Heart Scan Machine – Stroke Prevention Testing & Screening Near Me

Stroke Prevention  and also Screening near me
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5 Preventive Health Screenings for these Diseases:

 

 

Carotid Artery Disease – Heart Scan Machine

An ultrasound is executed to evaluate the carotid arteries (a set of capillary in the neck that provides blood to your brain) for the build up of fatty plaque. Heart scan machine.  This build up, called atherosclerosis, is one of the leading root causes of stroke.

Carotid (kuh-ROT-id) ultrasound is a secure, painless treatment that makes use of acoustic waves to examine the blood flow via the carotid arteries. Heart scan machine.

Your  2 carotid arteries  lie on each side of your neck. They  supply blood from your heart to your brain.

Carotid ultrasound  examinations for blocked or narrowed carotid arteries, which can  boost the risk of stroke. Heart scan machine.  The outcomes can help your medical professional establish a treatment to reduce your stroke threat.

Ischemic stroke. A carotid ultrasound is  done to test for narrowed carotid arteries, which  enhance the  danger of stroke.

Carotid arteries are generally narrowed by a buildup of plaque – comprised of fat, cholesterol, calcium and other compounds that flow in the blood stream. Early medical diagnosis and treatment of a tightened carotid artery can lower stroke risk.

Your medical professional will recommend carotid ultrasound if you have short term ischemic assaults (TIAs) or specific sorts of stroke and may recommend a carotid ultrasound if you have medical conditions that enhance the threat of stroke, consisting of:

  • Hypertension.
  • Diabetes.
  • High cholesterol.
  • Family history of stroke or heart problem
  • Current transient ischemic strike (TIA) or stroke.
  • Unusual noise in carotid arteries (bruit), found by your physician making use of a stethoscope.
  • Coronary artery disease.

To screen for tightened or obstructed blood vessels in various other locations of the body, you may need additional tests, including:

Abdominal ultrasound. Heart scan machine.  You may have an stomach ultrasound to check for problems influencing the capillary or body organs in your abdominal location.

Ankle-brachial index test. This examination measures and also compares the blood pressure in between your ankle as well as your arm. The examination shows reduced or obstructed blood flow to your legs.

Heart cardiovascular test. Heart scan machine.  This examination shows how well your heart performs when under anxiety, such as during workout. Results can show bad blood circulation to the heart.

Heart scan machine.  Your physician might likewise order imaging examinations to detect coronary artery disease.

 Various other uses of carotid ultrasound.
Your  physician may order a carotid ultrasound to:.

Evaluate blood flow  via the artery after surgery to  eliminate plaques (carotid endarterectomy).

Evaluate the positioning and performance of a stent, a mesh tube utilized to boost blood circulation via an artery.

Situate a collection of thickened blood (hematoma) that may prevent blood circulation.

 Find other carotid artery abnormalities that may  interfere with blood  circulation.

 

 

Outer Arterial Disease (PAD) – Heart Scan Machine

Heart scan machine.  An Ankle-Brachial Index (ABI) examination is performed using high blood pressure cuffs on the arms and legs. It is very important to evaluate for PAD since it enhances the threat of coronary artery condition, cardiac arrest, or stroke.

Peripheral artery  condition ( additionally called  outer arterial  condition) is a  typical  problem in which narrowed arteries  lower blood flow to the arms or legs.

In peripheral artery  illness (PAD), the legs or arms–  normally the legs–  do not  get enough blood  circulation to keep up with  need. Heart scan machine.  This might cause leg pain when walking (claudication) and also various other signs.

Outer artery condition is typically a sign of a build up of fatty deposits in the arteries (atherosclerosis). Atherosclerosis triggers narrowing of the arteries that can lower blood flow in the legs and, sometimes, the arms.

 Outer artery  condition treatment  consists of  working out, eating a healthy diet and not smoking or  utilizing  cigarette.

Symptoms.
 Lots of people with peripheral artery  illness have  moderate or no symptoms. Some  individuals have leg pain when walking (claudication).

Claudication symptoms include  muscular tissue  discomfort or cramping in the legs or arms that  starts during exercise and  finishes with rest. Heart scan machine.  The discomfort is most typically really felt in the calf bone. The discomfort varies from light to severe. Severe leg discomfort might make it difficult to stroll or do other kinds of physical activity.

