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Orthopaedic & Sports

Dr. Hamid Razak

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Orthopaedic Surgeons | Knee and Shoulder Specialists Physical therapy and surgery can help reduce knee pain, whether caused by acute injuries or chronic conditions such as arthritis.Many different conditions can cause knee pain. Some of these include acute fractures, sports injuries, and chronic conditions such as gout, osteoarthritis or rheumatoid arthritis. Knee pain can vary in severity and character. Some patients may feel that the pain is localized to one specific aspect of the knee, while others may experience pain non-specifically. A knee specialist will take a history of your pain, perform a targeted physical examination and order relevant investigations which may include imaging before deciding on the best form of treatment for your pain.What is a Knee Specialist?First and foremost, you must determine which type of doctor you should consult regarding your knee pain. After an initial assessment of your knee pain, your primary care physician may decide to refer you to a knee specialist for further evaluation and treatment.Orthopaedic surgeons are medical professionals specializing in the care of your bones and joints. A knee specialist is an Orthopaedic surgeon who specialises in disorders of the knee joint. You should keep in mind that most Orthopaedic surgeons today specialize in certain anatomic regions of the musculoskeletal system. Therefore, it would be important for you to confirm that you are seeing an Orthopaedic surgeon who is a knee specialist should you be suffering from knee pain.When Should Knee Surgery Be Considered?As mentioned earlier, treatment options for your knee pain depend on the condition causing the pain. Acute fractures most likely require surgery for fixation. First-line treatment for sports injuries as well as chronic knee conditions such as osteoarthritis include rest and physical therapy. If your pain and function does not improve with first-line treatment, then your doctor may recommend surgery.What is a Shoulder Specialist?The term "shoulder specialist" refers to an Orthopaedic Surgeon who is specialized in the diagnosis and treatment of a wide variety of shoulder injuries and disorders. For example, these specially trained doctors are frequently called upon to treat patients with a fractured clavicle (collarbone), a dislocation, or a rotator cuff tear in their shoulder. As a ball-and-socket joint with an extensive range of motion, the shoulder is prone to various injuries, including rotator cuff problems, which are common.What are the causes of shoulder pain?The following are the most typical causes why people suffer from shoulder pain:Torn rotator cuff - is made up of four muscles in your upper arm that are joined by tendons to form the rotator cuff, which, as the name suggests, allows you to rotate your arm. When the force is applied to these tendons, they might tear, resulting in a torn rotator cuff.Frozen shoulder - You may find yourself unable to lift your arm away from your body because of a stiff shoulder. You can get a frozen shoulder if you have scar tissue or if you don't have any at all.Sprains - It is possible to injure a shoulder by falling on an outstretched hand, especially if the ligaments holding the joint together are strained or torn.Fractures - When you fall and land on your outstretched hand, you're more likely to break your shoulder.Dislocation - A dislocation of the shoulder is distinct from a separation of the shoulder. It's possible to knock the humerus out of the socket with a hard hit to the shoulder. Partially or entirely dislocated joints are possible.Separation - If you fall on your shoulder or are hit with a strong force, you may suffer a separated shoulder. Injuries to the ligaments that connect the shoulder to the collar bone occur.Final WordsOrthopaedic surgeons are specialists who treat patients with bone and joint conditions. Knee and shoulder specialists are Orthopaedic surgeons with a special interest in knee and shoulder conditions.If you are suffering from knee and shoulder pain which is persistent, it is useful to get assessed by a knee or shoulder specialist. You may get a referral from a primary care physician or make an appointment to see them on your own accord.

