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26, 8, 2022

What you need to know about vein valves

2022-07-20T15:40:53-07:00

In the circulatory system, the vein valves carry deoxygenated blood back to the heart. The leg veins carry blood toward the heart, against gravity. Therefore, the leg veins have one-way valves to prevent backflow of blood. When the valves do not function properly, they allow blood to flow backward, causing the pooling of blood. This is referred to as venous reflux or venous insufficiency. Eventually, the backflow of the blood will cause varicose veins to develop and symptoms related to the increased pressure in the leg veins such as leg heaviness, aching, swelling, restless legs, night cramps, throbbing, and pain. Varicose veins  can be treated with different lifestyle changes.

 

Conservative Management & Lifestyle Modifications Include for varicose veins and vein valves:

 

The goals of treatment are to relieve symptoms, prevent complications and for some to improve appearance.  Lifestyle changes can ease the symptoms, but do not cause the veins to vanish.  These treatments include:

  • Avoid standing or sitting for long periods of time:  To keep blood moving when you have to sit or stand for long periods, try these tips: at work, take walking breaks and try walking during your lunch hour. While sitting, try flexing your feet up and down ten times an hour.
  • Exercise: Exercising is good for your veins because it improves blood flow. Walking, cycling or swimming are great exercises for vein health. But be sure to check with your doctor before starting any exercise program.
  • Weight loss or maintaining a healthy weight: Being overweight puts extra pressure on your veins.
  • Leg elevation: Use leg elevation three or four times a day for about 15 minutes at a time. Even elevating your legs on a step stool or ottoman is beneficial. If you need to sit or stand for a long period of time, flexing (bending) your legs occasionally can help keep blood circulating. If you have mild to moderate varicose veins, elevating your legs can help reduce leg swelling and relieve other symptoms.
  • Compression stockings: These elastic stockings squeeze or compress the veins and prevent blood from flowing backward. Compression stockings must be graduated, medical-grade compression to be beneficial. Over the counter,support hose or TED hose are not adequate to reduce symptoms in venous disease for active patients.
  • Supplements such as horse chestnut and grape seed extract can help reduce symptoms of venous disease. Check with your doctor before starting supplements.
  • Anti-inflammatory medications such as ibuprofen.
  • Anti-inflammatory topical agents such as OTC Arnica, or prescription voltaren gel may be helpful for painful phlebitis.
  • Ice packs can be applied to veins that are tender to reduce inflammation

 

Leg veins have one-way valves that prevent blood from flowing backward. Diseased valves are ‘leaky’ and allow blood flow both forward and backward, eventually causing bulging of the veins, i.e., varicose veins.

 

The valves inside the leg veins can be seen on ultrasound. 

 

 For more information and to book a consultation, please give our office a call at 858-550-0330. 

 

For more information please check out our Youtube Channel at this link.

 

For more information on varicose veins and eliminating underlying venous insufficiency, check this link out full of resources. 

 

What you need to know about vein valves2022-07-20T15:40:53-07:00

Signs of Venous Disease

2022-07-20T15:06:13-07:00

Signs of Chronic Venous Insufficiency & Venous Disease

Chronic venous insufficiency (CVI) is an inflammatory condition caused by long standing, untreated venous reflux disease which can cause very unique signs and symptoms.  Commonly, venous reflux disease causes a collection of symptoms such as leg swelling, heaviness, fatigue and varicose veins. But, over time, when blood is no longer circulating properly in the leg veins, skin changes can also appear. When skin changes appear, this is termed, chronic venous insufficiency (CVI). Venous stasis is another term used for this condition.   Chronic inflammation from CVI causes the skin around the ankles to darken, become dry, itchy, and firm. In severe cases, the skin can start to break down and ulcerate. The ulcer (wound) occurs in the inner or outer ankle and is also referred to as a stasis ulcer or venous ulcer.

Venous stasis skin changes associated with venous insufficiency include:

  • Darkening of the skin along the ankles
  • Itching and dry skin around the ankles (venous eczema)
  • Development of wounds around the ankles, called venous leg ulcers

HOW IS CVI TREATED?

The treatment of CVI cannot reverse the skin changes but it can prevent it from worsening and ulceration. In our experience, treatment of underlying venous reflux reduces the inflammatory changes and the skin may become less itchy and dry, but the permanent skin discoloration does not disappear. Treatment involves correction of the underlying venous reflux.

HOW ARE LEG ULCERS TREATED?

Venous leg ulcers, depending on the severity can be healed with a combination of correction of the underlying venous reflux, wound care clinic referral, and compression therapy. A detailed ultrasound will determine what specific treatment is needed depending on where the underlying reflux lies (for example, in the saphenous veins, perforator veins and tributaries). Deep vein reflux is also present in many individuals with ulcers.

Recognize the signs and symptoms of venous disease:

-heavy, tired and aching legs

-swollen legs and or ankles

-cramping in the legs

-dull or sharp pain in the calf

-varicose veins and spider veins

-red or warm veins

-itching around the veins

-skin changes around the ankles such as pigmentation, brownish discoloration, eczema, new red and blue veins, breakdown of the skin

-Heavy legs are a common sign of venous insufficiency and varicose veins.You should see your vascular specialist for any of the above signs and symptoms

If you experience any vein disease symptoms or signs, please call our office at (858)-434-5998 to schedule a consultation with one of our knowledgeable doctors at La Jolla Vein and Vascular. 

 

For more information on vein health please check out our Youtube Channel or visit our helpful guide of resources. 

 

 

 

 

 

Signs of Venous Disease2022-07-20T15:06:13-07:00

Vein Disease Prevention

2022-12-13T13:16:18-08:00

What is chronic venous insufficiency and how can you understand it for vein disease prevention?

Chronic venous insufficiency (CVI) is an inflammatory condition caused by long standing, untreated venous reflux disease.  Commonly, venous reflux disease causes a collection of symptoms such as leg swelling, heaviness, fatigue and varicose veins. But, over time, when blood is no longer circulating properly in the leg veins, skin changes can also appear. When skin changes appear, this is termed, chronic venous insufficiency (CVI). Venous stasis is another term used for this condition.   Chronic inflammation from CVI causes the skin around the ankles to darken, become dry, itchy, and firm. In severe cases, the skin can start to break down and ulcerate. The ulcer (wound) occurs in the inner or outer ankle and is also referred to as a stasis ulcer or venous ulcer.

Venous stasis skin changes associated with venous insufficiency include:

  • Darkening of the skin along the ankles
  • Itching and dry skin around the ankles (venous eczema)
  • Development of wounds around the ankles, called venous leg ulcers

When it comes to vein disease it is certainly possible to take measures that will help. Remember that varicose veins are veins that have been stretched so often that they have become chronically dilated. The trick is to limit the opportunity to distend the veins.

Here are some helpful tips to aid in vein disease prevention:

  1. Wear compression stockings
  2. stay fit and maintain a healthy weight
  3. exercise: exercising helps your veins pump blood.
  4. avoid prolonged sitting or standing
  5. avoid prolonged exposure to direct sunlight
  6. elevate your legs as much as possible
  7. Exercising the muscles in your legs helps your veins pump blood. This, in turn, will reduce the pressure within the veins and can help reduce symptoms related to vein problems

If you experience any vein disease symptoms, please call our office at (858)-550-0330 to schedule a consultation with one of our knowledgeable doctors at La Jolla Vein and Vascular. 

 

For more information on vein health and vein disease prevention please check out our Youtube Channel or visit our helpful guide of resources. 

 

Vein Disease Prevention2022-12-13T13:16:18-08:00

Results of non surgical vein treatment

2022-07-20T14:37:06-07:00

At La Jolla Vein and Vascular, we treat venous reflux disease which includes varicose veins. Venous reflux disease is also known as venous stasis, venous insufficiency or venous incompetence. Venous reflux disease refers to ‘leaky valves’ in the veins of the legs. Reflux may occur in the deep and/or superficial leg veins. The deep veins are those within the muscle; they bring at least 80-90% of the blood from the legs back to the heart. The superficial veins are outside of the muscle and under the skin.

The main superficial veins are the Great Saphenous Vein that courses up the middle of the thigh and calf and the small saphenous vein, which courses up the back of the calf. Normally, there are one-way valves within the leg veins, which help blood flow in one direction: toward the heart. This means blood is traveling against gravity.

The calf muscle also helps move blood toward the heart. When vein valves are leaky, blood flows backward (reflux) towards the feet. Blood pools in the lower legs, causing bulging veins at the surface. Symptoms include leg heaviness, leg fatigue, leg pain, ankle swelling, phlebitis (inflamed and painful veins), restless legs at night, and night cramps.

Venous reflux disease is progressive and worsens over time. Skin changes may also develop, including darkening of the skin around the ankles. The darkening of the skin is sometimes referred to as venous stasis skin changes. The skin can become dry and itchy (venous eczema). Eventually, the skin can break down causing a wound, called a venous leg ulcer.