 Various other  outer artery  condition  signs  might include:

  • Temperature in the lower leg or foot, particularly when compared with the opposite side.
  • Leg pins and needles or weak point.
  • No pulse or a weak pulse in the legs or feet.
  • Unpleasant cramping in one or both of the hips, upper legs or calf muscles after specific activities, such as walking or climbing up stairways.
  • Shiny skin on the legs. Heart scan machine.
  • Skin shade modifications on the legs.
  • Slower development of the toenails.
  • Sores on the toes, feet or legs that won’t {heal| recover,
  • Pain when utilizing the arms, such as aching as well as cramping when knitting, writing or doing various other manual tasks.
  • Erectile dysfunction.
  •  Loss of hair or slower hair  development on the legs.

If peripheral artery disease  worsens,  discomfort may occur during rest or when  relaxing. The pain  might  disrupt sleep. Hanging the legs over the edge of the bed or walking may  momentarily  soothe the pain.

Causes.
Advancement of atherosclerosis. Heart scan machine.  Outer artery condition is commonly triggered by a build-up of fatty, cholesterol-containing down payments (plaques) on artery wall surfaces. This procedure is called atherosclerosis. It lowers blood flow through the arteries.

Atherosclerosis  impacts arteries throughout the body. When it  takes place in the arteries  providing blood to the  arm or legs, it  triggers  outer artery  illness.

 Much less common  root causes of peripheral artery  illness include:

  • Capillary swelling.
  • Injury to the arms or legs.
  • Changes in the muscle mass or ligaments.
  • Radiation exposure.
  • Risk aspects.
  • Smoking or having diabetes  substantially  boosts the risk of  creating  outer artery disease.

 

Other things that increase the  threat of  outer artery  illness include:.

  • A family history of outer artery condition, cardiovascular disease or stroke.
  • Hypertension.
  • High cholesterol. Heart scan machine.
  • High degrees of an amino acid called homocysteine, which boost the threat for coronary artery disease.
  • Raising age, specifically after 65 (or after 50 if you have threat factors for atherosclerosis).
  • Obesity (a body mass index over 30).

 

Complications.
Difficulties of peripheral artery condition caused by atherosclerosis include:

Heart scan machine.   In this condition, an injury or infection  creates  cells to  pass away.  Signs  consist of open sores on the  arm or legs that don’t heal. 

Stroke and cardiac arrest. Plaque build up in the arteries can also affect the capillary in the heart as well as brain.

 Avoidance.
 The most effective  means  to stop leg pain  as a result of  outer artery disease is to  keep a  healthy and balanced lifestyle.

That means:.

  • Do not smoke.
  • Control blood sugar level.
  • Consume foods that are low in saturated fat.
  • Obtain regular exercise – yet check with your care carrier concerning what kind and also how much is best for you.
  • Maintain a healthy weight
  • Manage blood pressure and cholesterol.

 

Abdominal Aortic Aneurysm (AAA) – Heart Scan Machine

Heart scan machine.  An ultrasound is done to evaluate the abdominal aorta for the presence of an enhancement or aneurysm. AAA can lead to a ruptured aortic artery, which is a significant medical emergency.

An abdominal aortic aneurysm is an enlarged  location in the lower part of the  significant vessel that supplies blood to the body (aorta). Heart scan machine.  The aorta runs from the heart through the facility of the upper body and abdomen.

The aorta is the biggest capillary in the body, so a burst abdominal aortic aneurysm can create dangerous bleeding.

 Depending upon the  dimension of the aneurysm and  just how  quick it’s growing, treatment varies from watchful waiting to emergency  surgical procedure.

 Signs and symptoms.
 Stomach aortic aneurysms  usually  expand slowly without noticeable  signs and symptoms, making them  challenging to  find. Some aneurysms  never ever  fracture.  Several  begin small  as well as  remain  tiny. Others  enlarge over time,  occasionally  swiftly. 

If you have an enlarging stomach aortic aneurysm, you might see:

  • Deep, consistent pain in the tummy area or side of the tummy ( abdominal area).
  • Back pain.
  • A pulse near the belly button.

 Reasons.
Aneurysms can  create anywhere along the aorta,  however  many aortic aneurysms occur in the part of the aorta that’s in the belly  location ( abdominal area).

Several points can play a role in the advancement of an abdominal aortic aneurysm, including:

  • Hardening of the arteries (atherosclerosis). Atherosclerosis happens when fat as well as other compounds accumulate on the lining of a capillary.
  • Hypertension. Hypertension can harm and also damage the aorta’s wall surfaces.
  •  Capillary diseases. These are  conditions that cause  capillary to become  irritated.
    Infection in the aorta. Seldom, a microbial or fungal infection could create an abdominal aortic aneurysms.
  • Trauma. Being wounded in a vehicle mishap can cause an abdominal aortic aneurysms.
  •  Threat  elements.

Stomach aortic aneurysm danger aspects include:

Tobacco usage. Heart scan machine.  Smoking is the strongest risk element for aortic aneurysms. Smoking can compromise the walls of the aorta, enhancing the threat of aortic aneurysm and also aneurysm rupture. The longer as well as much more you smoke or eat cigarette, the higher the possibilities of creating an aortic aneurysm. Medical professionals advise a one-time stomach ultrasound to display for an stomach aortic aneurysm in men ages 65 to 75 who are current or previous cigarette smokers.

Age. Stomach aortic aneurysms occur frequently in individuals age 65 as well as older.

Being  man. Heart scan machine.  Guy develop abdominal aortic aneurysms far more typically than women do.
Being white.  Individuals who are white  go to higher  danger of  stomach aortic aneurysms.

Family history. Having a family history of abdominal aortic aneurysms increases the  danger of having the  problem.

Other aneurysms. Having an aneurysm in  one more  big  capillary, such as the artery behind the knee or the aorta in the  breast (thoracic aortic aneurysm),  may  boost the  threat of an  stomach aortic aneurysm.

Heart scan machine.  If you’re at danger of an aortic aneurysm, your doctor could recommend other procedures, such as drugs to lower your high blood pressure as well as soothe anxiety on damaged arteries.

 Difficulties.
Splits in one or more of the layers of the wall surface of the aorta (aortic breakdown) or a burst aneurysm are the primary issues. A rupture can trigger dangerous interior bleeding. In general, the bigger the aneurysm and also the quicker it grows, the greater the risk of tear.

Symptoms and signs that an aortic aneurysm has actually burst can consist of:

  • Sudden, extreme and also relentless stomach or pain in the back, which can be referred to as a tearing feeling.
  • Low high blood pressure.
  • Fast pulse.
  • Aortic aneurysms  additionally  enhance the risk of  establishing blood clots in the  location. If a blood clot breaks loose from the inside  wall surface of an aneurysm and  obstructs a blood vessel  in other places in your body, it can  trigger pain or block blood  circulation to the legs, toes, kidneys or  stomach organs.

 

Prevention.
To prevent an aortic aneurysm or keep an aortic aneurysm from aggravating, do the following:

  • Do not smoke or use tobacco items. Given up cigarette smoking or chewing tobacco and also avoid secondhand smoke. If you require help giving up, talk to your physician regarding drugs as well as therapies that might help. Heart scan machine.
  • Eat a healthy diet. Focus on eating a selection of vegetables and fruits, whole grains, chicken, fish, as well as low-fat dairy products. Prevent saturated and also trans fats and limit salt.
  • Maintain your high blood pressure and also cholesterol under control. If your doctor has suggested medicines, take them as instructed.
  •  Get regular  workout. Try to get at  the very least 150  mins a week of  modest aerobic activity. 

 

Atrial Fibrillation (AFib) – Heart Scan Machine

A 6-lead electrocardiogram (EKG) is executed by positioning sensors on the arms and also legs to screen for Atrial Fibrillation.  Heart scan machine. AFib can bring about embolism, stroke, and also heart failure, as well as various other heart-related issues.

Atrial fibrillation (A-fib) is an uneven and also often very quick heart rhythm (arrhythmia) that can cause embolism in the heart. A-fib increases the danger of stroke, cardiac arrest and other heart-related issues.

Throughout atrial fibrillation, the heart’s upper chambers (the room) beat chaotically and also off-and-on – out of sync with the lower chambers (the ventricles) of the heart. For lots of people, A-fib might have no signs and symptoms. Heart scan machine.  Nevertheless, A-fib may cause a quick, pounding heart beat (palpitations), lack of breath or weak point.

