ostfeld told me recently when I met with him…”The best host for the tick and pathogens is not deer but white-footed mice,” he said. “And they do beautifully when you chop the forest into bits. They thrive. And competitors do not.”
As for infection statistics, which I covered in some depth in an earlier blog post, The Lyme Wars – let’s just say that infection rates have been grossly underestimated. But to sum it up, here’s Stephen Buhner from Healing Lyme:
In 2004, as I was writing the first edition of this book, the CDC was insisting that only 20,000 new Lyme infections were occuring yearly…this despite the fact that Germany, a significantly smaller country, was reporting 30,000 new infections each year. Still, even then, Harvard researchers were insisting that infections were, at minimum, ten times the CDC number, in other words, at least 200,000 infections per year. In response to tremendous pressure from both researchers and Lyme support groups, in 2013 the CDC altered that figure, finally agreeing that, at least, 300,000 infections were occurring every year in the United States.
It’s argued (convincingly, in my perspective) that every state in the US is endemic to borrelial infections. Endemic = common to that locale.
A quick note of importance: Pets can bring infected ticks into the home. They can also get Lyme disease. See here for more.
Really, an issue that deserves its own blog post.
In sum – an infection transmitted by the bite of a black-legged deer tick infected with Bb is often complicated by coinfections. Coinfections are other bacteria, protozoa, and viruses carried by the same tick. Because some of these other diseases are caused by protozoans or viruses, not bacteria, antibiotics will not help. All infections must be treated for you to get well.
When you think of Lyme disease, therefore, consider a potential coinfection/coinfections as a rule. The most common causes? Bartonella, Babesia, Anaplasma, Ehrlichia, and more recently, Borrelia miyamotoi. (They all have their own distinct clinic symptoms, as well, so diagnosing coinfections can be tricky.)
And don’t forget! SAVE THE TICK! A natural reaction of disgust is to toss it to the ground with the desire to squash it into oblivion. Don’t do that. Put it in a sealed plastic bag with a lightly damp cotton ball (no alcohol); it may be more than helpful for you to have in the next month. Date the plastic bag and keep for at least 6 weeks.
Side note: Though there is limited research on this (well, there is some research on andrographis as an antibacterial herb), Stephen Buhner recommends applying andrographis tincture after removal of a tick and then covering that area with a green clay pack (simply mix green clay powder with an equal amount of water, apply, and cover). Buhner reports great success with this approach (though admittedly, at this point reported successes are only anecdotal). I carry a small, portable tick first-aid kit with me; it has a stainless steel tick remover, a couple of Band-Aides, a little container of green clay, and a small tincture bottle of andrographis (Andrographis paniculata).
Of utmost importance, so familiarize yourself.
Here’s a printable info sheet about tick prevention from The Lyme Alliance of the Berkshires. Also, see here. And here.
Does Chronic Lyme Exist?
It’s a persistent, controversial question. My opinion (based mostly in research, but affected by clinic experience) is YES. Because I already wrote about this in detail, please see The Lyme Wars for more on this (including links to much of the research that helped me form my personal approach).
Are all the questions answered? Nope. Does more research need to be done? Absolutely. Are the politics still raging on? Sigh….yes. Would you like an unbiased, succinct summation of these issues, from Columbia University Medical Center?
In short, Lyme infection can lead to severe illness and disability in some people. It can affect any system of the body. Lyme can cause (but is not limited to) extreme fatigue, arthritis in any joint, neurological problems, psychiatric problems, cognitive problems, ongoing headaches, muscle pain, and vision and hearing problems. No two cases of Lyme disease are the same; it should be considered, and is, difficult to diagnose.
Remember this: The diagnosis of Lyme disease is based on a clinical presentation; the laboratory can support or confirm the diagnosis, but it cannot rule it out. For more on testing and diagnosing Lyme, see here.
Left untreated, or under-treated, Lyme disease can persist of years, even a lifetime.
This is the 2nd post in a series of four posts. For the next two posts, see: