A And M Medical Blood Pressure

• Definition
  • What Is High Blood Pressure?
• Numbers
  • What Do the Diastolic and Systolic Numbers Mean?
  • What Is Considered High Blood Pressure (Numbers)?
• Causes
  • What Causes High Blood Pressure?
  • What Is Secondary Hypertension?
• Signs/Symptoms
  • What Are the Signs and Symptoms of High Blood Pressure?
• Call a Doctor
  • When Should You Call a Doctor for High Blood Pressure?
• Diagnosis
  • What Tests Diagnose High Blood Pressure?
  • How Often Should You Check Your Blood Pressure?
• Treatment
  • What Is the Treatment for High Blood Pressure?
  • What Medications Treat High Blood Pressure?
• Diet
  • Is There Is a High Blood Pressure Diet?
• Remedies/Therapies
  • What Natural Remedies, Therapies, and Supplements Lower Blood Pressure?
• Is It Fatal?
  • Is There a Cure for High Blood Pressure? Can You Die?
• How to Prevent
  • Can You Prevent High Blood Pressure?
• Guide
  • High Blood Pressure (Hypertension) Topic Guide
  • Doctor's Notes on High Blood Pressure Symptoms

What Is High Blood Pressure?

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High blood pressure is the leading cause of death and disability in the United States.

• High blood pressure (hypertension) is known as the "silent killer" since it has no initial symptoms but can lead to long-term disease and complications. Many individuals have high blood pressure but do not know it.
• Important complications of uncontrolled or poorly treated high blood pressure are due to chronic damage that occurs to different organs in the body and includes heart attack, congestive heart failure, stroke, kidney failure, peripheral artery disease, and aneurysms (weakening of the walls of an artery, leading to a sac formation or ballooning of the artery wall). Aneurysms can be found in the brain, along the route of the aorta (the large artery that leaves the heart), and other arteries in the abdomen and extremities.
• High blood pressure is the leading cause of death and disability in the United States. While it ranks second to tobacco use as a preventable cause of death for any reason, high blood pressure is the number one cause of preventable heart- and stroke-related death.
• Public awareness of these dangers has increased. High blood pressure has become the second most common reason for medical office visits in the United States.

What is blood pressure?

How the heart pumps blood into the arteries with enough force to push blood to the far reaches of each organ from the top of the head to the bottom of the feet. Blood pressure can be defined as the pressure of blood on the walls of the arteries as it circulates through the body. Blood pressure is highest as its leaves the heart through the aorta and gradually decreases as it enters smaller and smaller blood vessels (arteries, arterioles, and capillaries). Blood returns in the veins leading to the heart, aided by gravity and muscle contraction.

What Do the Diastolic and Systolic Numbers Mean?

How is blood pressure measured?

Blood pressure is measured with a blood pressure cuff and recorded as two numbers, for example, 120/80 mm Hg (millimeters of mercury). Blood pressure measurements are usually taken at the upper arm over the brachial artery.

• The top, the larger number is called the systolic pressure. This measures the pressure generated when the heart contracts (pumps). It reflects the pressure of the blood against arterial walls.
• At the bottom, the smaller number is called the diastolic pressure. This reflects the pressure in the arteries while the heart is filling and resting between heartbeats.

What Is Considered High Blood Pressure (Numbers)?

The American Heart Association and the American College of Cardiology have recommended guidelines to define normal and high blood pressure (all values are in mm Hg).

Guidelines to define normal and high blood pressure stages chart

Hypertension stage	Systolic (mm Hg)	Diastolic (mm Hg)
Normal blood pressure	< 120	< 80
Elevated blood pressure	120-129	< 80
Stage 1 hypertension	130-139	80-89
Stage 2 hypertension	> 139	> 89

Based on these new 2017 guidelines defining high blood pressure, as many as half of all Americans will have this disease (48% of men and 43% of women). Uncontrolled high blood pressure is responsible for many cases of death and disability resulting from a heart attack, stroke, and kidney failure.

According to research studies, the risk of dying of a heart attack is directly linked to high blood pressure, particularly systolic hypertension. The higher your blood pressure, the higher the risk. Maintaining lifelong control of hypertension decreases the future risk of complications such as heart attack and stroke.