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Women’s Health

Dr. Tan Thiam Chye

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Perimenopause Spotting and Menopause: What You Should Know? Menopause is natural and is part of ageing. Most women go through menopause gracefully but unfortunately, it can be challenging for some. During this perimenopausal period, the ovaries stop producing oestrogen. Thus, women may experience symptoms such as hot flushes and mood swings. These symptoms may last from few months to few years even after menopause. What is Perimenopause Spotting? Is This Normal?Women go through the perimenopause, which typically begins in mid-40s. Hormonal and menstrual changes begin to fluctuate during this period. Throughout this time, the ovaries shrink and produce less oestrogen, which causes irregular and lighter periods. Medically, menopause is described as cessation of menstrual cycles for one year. In Singapore, menopause is around 50 years old. Perimenopause, which translates as "around menopause," is the period preceding menopause. It can linger for as long as a decade.These changes are subtle and treatable. Abnormal bleeding during this period, on the other hand, is a symptom that should not be ignored.Perimenopause Spotting instead of period: Causes and SymptomsOvulation can be disrupted by external hormones, substances that can be found naturally in men and women alike. Taking Phyto-oestrogens can result in perimenopause spotting.Periods of inconsistencyYour periods may be short or long, light or heavy, and you may miss some cycles as ovulation is more unpredictable. In early perimenopause, you may notice a seven-day shift in the length of your monthly cycle. Late perimenopause is when the interval between periods is 60 days or longer.Other issues of MenopauseProblems sleeping and hot flushesDuring perimenopause, hot flushes can be a regular occurrence. However, it varies with intensity, duration, and frequency. Hot flushes and night sweats are common causes of insomnia.Mood swingsSome women may have mood fluctuations or depression. Hot flushes, which are known to interrupt sleep, may be blamed for these symptoms. These symptoms are related to the low oestrogen state.Urinary tract and bladder issueWhen oestrogen falls, the lubrication and suppleness of vaginal tissues may decrease, making intercourse more uncomfortable. Infection of the urinary or vaginal tract can be exacerbated by low oestrogen level. In addition, urinary incontinence may be caused by a decrease in tissue tone.Infertility is on the declineYour fertility declines as your ovulation cycles get more and more erratic. However, when you're experiencing periods, pregnancy is still a remote possibility. Do consider birth control to prevent unwanted conception.Modifications to sexual interestDuring perimenopause, sexual desire and arousal may fluctuate. Sexual intimacy you enjoyed before menopause is less likely to persist into perimenopause and beyond. You might also experience perimenopausal and post-menopausal fatigue during this time.Bone loss and osteoporosisLosing bone mass at a faster rate raises your risk of osteoporosis, a disease characterized by brittle bones.Changing levels of cholesterolLow-density lipoprotein (LDL) cholesterol — the "bad" cholesterol — may increase as oestrogen level declines, putting you in the risk of heart disease. In addition, as women age, their levels of HDL cholesterol, or "good" cholesterol, drop, raising their risk of cardiovascular disease.Risks during PerimenopauseStroke and coronary artery disease are two common health problemsAfter menopause, your risk of heart disease and stroke increases. High cholesterol, high blood pressure, and belly fat—all of which elevate the risk of heart disease and stroke—also rise.As you grow older, your bones gradually become thinner, which is a condition known as osteoporosisOnce the ovaries quit producing oestrogen, bone loss rises. Oestrogen helps prevent bone loss in women of childbearing age. As a result, osteoporosis becomes prevalent as women age. Weight-bearing exercise with calcium / vitamin D-rich diet, on the other hand, can help halt bone loss and reduce the risk of fractures.MetabolismYour metabolism naturally slows down as you age. However, remember that your metabolism and weight are under your control, and you can take steps to improve both. Try increasing your physical activity. Your metabolism accelerates during exercise and persists for a few hours even after exercise. Regular exercise also builds muscle over time. Therefore, increased resting metabolism is achieved with increasing muscular mass.DiabetesAge is associated with an increased chance of developing pre-diabetes and type 2 diabetes. Obesity, lack of exercise, and a family history of type 2 diabetes all increase your risk.Thyroid problemHypothyroidism is more common in women. The low thyroid level may contribute to some symptoms of perimenopause.What are the Treatments of Perimenopause and Menopause?Perimenopause spotting does not require treatment unless symptoms become distressing. Treatments can include following:Hormone therapy, either with oestrogen alone or with oestrogen and progestins, is used to balance hormone levels.Antidepressants help maintain a positive mood.Do see a doctor to exclude womb cancer. An ultrasound pelvic scan may be warranted.Your healthcare physician may also recommend the following lifestyle changes:Consume a balanced diet of fruits, vegetables, and whole grains.Consume between 1,000 milligrams of calcium daily, either through food or supplements.Keep track of what causes your hot flushes (for example, alcohol, coffee, or tea).With your healthcare physician’s supervision, discuss the use of alternative treatments for symptom relief such as Traditional Chinese medicine or Phyto-oestrogens.Menopause, Perimenopause, and Post menopause: When to see a doctor?While menopausal symptoms are relatively common, you should visit a physician to manage your symptoms and identify which treatments may help alleviate discomfort. Along with scheduling a physical exam if you suspect you may be premenopausal, the following are further symptoms that you should see your doctor:Extreme symptoms: If you are experiencing any of the common menopause symptoms to the point that they are interfering with your daily life, it is necessary to consult a physician. While mental and physiological changes are expected, if you find yourself unable to work or feeling constantly ill, it's always a good idea to seek medical attention.Unexpected symptoms: Some women experience more incredible difficulty throughout menopause than most others. Suppose you observe significant weight gain, dizziness, or increased anxiety in addition to the expected adverse effects. In that case, it is critical to seek medical attention. Prolonged heavy bleeding is an unusual sign too.Final WordsThe underlying cause ultimately determines the appropriate treatment for spotting or irregular bleeding. Still, they may include hormone therapy or surgical removal of polyps or endometrial lining. If you have an atypical bleeding, excessive bleeding, or bleeding that occurs more frequently than usual throughout your menstrual cycle, schedule an appointment with your gynaecologist.

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Women’s Health

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What Is the Endometrial Stripe (aka Endometrium)? The endometrial stripe, otherwise known as the endometrial lining or endometrium, is a complex structure of the womb with its own microenvironment that allows it to perform tits unique function: to allow implantation of embryo, leading to pregnancy. The cells and tissue that make up this stripe is not found anywhere else in the normal woman’s body, except the inner lining of the womb; when it does appear elsewhere, it becomes a disease.Every menstrual cycle begins with the uterus shedding its inner lining that has built up from the previous cycle. Estrogen produced by the eggs in the ovaries directly stimulates the lining to thicken, in preparation for a possible implantation of embryo when the maturing egg is released for fertilisation later on in the cycle. When this lining is exposed to abnormal levels of hormones (including estrogen), its growth may become abnormal, especially in certain women who are prone to developing conditions such as polyps or pre-cancerous changes. When the endometrial lining invades beyond its normal boundaries, either into the muscle wall of the womb, or even beyond the womb itself, disease states of adenomyosis and endometriosis are formed. These are very common diseases affecting many women, with variable symptoms, such as painful menstruation, painful passage of urine / stools, painful sex, chronic pelvic pain and infertility. Some may not experience any symptoms at all.Symptoms of endometrial stripe disease often include abnormal bleeding: regular heavy menstruation, irregular menstruation, prolonged menstrual bleed, bleeding in the middle of cycle, bleeding after sexual intercourse, markedly reduced or even total absence of menstruation, etc. Any such symptoms experienced (persistently) should alert the lady of possible disease of the endometrium and she should seek help from a gynaecologist.How is the Endometrium evaluated?The gynaecologist will conduct a thorough review of your menstrual history and risk profile for developing diseases of the endometrium. Then, complemented with a bedside ultrasound scan of the womb and ovaries, the endometrium can be clinically evaluated. The main objective of clinical assessment is to categorise the patient into high risk or low risk of developing endometrial disease; thereafter, the decision for a biopsy of the endometrium can be made.The ultrasound scan (especially a transvaginal one), will allow the gynaecologist to measure the thickness of the endometrial stripe, which should not exceed 14mm, even during the part of the menstrual cycle when the stripe is expected to be the thickest (the limit for post-menopausal women should be less than 5mm). In experienced hands, the appearance of the endometrial stripe may also shed light on the health of the womb lining. Pre-cancerous changes and presence of polyps may be picked up or at least suspected.Biopsy of the endometrium is the gold standard for determining the diagnosis. The biopsy may be taken in the clinic with the patient fully awake, or under anaesthesia with an endoscopic instrument (hysteroscopy). The harvested specimen will be sent to the lab for the pathologist to perform microscopic examination, to confirm the nature of the tissue and to determine if polyps, cancer and pre-cancer are present.The Center for Disease Control and Prevention (CDC) lists five cancers that impact women's reproductive system. Cervical, ovarian, uterine, vaginal, and vulvar cancers afflict women in the United States, with uterine cancer affecting 50,600 women per year. Endometrial or uterine cancer is more frequent in women after menopause when the endometrium should be very thin (less than 5mm); hence any menopausal woman with endometrial thickness