Episodes of atrial fibrillation might come and go, or they may be consistent. A-fib itself normally isn’t life-threatening, it’s a severe medical problem that calls for correct treatment to protect against stroke.

 Therapy for atrial fibrillation may include medications,  treatment to reset the heart rhythm and catheter  treatments to  obstruct faulty heart signals.

A person with atrial fibrillation may  additionally have a  associated heart rhythm  trouble called atrial flutter. Although atrial flutter is a  various arrhythmia, the  therapy is  fairly  comparable to atrial fibrillation. 

Symptoms.
Some  individuals with atrial fibrillation (A-fib) don’t notice any  signs and symptoms. Heart scan machine.  Those who do have atrial fibrillation symptoms may have signs and symptoms such as:.

  • Experiences of a quickly, trembling or battering heartbeat (palpitations).
  • Chest pain.
  • Dizziness.
  • Exhaustion.
  • Lightheadedness.
  • Decreased ability to exercise.
  • Lack of breath.
  • Weakness.

 

Atrial fibrillation may be:

Periodic (paroxysmal atrial fibrillation). Some people with occasional A-fib requirement treatment.

Relentless. With this sort of atrial fibrillation, the heart rhythm does not go back to regular by itself. If a person has A-fib signs and symptoms, cardioversion or treatment with medications might be used to recover as well as maintain a normal heart rhythm.

Long-lasting persistent. This kind of atrial fibrillation is constant and also lasts longer than 12 months.
Permanent. Heart scan machine.  In this type of atrial fibrillation, the uneven heart rhythm can not be recovered. Medicines are needed to manage the heart price and to prevent blood clots.

Causes.
To  recognize the  reasons for A-fib, it may be  useful to know how the heart  commonly  defeats.

The normal heart has 4 chambers – two top chambers (atria) and two lower chambers (ventricles). It generates the signal that begins each heartbeat.

In a regular heart rhythm:

  • The signal takes a trip from the sinus node through the two top heart chambers ( room).
  • The signal goes through a path in between the top and also reduced chambers called the atrioventricular (AV) node.
  • The motion of the signal triggers your heart to squeeze (contract), sending out blood to your heart and body.
  • In atrial fibrillation, the signals in the  top chambers of the heart are chaotic.  Because of this, the  top chambers shake (quiver). The AV node is then bombarded with signals  attempting to  get across the  reduced heart chambers (ventricles). This  creates a  quick  and also  uneven heart rhythm. 

 

The heart  price in atrial fibrillation may range from 100 to 175 beats a minute. The normal range for a heart rate is 60 to 100 beats a minute.

 Root causes of atrial fibrillation.
Problems with the heart’s structure are  one of the most common  reason for atrial fibrillation. Heart scan machine.  Feasible causes of atrial fibrillation consist of:.

  • Coronary artery disease.
  • Cardiac arrest.
  • Heart problem that you’re born with ( hereditary heart flaw).
  • Heart shutoff troubles.
  • High blood pressure.
  • Lung diseases.
  • Physical anxiety due to surgical treatment, pneumonia or other diseases.
  • Previous heart surgery.
  • Problem with the heart’s natural pacemaker (sick sinus disorder).
  • Rest apnea.
  • Thyroid disease such as an overactive thyroid (hyperthyroidism) and various other metabolic imbalances.
  • Use of stimulants, consisting of specific medications, caffeine, cigarette and alcohol.
  • Viral infections.

Some people who have atrial fibrillation have no known heart problems or heart  damages.

Danger aspects. Heart scan machine.
 Points that can  enhance the  threat of atrial fibrillation (A-fib)  consist of:.

Age. The older a person is, the  higher the  threat of  establishing atrial fibrillation.

Heart disease. Anyone with heart disease– such as heart valve problems, congenital heart disease, congestive heart failure, coronary artery disease, or a history of cardiac arrest or heart surgical treatment– has an enhanced threat of atrial fibrillation.

High blood pressure. Having high blood pressure, particularly if it’s not well controlled with way of living changes or medicines, can enhance the danger of atrial fibrillation.

Thyroid illness. In some individuals, thyroid problems might trigger heart rhythm problems (arrhythmias), consisting of atrial fibrillation.

Various other chronic health conditions. Individuals with certain chronic conditions such as diabetes mellitus, metabolic disorder, persistent kidney disease, lung condition or sleep apnea have an enhanced danger of atrial fibrillation.

Drinking alcohol. For some people, drinking alcohol can cause an episode of atrial fibrillation. Binge alcohol consumption additional increases the risk.

Obesity.  Heart scan machine.  People who have obesity are at greater risk of establishing atrial fibrillation.

Family history. An enhanced threat of atrial fibrillation takes place in some family members.

Issues.
Blood clots are a  harmful complication of atrial fibrillation that can  cause stroke.

In atrial fibrillation, the  disorderly heart rhythm can  create blood to  gather in the heart’s  top chambers (atria)  as well as  kind clots. Heart scan machine.  If a blood clot in the left upper chamber (left room) breaks without the heart area, it can take a trip to the mind and also cause a stroke.

The  threat of stroke from atrial fibrillation  enhances as you  get older.  Various other  health and wellness  problems  likewise  might  raise your risk of a stroke  because of A-fib, including:.

  • Hypertension.
  • Diabetes mellitus.
  • Heart failure.
  • Some valvular cardiovascular disease.
  • Blood  slimmers are commonly  suggested  to avoid blood clots and strokes in people with atrial fibrillation.

Prevention.
Healthy and balanced lifestyle options can minimize the risk of heart disease as well as might prevent atrial fibrillation. Heart scan machine.  Right here are some fundamental heart-healthy ideas:

  • Eat a nutritious diet regimen.
  • Obtain regular exercise as well as maintain a healthy and balanced weight.
  •  Do not smoke.
    Avoid or limit alcohol as well as caffeine.
  • Manage  anxiety, as  extreme  tension and  temper can  create heart rhythm problems.

 

Weakening of bones Risk – Heart Scan Machine

An ultrasound is performed to  determine the shin bone for  uncommon bone mass  thickness. Heart scan machine.  This can aid assess the risk of weakening of bones, a illness where bones become weak and fragile.

Osteoporosis triggers bones to end up being weak and weak – so fragile that a fall and even mild stress and anxieties such as bending over or coughing can cause a crack. Osteoporosis-related fractures most generally take place in the hip, wrist or spinal column.

Weakening of bones impacts males and females of all races. White and Asian females, specifically older women who are previous menopause, are at highest danger. Drugs, healthy and balanced diet regimen as well as weight bearing exercise can aid avoid bone loss or enhance currently weak bones.

Symptoms.
There usually are no signs in the beginning of bone loss. Once your bones have actually been weakened by weakening of bones, you may have signs and symptoms that consist of:.

  • Pain in the back, triggered by a broken or broke down vertebra.
  • Loss of elevation in time.
  • A stooped stance.
  • A bone that breaks  far more easily than  anticipated.

 Reasons.
 Contrasting the  inside of a  healthy and balanced bone with one that has  ended up being  permeable from  weakening of bones.
Osteoporosis  damages bone.

How likely you are to  establish osteoporosis depends  partially on  just how much bone mass you  achieved in your youth. Peak bone mass is  partially  acquired and  differs also by ethnic group. The higher your peak bone mass, the more bone you have “in the bank”  and also the less likely you are to  establish osteoporosis as you age.

 Danger  elements.
A number of factors can increase the possibility that you’ll develop weakening of bones– including your age, race, lifestyle choices, and medical problems and therapies. Heart scan machine.

Unchangeable  dangers.
Some danger factors for osteoporosis are out of your control, including:

  • Your sex. Ladies are much more likely to create osteoporosis than are males.
  • Age. The older you obtain, the higher your threat of osteoporosis.
  • Race. You’re at greatest threat of osteoporosis if you’re white or of Asian descent.
  • Family history. Having a parent or brother or sister with osteoporosis places you at higher danger, especially if your mother or father fractured a hip.
  • Body framework size. Men and women who have little body frameworks tend to have a higher risk since they could have much less bone mass to draw from as they age.
  • Hormone  degrees.

Osteoporosis is more typical in individuals that have way too much or too little of specific hormonal agents in their bodies. Examples include:

Sex  hormonal agents.  Decreased sex  hormonal agent  degrees tend to  compromise bone. The fall in estrogen levels in  ladies at menopause  is just one of the  best  threat  variables for  creating  weakening of bones. Treatments for prostate cancer that  minimize testosterone levels in men and treatments for  bust cancer that  decrease estrogen levels in women are  most likely to  increase bone loss. 

Dietary factors.
 Weakening of bones is  most likely to  take place in  individuals who have:

Reduced calcium intake. A lifelong lack of calcium contributes in the development of weakening of bones. Reduced calcium intake contributes to diminished bone thickness, very early bone loss and an increased risk of fractures.

Eating disorders. Drastically restricting food intake and being underweight weakens bone in both men and women.

Long lasting use oral or infused corticosteroid medicines, such as prednisone as well as cortisone, disrupts the bone-rebuilding process. Heart scan machine.  Weakening of bones has actually also been related to medications made use of to fight or avoid:

  • Seizures.
  • Stomach reflux.
  • Cancer.
  • Transplant being rejected.
  • Medical  problems.

The  threat of osteoporosis is  greater in  individuals  that have  particular medical  issues, including:.

  • Celiac condition.
  • Inflammatory digestive tract illness.
  • Kidney or liver disease.
  • Cancer.
  • Multiple myeloma.
  • Rheumatoid arthritis
  • Lifestyle  options.

Some bad habits can enhance your danger of weakening of bones. Instances consist of:

Less active way of life. People that spend a lot of time sitting have a greater risk of osteoporosis than do those who are a lot more energetic. Any type of weight bearing workout and activities that advertise equilibrium and also good position are beneficial for your bones, yet strolling, running, jumping, dancing as well as weight training appear especially valuable.
Excessive alcohol consumption. Heart scan machine.  Regular consumption of greater than two alcohols a day enhances the danger of osteoporosis.

Tobacco use. The precise role tobacco plays in osteoporosis isn’t clear, however it has actually been shown that tobacco use contributes to weak bones.

Problems.
 Just how osteoporosis can  create vertebrae to crumple and collapse.
Compression  cracks.

In some cases, spinal  cracks can  take place even if you haven’t fallen. The bones that  comprise your spine (vertebrae) can weaken to the point of  breaking down, which can result in back pain, lost height  as well as a  stooped  onward  stance.

Prevention.
Good  nourishment  as well as  routine  workout are  important for keeping your bones healthy throughout your life.

Calcium.
Men and women  in between the ages of 18  and also 50  demand 1,000 milligrams of calcium a day. This  day-to-day  quantity  boosts to 1,200 milligrams when women  transform 50 and men  transform 70.

Good resources of calcium include:

  • Low-fat dairy items.
  • Dark environment-friendly leafy {vegetables| veggies
  • Canned salmon or sardines with bones.
  • Soy items, such as tofu.
  • Calcium-fortified cereals  and also orange juice.

 

The Health  and also Medicine Division of the National Academies of Sciences, Engineering, and Medicine  suggests that  complete calcium  consumption, from supplements and  diet regimen  incorporated,  need to be no more than 2,000 milligrams daily for people older than 50.

Vitamin D.
Vitamin D  boosts the body’s ability to absorb calcium  as well as  boosts bone  health and wellness in  various other ways. Heart scan machine.  Individuals can get several of their vitamin D from sunlight, yet this may not be a excellent source if you live in a high latitude, if you’re housebound, or if you consistently make use of sunscreen or stay clear of the sunlight because of the risk of skin cancer.

 Nutritional sources of vitamin D  consist of cod liver oil, trout  as well as salmon.  Numerous types of milk  as well as  grain have been  strengthened with vitamin D.

Most  individuals  require  at the very least 600  worldwide units (IU) of vitamin D a day. That  referral increases to 800 IU a day after age 70.

People without other resources of vitamin D and also specifically with minimal sunlight exposure could require a supplement. The majority of multivitamin products consist of in between 600 as well as 800 IU of vitamin D. Up to 4,000 IU of vitamin D a day is safe for lots of people.

 Workout.
Workout can aid you construct strong bones and also sluggish bone loss. Heart scan machine.  Exercise will certainly benefit your bones no matter when you begin, but you’ll get one of the most benefits if you begin working out frequently when you’re young and remain to exercise throughout your life.

Weight-bearing workouts– such as strolling, jogging, running, stairway climbing, missing rope, skiing as well as impact-producing sporting activities– impact mainly the bones in your legs, hips as well as reduced spinal column. Equilibrium exercises such as tai chi can decrease your threat of falling especially as you get older.

 

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