QUESTION

Salt and sodium are the same. See Answer

What Causes High Blood Pressure?

In 90% of individuals with hypertension, the cause of high blood pressure is not known and is referred to as primary or essential hypertension. While the specific cause is unknown, there are risk factors that can contribute to developing high blood pressure.

Factors that cannot be changed

• Age: The older a person is, the greater the likelihood that he or she will develop high blood pressure, especially elevated systolic readings. This is largely due to arteriosclerosis, or "hardening of the arteries."
• Race: African Americans develop high blood pressure more often than Caucasians. They develop high blood pressure at a younger age and develop more severe complications sooner in life.
• Age and Race: For adults who are older than 45 years old and do not have high blood pressure, the risk of developing the disease later in life is 93%for African-Americans, 92% for Hispanics, 86% for Caucasians, and 84% for Chinese.
• Socioeconomic status: High blood pressure is found more commonly among the less educated and lower socioeconomic groups. Residents of the southeastern United States, both Caucasian and African American, are more likely to have high blood pressure than residents of other regions.
• Family history (heredity): The tendency to have high blood pressure appears to run in families.
• Gender: Generally men have a greater likelihood of developing high blood pressure than women. This likelihood varies according to age and among various ethnic groups.

Factors that can be changed

• Obesity: As body weight increases, the blood pressure rises. Obesity is defined as having a body mass index (BMI) greater than 30 kg/m. A BMI of 25-30 kg/m is considered overweight (BMI=weight in pounds x 703/ height in inches). Being overweight increases the risk of high blood pressure. Healthcare professionals recommend that all individuals who are obese and have high blood pressure lose weight until they are within 15% of their healthy body weight.
  • Obese people are two to six times more likely to develop high blood pressure than people whose weight is within a healthy range.
  • Not only the degree of obesity is important, but also the manner in which the body accumulates extra fat. Some people gain weight around their belly (central obesity or "apple-shaped" people), while others store fat around their hips and thighs ("pear-shaped" people). "Apple-shaped" people tend to have greater health risks for high blood pressure than "pear-shaped" people.
• Sodium (salt) sensitivity: Some people have high sensitivity to sodium (salt), and their blood pressure increases if they use salt. Reducing sodium intake tends to lower their blood pressure. Americans consume 10-15 times more sodium than they need. Fast foods and processed foods contain particularly high amounts of sodium. Many over-the-counter medicines also contain large amounts of sodium. Read food labels and learn about salt content in foods and other products as a healthy first step to reducing salt intake. Fast food restaurants also make the salt and calorie content of their food available to consumers at their restaurants,
• Alcohol use: Drinking more than one to two drinks of alcohol per day tends to raise blood pressure in those who are sensitive to alcohol.
• Birth control pills (oral contraceptive use): Some women who take birth control pills develop high blood pressure.
• Lack of exercise (physical inactivity): A sedentary lifestyle contributes to the development of obesity and high blood pressure.
• Medications: Certain drugs, such as amphetamines (stimulants), diet pills, and some medications used for cold and allergy symptoms such as pseudoephedrine, tend to raise blood pressure.

What Are the Signs and Symptoms of High Blood Pressure?

High blood pressure usually causes no symptoms and high blood pressure often is labeled "the silent killer." People who have high blood pressure typically don't know it until their blood pressure is measured. Sometimes people with markedly elevated blood pressure may develop complications because organs are stressed when they are exposed to the elevated pressures.

High blood pressure brain symptoms:

1. Headache
2. Dizziness
3. Blurred vision
4. Nausea and vomiting

High blood pressure and heart symptoms

1. Chest pain
2. Shortness of breath
3. Weakness
4. Nausea and vomiting

People often do not seek medical care until they have symptoms arising from the organ damage caused by chronic (ongoing, long-term) high blood pressure. These types of organ damage are commonly seen in chronic high blood pressure.

1. Heart attack
2. Heart failure
3. Stroke or transient ischemic attack (TIA, mini-stroke) caused by narrowed blood vessels or because of an aneurysm
4. Kidney failure
5. Eye damage with progressive vision loss
6. Peripheral arterial disease causing leg pain with walking (claudication)
7. Outpouchings of the aorta, called aneurysms

About 1% of people with high blood pressure do not seek medical care until the high blood pressure is very severe, a condition known as malignant hypertension or a hypertensive emergency.

1. In malignant hypertension, the diastolic blood pressure (the lower number) often exceeds 120 mm Hg.
2. Malignant hypertension may be associated with headache, lightheadedness, nausea, vomiting, and stroke like symptoms
3. Malignant hypertension requires emergency intervention and lowering of blood pressure to prevent brain hemorrhage or stroke.

It is of utmost importance to realize that high blood pressure can be unrecognized for years, causing no symptoms but causing progressive damage to the heart, other organs, and blood vessels.

When Should You Call a Doctor for High Blood Pressure?

Many symptoms present gradually after years of poorly blood pressure control. Often, the first knowledge of hypertension occurs when a person complains of chest pain or has stroke-like symptoms. Should these occur, it is appropriate to call 911 immediately (if available) to activate emergency medical services and seek care.

You may be directed to seek medical care if blood pressure readings are elevated if done as part of a community health screening. Isolated elevated blood pressure readings do not necessarily make the diagnosis of hypertension. Blood pressure readings vary throughout the day, and your primary care provider may record a different reading than the one that was measured in a screening that sent you in for care.

There are non-specific symptoms associated with hypertension that may cause a person to seek care that includes;

• lightheadedness,
• dizziness,
• headache with or without nausea,
• changes in vision, or
• Lethargy and fatigue.

There are many other reasons to develop these symptoms other than high blood pressure.

What Tests Diagnose High Blood Pressure?

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Blood pressure is measured with a blood pressure cuff (sphygmomanometer). This may be done using a stethoscope and a cuff and gauge or by an automatic machine. It is a routine part of the physical examination and one of the vital signs often recorded for a patient visit. Other vital signs include pulse rate, respiratory rate (breathing rate), temperature, and weight.

The American Heart Association and the American College of Cardiology recommend specific steps to measure blood pressure in a medical setting.

• The patient should relax in a chair for at least five minutes, with the back supported and feet on the floor
• The patient should not have had caffeine, tobacco products or participated in any exercise for at least 30 minutes before the blood pressure check
• The patient should not talk for the five minute rest period
• The blood pressure cuff should not be placed over clothing; instead it should be placed directly on the skin
• The arm being tested should be supported or be rested on a table or arm rest
• The cuff being used should be the appropriate size for the patient
• Blood pressure should be checked at least two times, separated by 1-2 minutes, and an average taken to estimate that person's blood pressure
• For the first visit for a blood pressure check, the blood pressure reading should be measured in both arms and the higher of the two readings should be used to decide upon treatment

When discussing blood pressure issues, the healthcare professional may ask questions about past medical history, family history, and medication use, including prescriptions, over-the-counter medications, herbal remedies, and food additives. Other questions may include lifestyle habits, including activity levels, smoking, alcohol consumption, and illegal drug use.

Physical examination may include listening to the heart and lungs, feeling for pulse in the wrist and ankles, and feeling and listening to the abdomen looking for signs of an enlarged aorta. The examiner may also listen in the neck for carotid bruits (sounds made by a narrowed artery in the neck) and in the abdomen for bruits made by an abdominal aortic aneurysm.

Eye examination with an ophthalmoscope may be helpful by looking at the small blood vessels on the retina in the back of the eyeball.

Blood tests may be done to assess risk factors for heart disease and stroke as well as looking for complications of hypertension. These include complete blood count (CBC), electrolytes, BUN (blood urea nitrogen), and creatinine and GFR (glomerular filtration rate) to measure kidney function. A fasting lipid profile will measure cholesterol and triglyceride levels in the blood. If appropriate, blood tests may be considered to look for an underlying cause of high blood pressure (secondary hypertension) including abnormal thyroid or adrenal gland function.

Ultrasound of the kidneys, CT scan of the abdomen, or both may be done to assess damage or enlargement of the kidneys and adrenal glands.

Other studies may be considered depending upon the individual patient's needs

• Electrocardiogram (ECG) may help evaluate heart rate and rhythm. It is a screening test to help assess heart muscle thickness. If hypertension is long-standing, the heart muscle has to hypertrophy, or get larger, to push blood against the increased pressure within the arteries of the body.
• Echocardiogram is an ultrasound examination of the heart .It is used to evaluate the anatomy and the function of the heart. A cardiologist is required to interpret this test and can evaluate the heart muscle and determine how thick it is, whether it moves appropriately, and how efficiently it can push blood out to the rest of the body. The echocardiogram can also assess heart valves, looking for narrowing (stenosis) and leaking (insufficiency or regurgitation). A chest X-ray may be used as a screening test to look for heart size, the shape of the aorta, and to assess the lungs.
• Doppler ultrasound is used to check blood flow through arteries at pulse points in your arms, legs, hands, and feet. This is an accurate way to detect peripheral vascular disease, which can be associated with high blood pressure.
• Abdominal ultrasound is able to evaluate organs in the abdomen as well as blood flow in major arteries including the aorta, the renal arteries to the kidneys, and the mesenteric arteries to the stomach and intestine.

Elevated blood pressures in the medical setting may not necessarily reflect the person's real status. "White coat hypertension" describes a patient whose blood pressure is elevated because of the stress of the visit to the doctor or other healthcare professional, and the worry that their blood pressure might be elevated. Repeated blood pressure checks at the doctor's office or the use of a home blood pressure monitoring device may be used to confirm that you have high blood pressure.

SLIDESHOW

How to Lower Blood Pressure: Exercise Tips See Slideshow

What Is the Treatment for High Blood Pressure?

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Blood pressure control is a lifelong challenge. Hypertension can progress through the years, and treatments that worked earlier in life may need to be adjusted over time. Blood pressure control may involve gradually making lifestyle changes like diet, weight loss, exercise, and possibly taking medicine if necessary. In some situations, medications may be recommended immediately. As with many diseases, you and your doctor should work together to find the treatment plan that works for you.

There also is a stepwise approach to treating high blood pressure, and it combines the stage of hypertension with the calculated risk of future atherosclerotic cardiovascular disease (ASCVD, heart attack or stroke). There are online calculators that are available from the American Heart Association.

• If the person has normal blood pressure, the recommendation is to promote positive lifestyle habits and have blood pressure readings checked every year.
• If there is elevated blood pressure, lifestyle modifications should be attempted and blood pressure should be rechecked in 3-6 months.
• In stage 1 hypertension, if the risk of ASCVD is less than 10%, lifestyle modification is recommended with recheck in 1-6 months.
• In stage 1 hypertension with ASCVD risk greater than 10%, medications should be added to lifestyle modification with reassessment in 1 month. If normal blood pressure goals are not met, additional medications may be added.
• With Stage 2 hypertension, medications and lifestyle modification should begin immediately, with recheck in 1 month and adding additional medications if goals are not met.

What Medications Treat High Blood Pressure?

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The decision as to which medication to use depends upon the patient's situation and underlying medical conditions. Individuals with diabetes, kidney disease, pregnancy, and other secondary causes of hypertension may have specific medication needs.

Water Pills (diuretics)

• Diuretics are used very widely to control mildly high blood pressure, and are often used in combination with other medications.
• They increase sodium excretion and urine output and decrease blood volume. The sensitivity to the effect of other hormones in your body is decreased.
• Thiazide diuretics, for example, chlorthalidone (Hygroton, Thalitone), and is hydrochlorothiazide (HydroDIURIL)
• Loop diuretics, for example, furosemide (Lasix) and torsemide (Demadex),
• Combination of triamterene and hydrochlorothiazide (Dyazide), and
• metolazone (Zaroxolyn).
• Of appropriate, chlorthalidone is the preferred diuretic.

Beta-Blockers

• Beta-blockers reduce heart rate and decrease the force of heart contraction by blocking the action of adrenaline receptors. Beta blockers are widely prescribed and effective but can cause increased fatigue and decreased exercise tolerance because they prevent an increased heart rate as a normal response to physical activity.
• They are also prescribed for people who have associated heart disease, angina, or history of a heart attack.
• Examples of beta blockers include, carvedilol (Coreg), metoprolol (Lopressor), atenolol (Tenormin)

Calcium Channel Blockers (CCBs)

• Calcium channel blocking agents work by relaxing the muscle in artery walls and by therefore reducing the force of contraction of heart muscle.
• Example of calcium channel blockers include, nifedipine (Procardia), diltiazem (Cardizem), verapamil (Isoptin, Calan), nicardipine (Cardene), amlodipine (Norvasc), and felodipine (Plendil)

Angiotensin-Converting Enzyme (ACE) Inhibitors

• ACE inhibitors stop the production in the body of a chemical called angiotensin II, which causes blood vessels to contract. Narrower blood vessels are associated with increased blood pressure. Relaxing artery walls leads to lower blood pressure.
• Examples of ACE inhibitors include Captopril (Capoten), enalapril (Vasotec), lisinopril (Zestril, Prinivil), quinapril (Accupril), and fosinopril (Monopril)

Angiotensin Receptor Blockers (ARBs)

• ARBs work block angiotensin II receptors and prevent vasoconstriction, or narrowing of blood vessels.
• Examples of ARBs include losartan (Cozaar), valsartan (Diovan), candesartan (Atacand), and irbesartan (Avapro)

Blockers of Central Sympathetic (autonomic nervous) System

• These agents block messages from the brain's autonomic nervous system that contract blood vessels. The autonomic nervous system is the part of the unconscious nervous system of the body that controls heart rate, breathing rate, and other basic functions.
• These medications relax blood vessels, thus lowering blood pressure, for example, clonidine (Catapres)

Direct Vasodilators

• Direct vasodilators relax (dilate) the blood vessels to allow blood to flow under lower pressure.
• These medications are most often used in times of hypertensive emergency and are injected intravenously to quickly lower blood pressure readings.
• Examples include nitroprusside (Nitropress), and diazoxide (Hyperstat).

Take your high blood pressure medicine as prescribed and only discontinue them on the advice of your doctor or other healthcare professional.

Is There Is a High Blood Pressure Diet?

In about half of people with high blood pressure, limiting sodium intake by eliminating table salt, cooking salt, and salty and processed foods can reduce blood pressure by 5 mm Hg. Losing weight and participating in regular physical activity can reduce blood pressure further.

If these lifestyle changes and choices don't work, medications should be added. The medications have been proven to reduce the risk of stroke, heart disease, and kidney problems.

Weight Control

• Aim for a healthy weight range for your height and body type. Your health care practitioner can help you calculate a healthy target weight.
• Even a small amount of weight loss can make a major difference in lowering or preventing high blood pressure.
• You must burn more calories than you take in to lose weight.
• Crash or fad diets are not helpful and may be dangerous.
• Some weight loss medications also carry major risks and may even elevate blood pressure, and great caution is advised in using these drugs. Please ask your health care practitioner or pharmacist for help in deciding if a weight loss medication is appropriate for your situation.

Exercise or Increase Physical Activity

• Physical activity reduces total cholesterol and bad cholesterol (low density lipoprotein or LDL) and raises the good cholesterol (high density lipoprotein or HDL).
• Both the American Heart Association (AHA) and the U.S. Surgeon General recommend 30 minutes of physical activity on most days of the week.
• Physical activity includes many daily activities such as cleaning the house, raking the lawn, and walking. Other possible sources of activity can include using the stairs instead of an elevator or escalator, walking for errands instead of driving a car, and participating in a sport or social activity such dancing.

What Natural Remedies, Therapies, and Supplements Lower Blood Pressure?

Alternative therapies may be helpful to people trying to control their blood pressure.

• Acupuncture and biofeedback are well-accepted alternative techniques that may help some people with high blood pressure.
• Techniques that induce relaxation and reduce stress are recommended. These include meditation, yoga, and relaxation training.
• These techniques alone may not control high blood pressure for many people. They should not be used as a substitute for medical therapy without first consulting with your health care practitioner.

Dietary supplements and alternative medications and therapies are sometimes recommended for high blood pressure.

• Examples include vitamins, garlic, fish oil, L-arginine, soy, coenzyme Q10, herbs, phytosterols, and chelation therapy.
• While these substances may be beneficial, the exact nature of their benefits is not known.
• Scientific studies have produced no evidence that these therapies lower blood pressure or prevent the complications of high blood pressure.
• Most of these substances are harmless if taken in moderate doses. Most people can take them without problems.
• Talk to your health care practitioner if you are considering any of these treatments. Substituting these therapies for medical therapies that have been shown to lower blood pressure and the risk of complications may have a harmful effect on your health.