of 5mm or more should be evaluated carefully, preferably with a biopsy.Women who do not ovulate regularly during their reproductive years (20-50 years) are at risk of having cancerous change in their endometrium. A well-known condition that affects of such groups of women is Poly-Cystic Ovarian Syndrome (PCOS). Hence women with PCOS should continue regular follow up with their gynaecologists to look for signs of such cancers forming and also consider preventive treatment wherever appropriate.Signs and Symptoms of Endometrial DiseaseThe following symptoms are indicative of possible endometrial disease:Bleeding after menopauseIrregular menstrual bleedingHeavy menstrual bleedingProlonged menstrual bleedingBleeding after sexBleeding unexpectedly during the second half of menstrual cycleMarkedly reduced menstrual bleeding, or absent menstruationMenstrual cycles longer than 35-40 daysCan Endometrial Cancer be prevented?Although certain women are more prone to develop endometrial cancer than others, the primary stimulant for causing the endometrium to change into cancer is estrogen. Estrogen is produced in every healthy woman before menopause. The impact of estrogen on the endometrium can be counteracted by progesterone, which as also a hormone produced by ovulating women. When this balance of hormone production is lost, cancer or pre-cancer may occur. As estrogen is fat-soluble, overweight or obese women are likely to have higher amounts of estrogen present in their bodies, hence they have a higher chance of developing endometrial cancer. Also, obese women are less likely to ovulate regular, which is another risk factor for developing cancer of the endometrium. Certain drugs may also directly stimulate the endometrium to change towards cancer / pre-cancer, such as Tamoxifen. Diabetes is found to be another significant risk factor for developing endometrial cancer. The exact mechanism is unknown, but it may be related to obesity as well.As estrogen is pivotal to the development of endometrial cancer for most cases, reducing the exposure to estrogen is the key to prevention of this dreaded disease:Pregnancy (high progesterone to counter estrogen effect)Breastfeeding (reduction of estrogen production)Combined oral contraceptive pills (contains progesterone)Loss of weight (less estrogen stored in fats)Progesterone-containing contraceptives: combined pills, Mirena intra-uterine device, progesterone implants, etcEndometrial HyperplasiaEndometrial hyperplasia is considered the precursor of endometrial cancer. Depending on the severity of the hyperplasia, the treatment varies from cyclical progesterone or Mirena intra-uterine device, to removal of the womb. During the course of conservative treatment, regular biopsies of the endometrium is required to ensure disease response and not let cancer progression go unnoticed. Your gynaecologist will be able to assist you in determining the best treatment choice for you.Questions to ask your doctorThe following are just a few of the essential questions you should ask your doctor about your endometrial health:1. Does my endometrium look normal?2. What are my risks of developing endometrial hyperplasia or cancer?3. What can I do to reduce my risks of endometrial cancer?4. How can I optimise my endometrial lining for pregnancy?5. Do I need to do a biopsy of my endometrium?Final WordsThe endometrium is a structure that is easily assessed by an experienced gynaecologist with a simple bedside ultrasound scan. Different conditions of the endometrium may be detected by scan and subsequent decisions for biopsy may be undertaken for confirmation. Endometrial hyperplasia is usually curable, with the correct treatment regime for the specific individual. Develop a treatment plan with your physician. Regular follow-up with your specialist is essential to monitor for disease improvement / progression.

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Dr. Jun Yang Chan

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What is the Meaning of Blue Balls? Men have experienced the unfortunately named blue balls, or epididymal hypertension. It is a condition that can affect people with male genitals and causes pain in addition to an ache when they become erect without having reached climax through sexual stimulation beforehand. In addition, there will often be visible signs such as stains from semen on underwear after an erection has occurred because of this bodily reaction - not severe but uncomfortable nonetheless! Most men do not get EH frequently, though, so don't worry if yours happens too soon for your liking (or ever).Blue Balls: Everything You Should KnowBlue balls meaning is the slang term to refer to not-so severely painful experience in the testicles called epididymal hypertension. It can occur when a male stays stimulated but does not engage in orgasm. It produces a transient blood accumulation in the testicles. Epididymal hypertension is the medical word for blue balls.Blue balls is a contentious topic because there is no scientific consensus that they exist. In addition, there has been virtually little investigation into this area.What Causes Blue Balls?Many men are asking, “is blue balls real?” The answer is definitely yes. As previously stated, blue balls can occur when a male remains aroused but does not experience orgasms. This scenario eventually results in a brief accumulation of blood in the testicles.What are the Symptoms of Blue Balls?Symptoms of blue balls are straightforward: soreness or discomfort in the balls during sexual stimulation, occasionally accompanied by a bluish hue to the scrotum.The ailment was given the nickname "blue balls" since some men describe a bluish color around their testicles as a consequence of enhanced blood circulation to the region and an increase in heart rate.How Do You Get Rid of Blue Balls?The simplest and quickest technique on how to get rid of blue balls is to get an orgasm - involving masturbation - which typically relieves any discomfort rapidly. If this is not possible for whatever reason, the next alternative is to become sexually unaroused, which can be accomplished in a variety of ways. There are several techniques on how to cure blue balls including the following:Distracting yourselfDistraction therapy, such as playing music or exercising, can be beneficial. Exercise may also be helpful since it can redirect blood away from the sexual organs and other parts of the body.Take a refreshing showerFor years, the ancient cold shower method has been advocated, believing that the cold diminishes enlargement of the sexual organs and diminishes sexual feelings. However, if you don't have access to a shower, applying a cold compress to the affected area can have the same effect.Get to work!Sexual desires, like urges for tobacco or cake, will subside if you ignore them. So keep yourself busy with work or focus on another thing.Discuss itTalking therapy can be helpful for you to explore your emotions and opinions about sex, love, and relationships if you are unhappy with your sex life. Try cognitive behavior therapy (CBT), a talking treatment that focuses on modifying unhelpful behaviors in order to enhance how you feel, or chat with a sex therapist.Other Common Causes of Testicular PainPain and swelling felt in one, or both testicles is referred to as testicular pain. Acute or chronic pain might be mild, severe, or a feeling of soreness or undefined tension. Testicular pain can be caused by various diseases and other health issues, some of which are emergency cases.Below are some of the common causes of testicular pain:Epididymitis (caused by sexually transmitted diseases or STD)Stones in the kidneyTesticular tumor, testicular torsion, or testicular traumaHernia inguinalOrchitisInfections such as the mumpsCancersTorsion of the testicles - testicular torsionWhen Should You See a Doctor?Blue balls are not severe enough to require rapid medical intervention. However, consult a doctor or urologist if you are frequently in excruciating discomfort. Likewise, if you detect a decline in your sexual performance, consult a doctor or a sex therapist.Seek blue balls treatment if you are in pain and suffering the following symptoms:Uncomfortable feelings that are unrelated to sexual activityHurts in your entire groin areaLower backacheOne of your testicles has lumpsFinal WordsPain in one or both testicles can be caused by a variety of diseases and other health issues. Therefore, the presence of testicular pain and other symptoms and indicators varies according to the underlying reason. Unfortunately, the signs of the many causes might be highly similar, making it difficult to differentiate between the disorders that require immediate medical attention. As a result, if you feel testicular pain, contact your health care provider or go to the local Emergency Department right once.

