[Information needs of patients with cardiovascular disease in health information seeking process: a qualitative study]

Introduction: Seeking health information is of salient importance in management of cardiovascular diseases [CVDs]. The present study aimed to explore and reveal the information needs of patients with cardiovascular diseases when seeking healthcare information. Our data sources were patients', family caregivers' and healthcare providers' experiences

Method: In a qualitative research approach, content analysis method was used. There were 31 participants comprising 16 cardiovascular patients, 5 family caregivers, and 10 healthcare providers. Required data were gathered through semi-structured interviews and purposeful sampling, and continued until data saturation. Analysis of data was performed concurrently with data collection and through a comparative method

Results: Four central themes including disease-related, healthcare-related, health system-related and life-related information needs emerged out of content analysis

Conclusion: The results showed that information seeking in patients with cardiovascular diseases is holistic and is beyond physical health and the disease. Some of the important findings of this study are seeking information about prognosis, role playing, mental and sexual health, healthcare system performance, modern medicine, Islamic and traditional medicine. Therefore, providing information through various modes of communication for meeting patient needs, having their participation in decisions for treatment, and optimal management of life is necessary

[Internet addiction and its related factors among nursing students in Tehran university of medical sciences in 2013]

Introduction: In recent years, internet is becoming an integral part of individuals, especially activities in everyday life. Continual technological change, first question that comes to mind is the internet addiction status among nursing students at universities. The aim of this study was to determine internet addiction and its related factors among nursing students in Tehran University of Medical Sciences in 2013

Method: In this analytical study, 330 Nursing Students from Tehran Universities of Medical Sciences enrolled in the study. Data collection were carried out using Young's Internet addiction test and demographic variables questionnaire and then analyzed using SPSS version 21

Results: Based on our findings, 82.3% of the students did not have Internet addiction. There were statistically significant relationship between internet addiction and demographic variables including gender, status, personal computers, science websites, personal blogs, personal websites, Web chat [chat], listening to music, surfing the Web, making friends, playing online games, blogging, duration of internet use per hours per day, time of the week, time of Internet use [P < 0.001]

Conclusion: The findings of this study indicate that 17.7% of the nursing students in this study had Internet addiction. Regarding the increased pattern of Internet use among students, appropriate training programs and effective Internet based interventions to promote knowledge and inspire healthy behaviors in the nursing students, are essential

[Relationship between suicidal ideations and psychosocial characteristics in depressed patients]

Introduction: More than 1000 suicides occur daily worldwide and suicidal attempts occures 10 to 20 times. Identification of risk factors can lead to design preventive interventions to reduce the incidence of suicide. The aim of this study is to determine the association between suicidal ideations and psychosocial characteristics in depressed patients of Razi Hospital in Tabriz

Methods: This descriptive analytical study was conducted in 2013. 80 depressed patients who have suicidal ideation were selected through convinience sampling method. To collect data, a questionnaire consisting of social and mental questionnaire and Beck suicide ideation scale was used. To analyze data, descriptive and inferential statistics was used

Result: The overall results of this study showed that significant relationship was seen between suicide ideation and dimensions and gender, job, education, history and method of suicidal attempt, physical disorders, using non psychotropic drugs [P<0.05]

Conclusion: Regarding the issue that suicidal ideation is an important risk factor for successful suicide and identification of vulnerble groups have important role in suicide prevention; therefore, According the result of study we suggest that female patients with lower education less than diploma that use psychotropic drugs should be further considered as a risk group

[ effects of the group reminiscence on cognitive status of mild cognitive impaired elders]

Introduction: The growth of the elderly society and contagion of various cognitive impairments and disorders among this age group, attending accessible, inexpensive and low-side cure and care methods has become a necessary issue. The purpose of the present study was to investigate group reminiscence effects on cognitive abilities of mild cognitive impaired elders

Methods: This research was in the semi-experimental category aimed to determine the influences of group reminiscence on cognitive abilities of mild cognitively impaired elderly at the "Jahandidegan-e-Shiraz" institute. Thus, Seventy two 60-84 years old people of this institute [48 females and 24 males] were purposefully chosen, as the subjects, and were divided into three teams of group reminiscence, group intervention and without intervention, considering the same proportion between the three teams. Mini-Mental State Examination [MMSE] was implemented on the subjects, before and after the interventions. The reminiscence intervention was in a manner that the group reminiscence team attended 8 group reminiscence sessions [one weekly session with the spans of 60 to 90 min]. Meetings of the first evidence team [group talks] were similar to the group reminiscence one, except for those meetings which were held without any reminiscence, and its subjects were talking about usual and daily issues, as a group. The third team [the second evidence group] didn't receive any intervention, during the research

Results: Cognitive abilities increased significantly, among the two teams of group reminiscence and group intervention. Also, the increase in group reminiscence team was significantly further than those of two other groups, and the increment of group intervention team was significantly more than that of the group without intervention [P<0.05]

Conclusion: According to results of this study, it should be considered that the elderly, who have mild cognitive impairments, could improve their cognitive abilities by group reminiscence. It seems, even group talking could increase cognitive abilities of these elders. Though, it is appropriate to execute the group talking in a group reminiscence manner. However, further researches are required, to achieve more accurate conclusions

[Prehospital services by focus on road traffic accidents assessment developed and developing countries]

Prehospital services in road traffic accidents are one of the critical aspects of prehospital services. The goals of these services in traffic accidents is providing services to clients who need to on time interventions, prevention of disabilities and rapid and safe transportation by trained practitioners. The aim of this article was review the prehospital services by focus on road traffic accidents, in developed and developing countries. In this review article for data gathering, data bases of Google Scholar, PubMed, CINAHL and Science Direct searched by key word strategies. Eventually 43 articles since 1999 to 2012 selected. There are differences in structure, level of services and human resources in prehospital systems that created different patterns in countries. Many countries by strategies such as continuous public and professional education have compensated the weakness of other aspects. Prehospital service systems have several aspects such staffing, education, technology, management and organization. Each country must design their appropriate pattern to provide the best service to community

[Designing an adaptation model for retired nurses]

Increasing number of retirees and improved life expectancy has been resulted in increased retirement years. The status of Iranian nurses seems to be different from nurses in other countries; yet no model has been proposed regarding the adaptation of nurses with retirement. The aim of this study was to propose an adaptation model for retired nurses. It was a qualitative grounded theory study. The participants were 20 retired nurses from Semnan city who were recruited by purposeful and theoretical sampling. In the first stage data was generated by semi- structured interviews. Field notes were also used as data. Data collection and analysis by constant comparison was done simultaneously using Strauss and Corbin method. In the second stage, the model of adaptation with retirement was composed using the themes emerged in the first stage and literature review according to the Walker and Avant method. the proposed Model included some stages for nurses' adaptation with retirement: preparation for the experience of retirement, identity reconstruction strengthening, optimum use of supportive factors, attention to negative interactions, and providing facilities for a normal life. Since retirement is not a mono- stage, simple transition process, but is an adaptation process that occurs during time, the proposed model would help nurse retirees to control stressors and imbalances in their lives and adapt with retirement successfully

Characteristics of care and caregivers of alzheimer's patients in elderly care homes: a qualitative research

Due to the increase in the number of Alzheimer's patients in Iran and also the limitation of cultural knowledge about caring of these patients, this study was designed to explore the perceptions of Iranian caregivers about caring Alzheimer patients in the elderly care homes. A qualitative content analysis method was conducted on two elderly care homes of Shiraz/Iran, during 2009-2011. Fourteen key informants [10 women and 4 men, between 25-35 years of age], who had been working in elderly care homes caring for the elderly with Alzheimer disease for about 1-11 years [Mean=30 months] were selected by purposive sampling method. The caring experience and ability of transferring their experience to others were the main criteria for selection of the participants. They were participated in 2 focus groups and 4 interviews. Nearly, 800 initial codes were extracted and categorized into 3 groups of "multidimensional care", "going along with the patients" and "need to be professional" and 12 subcategories. Although several aspects of care were mentioned by the participants but the main aspect was physical care. Infantilizing the patients was the main feature of care and caring personality was an important characteristic of caregivers. An appropriate schedule of care considering main categories and subcategories of this research based on cultural context should be prepared. Moreover, consistent promotion of the schedule, employment of trained staff and plans for continued education for them can improve the quality of care and patient's life in elderly care homes

[ impact of multi-dimensional model of psychiatric rehabilitation care on hemodialysis patient's depression]

Hemodialysis in chronic renal failure, which has affected all aspects of the incidence of disease and disorders such as, depression. One of the ways to have an appropriate quality care in hemodialysis units is to employ nursing care model. This study aimed to determine the effect of multi-dimensional model of psychiatric rehabilitation care on hemodialysis patients who were depressed. This study is a quasi-experimental study of two groups before and after the sampling method based on 35 hemodialysis patients of Razi hospital in Rasht [test] and 35 hemodialysis patients from Shahid Beheshti Hospital in Anzali [control]. Intervention was based on psychiatric rehabilitation of multi-dimensional model with a doctor, nurse, psychologist, nutritionist, and comprehensive client and family as a team and with consideration of physical, mental, social and spiritual clients separately and each was done in three months. The instruments included a questionnaire for collecting demographic and the Beck Depression Inventory [BDI], which was measured before and three months after the intervention. Then the data were analyzed using SPSS 16 software and descriptive statistical, paired t-test, independent t-test, analysis of covariance, Chi-square and Fisher test. Data analysis between the mean depression score of samples before [8/285 +/- 30/11] and after the intervention [10/309 +/- 24/20] group showed a significant difference [p<0/001]. The multi-dimensional model of psychiatric rehabilitation care, a significant difference in depression scores in hemodialysis patients is caused, so the implementation of this model of care is associated with better living conditions in hemodialysis patients

[Needle sticks injuries among health care workers in emergency medical centers in Tehran University of Medical Sciences Hospitals [2007-2010]]

Today, Needle Stick Injuries [NSI] are very important occupational hazards experienced by healthcare workers lead to exposure to blood-borne viruses especially hepatitis B, hepatitis C and HIV. The aim of this study was to determine needle sticks injuries among health care workers in emergency medical centers in Tehran University of Medical Sciences hospitals [2007- 2010]. In this descriptive study 991 health care workers worked in emergency wards in Tehran University of Medical Sciences hospitals were followed for needle stick events from 2007 to 2010. Sampling method was census. Data were collected by a researcher-made questionnaire consisted of 32 questions included demographic variables and NSI included the event that leads to needle stick injuries. Content and face validity and also test-retest reliability [r = 0/71] were measured and data was analyzed by SPSS 16. The study population reported 167 needle stick injuries during the study period [167 health care workers exposure group, 554 health care workers not exposure group]. Incidence rate of NSI was 16/85%. Majority of subjects in exposure group were female [50/89%], married [52/69%] and nurse [53/2%] and also the mean age was 35/3 +/- 6/4. In most cases, needles [55/08%] and vein catheter [22/75%] were responsible for injuries. IV access [24/7%] and recapping of needles [23/3%] were most common action resulted to exposure. There weren't statistically significant different in demographic variables except working experience between exposure groups and not exposure group. According to the results of this study, incidence rate of NSI among HCWs worked in emergency wards in TUMS less than other studies in different countries. This might be an indication of inadequate reporting. It is suggested that, NSI in hospitals should be managed through obtaining an appropriate reporting system and organizing blood and body fluid exposure surveillance system

[Evaluation of clinical skills of medical emergency personnel in Tehran Emergency Center confronting the trauma]

Capability evaluation of medical emergency personnel, which is considered as one of the priorities in confronting the diseases, may provide an appropriate reflection of the performance of pre-graduation training programs and continuous training. The aim of this study was evaluation of clinical skills of medical emergency personnel in Tehran Emergency Center confronting the trauma. This descriptive study has been applied on 536 medical emergency personnel of Tehran Emergency Center. 213 persons were selected via stratified random sampling method. Data were collected through demographic questionnaire and "Clinical Skill Checklist". Content validity of the "Clinical Skill Checklist" has been evaluated and confirmed by 10 lectures and experts. Also reliability coefficient of all skills was equal to 0.803. The researcher observed the medical emergency personnel skills and then completed the "Clinical Skill Checklist". Data was analyzed with SPSS/17, statistical independent T tests, univariante variance analysis, Bonferroni post hoc test and correlation coefficient of Pearson. The results of the study indicated that 62.4% of the medical emergency personnel had good grade in trauma skill but practicing two skills of seated patient's spinal immobilization and traction splint had major skill deficiency. Between age, educational level, field of study, employment records and trauma clinical skill a significant statistical relationship existed [P<0.05]. Although in most skills, the medical emergency personnel had good grade skill, but it is required to provide necessary trainings in two skills that have not obtained sufficient point

[Retired nurses' experience from retirement: a qualitative study]

Retirement is a new phase in the life cycle and away to improve health and self-care and living conditions. The aim of this study was to explore the experiences of retired nurses in retirement time. This study was performed by qualitative design and content analysis method. Sampling was based on purposive and participants were 20 retired nurses that live in Semnan. In addition, participants had a BSc in nursing and 1 to 5 years of retirement time. However, they had different positions in various wards and hospitals with 23-30 years' of full-time experience. Data was collected through semi- structured interviews and the sampling ended when the data reached saturation. The main theme extracted from the data analysis was to identity the threat. Classes include "shock and disbelief", "hard separation of the work" and "frustration" that contained several sub-classes. The experience of retired nurses during the retirement was identity threat. Suitable retirement planning and effective interventions to improve existing conditions by authorities and managers of nursing, can prevent incidence of identity threat in retired nurses and provide health promotion and efficiency for nurses. Furthermore, findings of this study can provide and facilitate more future studies in this field

Prevalence of Musculoskeletal disorders and it's risk factors among, mothers' home working

Background: Musculoskeletal disorders are one of the most important occupational health issues in the world

Materials and methods: This cross-sectional study was conducted on 333 stay-at-home working mothers. We used modified Nordic questionnaire for this study. Data was collected by trained interviewers

Results: The most common musculoskeletal disorders were in the low back [49.5%], neck [24.1%], and shoulder [21.2%] areas. The results showed that there were significant relationships between low back and knee pain and BMI [p=0.008], between shoulder pain and laundry method [p=0.04], between leg pain and house cleaning method [p=0.01], and between knee pain and use of stairways [p=0.004]

Conclusion: There is a significant relationship between musculoskeletal disorders and the use of various devices in household chores. More research is recommended to clearly identify the correlates of musculoskeletal disorders

Effects of Daphnia magna fed with B group vitamins-enriched Chlorella sp. and Scenedesmus obliquus on the growth rate of Rutilus frisii kutum fry

Currently, white fish or Kutum Rutilus frissi is considered to be a good candidate for commercial aquaculture. However, little information is available regarding the nutritional requirement of this fish fry. Experiments were conducted to examine the effects Daphnia magna as live food cultured on two freshwater green algae, Chlorella sp. and scenedesmus obliquus enriched with different B group vitamin dosages [0.00 as control, 0.50, 1.00 and 2.00 mL of enriching solution per liter of algae culture medium] on the growth and survival rates of Rutilus frisii kutum fry. Results demonstrated that increasing in B group vitamin dosages are caused an increasing in nutritional value [Kcal] of two freshwater green algae species Chlorella sp. and Scenedesmus obliquus significantly. Significant differences were observed in BWG [%] and SGR between different vitamins treatments both the fed Daphnia magnia cultured on Chlorella sp. and Scenedesmus obliquus enriched [P<0.05] but not in survival percentage [P>0.05]

Positive effects of illness following acute myocardial infarction

Myocardial infarction is an important event and a huge change in patients' and their family life. The negative psychosocial consequences of the disease are well documented. However, studies on positive effects following myocardial infarction are much more limited. The aim of this study was to explore positive effects of illness following acute myocardial infarction. This paper is a part of findings of a more extensive grounded theory study. Eighteen people with first time myocardial infarction were selected by purposeful and theoretical sampling. Semi-structured interviews were used for data collection. The data were analyzed using constant comparison method. The findings showed that the participants have experienced one or more positive effects of the disease. Positive effects of illness were emerged in three main categories including: healthy lifestyle, worthwhile life/health, and promotion of social interaction/ interpersonal relationship. Patient with myocardial infarction experience huge tensions. However, the disease would also result in positive effects which could, in turn, facilitate recovery from illness and the process of adjustment to illness

[Needs of family caregivers of the patients with Alzheimer disease: analyzing of family caregivers experiences]