How Often Should You Check Your Blood Pressure?

The most important element in the management of high blood pressure is follow-up care.

• Routine blood pressure check-ups are important to monitor readings and decide upon a treatment plan.
• With age and the natural progression of hardening of the arteries, systolic blood pressure may elevate over time. A treatment that once worked well may no longer work as well and your medication treatment may need to be changed.
• Routine physical exams and screening blood tests may be suggested to help monitor the success of blood pressure management.
• Follow-up visits are a good time to discuss with your doctor any medication side effects that you may be experiencing. Your doctor will have suggestions for managing side effects or may change your treatment.
• Follow-up visits are a great opportunity for monitoring for other associated risk factors, such as high cholesterol, smoking cessation, and obesity.

Is There a Cure for High Blood Pressure? Can You Die?

Lifelong control of hypertension will minimize the risk of developing heart attack, stroke, kidney failure, blindness, and a variety of other illnesses. Unlike other illnesses in which medications are taken for only a short period of time, high blood pressure medication is usually expected to be taken for the rest of the individual's life. It is uncommon, but not rare, that significant lifestyle changes can lower blood pressure readings to normal.

Untreated or poorly controlled high blood pressure is a major risk factor for heart attack, stroke, and kidney failure. That is why high blood pressure is called "the silent killer."

Can You Prevent High Blood Pressure?

High blood pressure may be prevented by living a healthy lifestyle include:

• Eat a nutritious, low-fat diet. The National Heart, Lung and Blood Institute of the NIH outlines the DASH diet, that is describes as a "flexible and balanced eating plan that helps create a heart-healthy eating style for life."
• Get regular exercise.
• Decrease salt (sodium) intake, read food labels so you know the salt content before you buy a product in the grocery store or eating a meal at a fast food restaurant, and avoid adding salt to foods.
• Maintain a healthy weight, and if you are overweight or obese, try to lose weight.
• Drink alcohol in moderation.
• Stop smoking.
• Get routine health assessments and blood pressure screening.
• Take your blood pressure medications as directed, even if you're feeling fine.
• Reduce stress and practice relaxation techniques, for example, meditation, Yoga, Tai Chi, and other types of physical activity.

From

What Causes Heart Attacks?

Heart attacks can be caused by;

• high blood pressure,
• diabetes,
• smoking cigarettes,
• inherited,
• coronary artery heart problems,
• using cocaine,
• severe anemia,
• respiratory failure, and
• poisoning.

Reviewed on 6/2/2021

References

Czupryniak L, et al. Circadian blood pressure variation in morbidly obese hypertensive patients undergoing gastric bypass surgery; Am J Hypertens. 2005 Apr;18(4 Pt 1):446-51.

Dyer KL, et al. Use of myocardial performance index in pediatric patients with idiopathic pulmonary arterial hypertension; J Am Soc Echocardiogr. 2006 Jan;19(1):21-7.

Hoeper MM, et al. Goal-oriented treatment and combination therapy for pulmonary arterial hypertension; Eur Respir J. 2005 Nov;26(5):858-63.

Lipsitz LA, et al. Antihypertensive therapy increases cerebral blood flow and carotid distensibility in hypertensive elderly subjects; Hypertension. 2005 Feb;45(2):216-21. Epub 2005 Jan 17.

Pischke CR, et al. Comparison of coronary risk factors and quality of life in coronary artery disease patients with versus without diabetes mellitus; Am J Cardiol; 2006 May 1;97(9):1267-73. Epub 2006 Mar 10.

Whelton PK, et al. 2017 High Blood Pressure Clinical Practice Guideline: Executive Summary. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Nov 2017.
<http://hyper.ahajournals.org/content/hypertensionaha/early/2017/11/10/HYP.0000000000000066.full.pdf?download=true>

NIH. Description of the DASH Eating Plan. Updated: Sep 16, 2015.
<https://www.nhlbi.nih.gov/health/health-topics/topics/dash>

David Baldwin, MA, DM FRCPsych. Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. 3 April 2018. 14 November 2018

Denise Griswold, MSc, LCAS. How Anxiety Affects Blood Pressure. 27 October 2018. 14 November 2018

https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings

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