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Dr. Tunn Lin Tay

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Morbidly Obese: Causes, Diagnoses, Weight Management and Risk Morbid obesity can interfere with essential physical functions such as breathing or walking. In addition, those who suffer from it are at greater risk for illnesses, including diabetes, high blood pressure, and cancerous cell growth in their body. Obesity is determined by the BMI (Body Mass Index). This ratio includes height and weight measurements that takes the weight divided by the square of the height. The BMI correlates with the amount of body fat. If the BMI is above 30 kg/m2, that indicates obesity; at a BMI more than 35, it is considered morbidly obese. What is Morbid Obesity?Morbid obesity symptoms contribute to primary physical disorders such as breathing problems and walking difficulties. In addition, individuals found morbidly obese are at higher risk for certain diseases, including high blood pressure, diabetes, gallstones, sleep apnea, cancer, and other related illnesses.The condition includes people who have a body mass index (BMI) that is considerably higher than 35. What Causes Morbid Obesity?Morbid obesity is the direct result of too much fat stored in one’s body, which can result from excessive caloric intake in the diet with insufficient exercise; a family history of obesity; and less commonly, due to undiagnosed hormone disorders leading to weight gain. Fat will gradually build up every time you consume more calories than what your body needs. And the result of too much fat stored in your body leads to obesity or morbid obesity.Common Obesity-Related ConditionsListed below are common obesity complications:Osteoarthritis The inflammation of weight-bearing joints due to osteoarthritis. Inflammation and pain are triggered by additional weight placed on joints, particularly on knees and hips. Similar problems can arise in the back when bones and muscles are stressed, such as damaged disks and back pain.Depression The inflammation of weight-bearing joints due to osteoarthritis. Inflammation and pain are triggered by additional weight placed on joints, particularly on knees and hips. Similar problems can arise in the back when bones and muscles are stressed, such as damaged disks and back pain.Sleep apnea/respiratory problems People who sleep on their backs, especially those with fat deposits in their tongue and neck, may have trouble breathing. During the daytime, they become drowsy and have headaches as a result.High blood pressureWhen the body carries around excess weight, the heart cannot function properly. Consequently, obesity usually leads to hypertension (high blood pressure), which can cause stroke and damage to the heart and kidneys.Type 2 diabetesWhen people become morbidly obese, their insulin resistance increases, increasing blood sugar levels. It leads to Type 2 diabetes.Who Is at Risk for Morbid Obesity?According to the National Health and Nutrition Examination Survey:There were no significant differences in obesity rates between men and women between all adults or by age groups in 2017–2018, according to age-adjusted obesity prevalence rates for adults.Women have a higher chance to be obese than men.Adults of non-Hispanic black racial and ethnic origin had the highest prevalence of both obesity and severe obesity.Adults aged 40–59 had the highest prevalence of severe obesity compared to other age groups.Adult obesity and severe obesity rates have increased among adults from 1999–2000 through 2017–2018.Diagnosing Morbid ObesityThe doctor will typically prescribe some tests and perform a physical examination to diagnose obesity and discuss obesity treatment.Generally, these tests and exams include:Taking your medical history. In addition to reviewing your medical history, your doctor may ask about your habits. It includes exercise, eating patterns, conditions you have, medications, stress levels, and other matters related to your health. It is also possible to determine predispositions to certain diseases based on your family history.A general physical examination. Your height, blood pressure, temperature, heart rate, and lungs are all checked, as well as your abdomen.BMI calculation. Your doctor will assess you regarding your body mass index. An obese individual has a body mass index greater than 30. The higher the number, the higher the health risks. It is imperative to have your BMI checked at least once a year to assess your health risks and prescribed appropriate treatments.Taking your waist measurement. You can increase your risk of heart disease and diabetes by storing fat around your waist, also known as visceral fat or abdominal fat. The waist measurement (circumference) of women greater than 35 inches (89 centimeters) and the waist measurement of men greater than 40 inches (102 centimeters) may be associated with more health risks than the waist measurements of individuals just a few inches shorter. At least once a year, waist circumference should also be measured.Examining other health issues. Your doctor will assess your health issues if you have any. Your doctor will also check for other health problems, such as hypertension, high cholesterol, thyroid problems, liver problems, and diabetes.What makes obese hosts so vulnerable to Covid-19 (Coronavirus)In a healthy body, adipose tissue serves as a repository of energy in times of food scarcity. And in lean, healthy individuals, it gives off elements that are anti-inflammatory.If, however, the fat tissue becomes detrimental, which usually happens in obese individuals, it can become dysfunctional. It secretes hormones and other chemical signals that promote chronic low-grade inflammation. Impact of COVID-19 lockdown on weight managementThere is a strong link between obesogenic practices and COVID-19 quarantine plans, deficient physical activity, excessive food intake, and unhealthy eating habits. In addition, people are being forced to sit in the same position for more extended periods, enhancing sedentary behaviours. Such behaviours include:The exposure to screens (computers, video games, tablets, televisionThe move to remote working.The closing of gardens and gyms.These practices result in morbidly obese individuals. Keeping a regular physical activity schedule when isolated is essential for weight loss prevention. Final WordsTo maintain good health, it is crucial to maintain a healthy weight. The first step to prevent obesity is to take action every day. You can avoid the effects of obesity by making small changes, such as eating more vegetables and going to the gym a few times a week.Taking a more customised approach to your diet is possible with the help of a dietitian or nutritionist. Finally, due to the difficulties in maintaining weight loss or even losing significant amounts of weight, medications or even procedures like bariatric surgery can help to get patients to lose weight healthily.

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