With the increasing elder population, providing effective family care is turning to be the most important challenge in health and welfare of elder people. The aim of this study was to explore needs of family caregivers of the patients with Alzheimer disease by analyzing of family caregivers experiences. This qualitative study was conducted by latent conventional content analysis. 35 family caregivers of elder patients with Alzheimer disease participated in the study. Participants were selected based on purposive sampling. Sources of information included documents of participant's diaries, about their problematic and complicated days of caring. Data were analyzed through reading and rereading documents, determining meaning units, extracting of codes and categorizing of them. Most of participants [80%] were female, with mean age of 56/2 and literate [under diploma level]. The findings generated 794 initial codes, which were grouped in 7 categories of: need to knowledge, receiving help from other family members in caring, modification of the home environment, self caring of caregivers, need "to be visible", compatible and complimentary health care system and caring equipments. Regarding to Global expansion of Alzheimer disease, considering the family care giving issue of elders with Alzheimer disease is essential. Therefore, providing suitable information, establishing education for caregivers related to disease and patient care management, management of caregivers' health, psych-social support and establishing of appropriate complimentary health care system for elderly patients should be considered. These strategies would facilitate the family care giving and support the caregivers on their journey

prevalence of musculoskeletal disorders in health- treatment employees at sabzevar university of medical sciences, iran in 2008

Background and Purpose: Musculoskeletal disorders among the most important occupational health issues nowadays. As the ministry of health is responsible for the community health and providing better services requires healthy workforce, the present study was conducted to determine the prevalence of musculoskeletal disorders in health-treatment employees at Sabzevar University of Medical Sciences, Iran in 2008

Methods and Materials: This cross-sectional descriptive analytical study was conducted on 364 personnel of health treatment employees at Sabzevar University of Medical Sciences, Iran in 2008, who were selected through convenient sampling. The disorders were investigated through Nordik Questionnaire including those in 9 body parts within the past week, past year, and falling behind work due to disorders. The obtained data were analyzed in SPSS 13 using independent test and correlation coefficient.

Results: Mean +/- SD and employment period of the participants were 31.81?6.?? and 9.36?7 respectively. The highest prevalence of the past year in all participants was related to their waist [57.8%], knee [44%] and [42.6%]. However, in participants working for treatment centers, the figures were 61.6%, 46.9% and 48.6% respectively. In the paramedical employees, disorders of was 29.7% and in health center employees, wrist disorders were 28.4%

Conclusion: The prevalence of disorders in university employees is high and the highest rates are related to waist and knee. Disorders of back, waist, knee in the treatment and center employees, and neck disorders in health center employees were higher

[Home care effectiveness in preventing rehospitalization of acute schizophrenic patients]

Frequent rehospitalization is one of the complications in treatment of schizophrenic patients. The present study was design to determine the effectiveness of home care service in preventing rehospitalization of schizophrenic patients. A semi-experimental study was conducted with 48 schizophrenic patients who were randomly allocated in two groups of intervention and control [20 patients in each group]. Home care services after discharge were delivered to the intervention group for three months. Control group received routine services included appointing a date for next visit at psychiatric clinic. Both groups were followed up for six months, after discharge. They were compared for their rate of rehospitalization. Chi square and Student's t-test were used to analyze the data. The results revealed that rate of rehospitalization after three month follow up was%25 [6 of 24 patients] in control group and zero in interventional group which was significantly different [P<0.001]. Six months later, the rate turned to%21 [5 of 24 patients] in intervention group and%46 [11 of 24 patients] in control group which was significantly different [P=0.002] as well. Home care after discharge reduces rehospitalization of schizophrenic patients

[Evaluating the effect of continuous care on quality of life in discharged schizophrenic patients from Sina educational and medical center, Hamedan]

Considering chronic nature of schizophrenia and failure of current plans, developing an effective continuous care model is needed. One of the methods to promote quality of life is applying continues care nursing model. The present study aimed at evaluating the effects of continuous care model on quality of life of schizophrenic patients in Hamadan. All 36 patients have been selected based on inclusion criteria [census], and divided randomly in two similar control and interventional groups of research. The data gathered from demographic, [QLS: alpha=0.81] questionnaires and control check list [alpha=0.92]. The orientation and sensitivization phases of the model applied on the interventional group in the hospital [6 sessions of education, A quasi-experimental study was conducted with a sample of 36 schizophrenic patients. They have been drawn from Sina Hospital, among 89 patients who fulfilled the inclusion criteria. The participants were allocated to two groups of control and intervention through simple random allocation. Data were collected using questionnaires of Heinrich Quality of Life and self-control check list. Continuous care model was applied for intervention group through orientation and sensitivization [six educational sessions: two times a week] in hospitals, then control and evaluation [6 home visits: two times a week] at their home. Data were analyzed using independent T-test, paired T-test and analysis of variance. There was no significant difference between quality of life mean scores of two groups prior to the intervention [P>0.05]. After the intervention, mean score of quality of life in interpersonal relationship was significantly different [P=0.03] but Independent T-test didn't show any significant differences between groups in spite of increased scores of quality of life and its dimensions in intervention group [P>0.05]. The study demonstrated the effect of continuous care model on interpersonal relationship. Since improving interpersonal relationship is the most important aim of care for chronic patients, and it could consequently have an effect on other dimensions of quality of life, using the model could improve total quality of life and other dimensions. Results of present study and similar studies illustrate the necessity of providing nursing care after discharge for chronically ill patients. It could decrease the relapse rate and hospitalization, besides valuable impact on their quality of life

[ effect of spiritual-religious group therapy on mental status of schizophrenic inpatients]

Schizophrenia is one of the complex psychiatric disorders. Although the antipsychotic agents are the main treatment for the disorder, but psychological interventions are effective on clinical symptoms as well. The study aimed at assessing the effect of spiritual-religious group therapy on mental status of schizophrenic patients. Using semi-experimental study method 67 patients with schizophrenia were selected through Randomized Permuted Block method. They were divided to intervention [32 patients] and control [35 patients] groups. Intervention group were participated in 12 sessions of Spiritual Religious Group Therapy within 4 weeks [3 sessions per week]. Each session lasted one hour. Data was collected through a Demographic Information Questionnaire and Brief Psychiatric Rating Scale [BPRS]. Statistical Analysis was carried out, using Paired T-Test and One Sample T-Test. Significant differences were found between patients' mental status before and after the intervention [P=0.001], whilst the difference was not significant in the control group [P=0.268]. There were no significant differences between intervention and control groups prior to the intervention [P=0.093]. Spiritual Religious Group Therapy can be effective on improvement of the mental status of schizophrenic Patients

[Incidence of sepsis in neonates with indirect hyperbilirubinemia in Shohadaye Tajrish hospital]

Jaundice is one of the common problems in neonates and may lead to some irreversible complications. 60% of term and 80% of preterm neonates during first week of their life are icteric which mostly are due to indirect and physiologic hyperbilirubinemia. This problem could have some important pathologic causes, such as sepsis. Because of the high referral rate of neonates with jaundice and suspicion of bacteremia and sepsis, this research conducted to determine the rate of bacteremia and causative microorganisms in Shohadaye Tajrish hospital. This study was based on patient's records. All patients were fullterm [>37 weeks] newborn with age of <28 days and birth weight of >2500 g with chief complaint of indirect hyperbilirubinemia without any symptoms of sepsis that were admitted in Shohadaye Tajrish hospital during years 2002-2003. Neonates with symptoms of sepsis and direct hyperbilirubinemia were excluded. Positive blood cultures confirmed sepsis. During the period of this study, 394 neonates were admitted due to hyperbilirubinemia and 201 cases had the criteria of research. 153 cases had positive blood culture and 21 [13.7%] had bacteremia but in second blood culture of these neonates, 5 cases had positive blood culture and only in 2 cases the same bacteria were grown and in 3 other cases different bacteria were detected in sepsis work up, 2.8% had erythrocyte sedimentation rate more than 15, C-Reactive Protein [CRP] was 1+ in 3.6% of patients, 2+ in 1.2% of patients, 3+ in 0.6% of patients. In 94.5%, CRP was negative, the serum levels of bilirubin in 14.9% were less than 15, 54.7% between 15 and 20, and in 30/4% were more than 20. 97.4% had jaundice on the first week of life, 4% were Glucose-6-phosphate dehydrogenase deficient, 18.9% had ABO incompatibility, and 8.4% had Rh blood group incompatibility. Cause of jaundice in 67.8% was unknown. There was no positive urine culture in suprapubic specimen, but in 17% of patients' urine culture were positive in urine bag specimen. It seems that bacteremia and sepsis without any clinical symptom [other than direct hyperbilirubinemia] is unlikely to happen and sepsis work up can cause excessive sampling, and sometimes lead to misdiagnosis