 

Below you will see various before and after pictures of non-surgical removal of varicose veins at La Jolla Vein and Vascular. The before picture shows bulging varicose veins that arise from an incompetent great saphenous vein (this vein is not visible to the naked eye). In the past, these veins would have been stripped with vein stripping surgery. Fortunately, new technology allows for even large varicose veins to be removed without surgery. This patient underwent radiofrequency ablation (or endovenous ablation) of the great saphenous vein and foam sclerotherapy of the bulging varicose veins at La Jolla Vein and Vascular. 

varicose veins varicose veins 9 10 11 12 1

If you experience any vein disease symptoms, please call our office at (858)-434-5998 to schedule a consultation with one of our knowledgeable doctors at La Jolla Vein and Vascular. 

 

For more information on vein health please check out our Youtube Channel or visit our helpful guide of resources. 

 

Results of non surgical vein treatment2022-07-20T14:37:06-07:00

Blood Clotting & Vein Health

2022-12-13T13:24:38-08:00

When blood moves too slowly in your veins, it can cause a clump of blood cells (a blood clot or Thrombus). Deep vein thrombosis (DVT) is a condition in which a blood clot forms in the deep vein located in the leg, thigh, or pelvis. While Deep vein thrombosis (DVT) is common in the lower leg, it can also develop in other body parts, including the arms. So, how do blood clots form in the veins, and is it dangerous? 

To answer this, let us look at how the blood circulates in the body. The blood circulatory system consists of two blood vessels, namely the arteries and veins. The arteries carry blood rich in nutrients and oxygen from the heart, while the veins carry the deoxygenated blood back to the heart. Arteries have thin muscles within their walls that make them capable of withstanding the pumping pressure from the heart. However, the veins have no muscle lining and entirely depend on the muscle movement to take the blood back to the heart. 

Blood clots may form when something slows or changes the flow of blood in the veins. Risk factors include:

  • After a pacemaker catheter has been passed through the vein in the groin
  • Bedrest
  • Cigarette smoking
  • Family history of blood clots
  • Fractures in the pelvis or legs
  • Giving birth within the last 6 months
  • Heart failure
  • Obesity
  • Recent surgery (especially hip, knee, or female pelvic surgery)
  • Too many blood cells being made by the bone marrow (polycythemia vera), causing the blood to be thicker and slower than normal

You’re also more likely to develop DVT if you have any of the following conditions:

  • Blood that is more likely to clot (hypercoagulability)
  • Cancer
  • Taking estrogens or birth control pills.
  • Long airplane flights: London’s Heathrow Airport reports one passenger death a month from DVT. One nearby hospital recorded thirty passenger deaths from DVT in the past three years including a 28-year-old man. To reduce the risk of DVT during air travel,  passengers are advised to wear compression stockings on flights, frequently moving around the cabin and pumping the calf muscles, leg elevation and avoidance of sedentary positions for long periods of time without moving.

 

An interesting finding: A point mutation (G20210A) in the Factor II (prothrombin) gene is the second most common cause of inherited blood clots and accounts for 20% of the inherited blood clotting disorders. The incidence of this mutation in the Caucasian population is 1-2% and in African Americans it is 0.1%. Carriers of this mutation have an increased risk (3x) of developing a blood clot in the deep veins (deep venous thrombosis or DVT).  A test for this mutation is usually only recommended if there is a family history of blood clots (DVT) or in cases where the cause of the blood clot is not clear or in pregnant women with recurrent miscarriages.  A more common cause of a blood clotting disorder that is inherited from the parents is the Factor V Leiden mutation.

 

If you experience any vein disease symptoms, please call our office at (858)-550-0330 to schedule a consultation with one of our knowledgeable doctors at La Jolla Vein and Vascular. 

For more information on vein health please check out our Youtube Channel or visit our helpful guide of resources.

Blood Clotting & Vein Health2022-12-13T13:24:38-08:00

Varicose Veins vs Spider Veins

2022-12-13T14:17:35-08:00

What is the difference between varicose veins and spider veins? 

At La Jolla Vein and Vascular, we treat numerous patients with varicose veins and spider veins. Knowing the difference is important. 

Varicose veins are the twisted, bulging veins just beneath the surface of the skin. Varicose veins are swollen, twisted veins that you can see just under the surface of the skin. These veins usually occur in the legs, but they also can form in other parts of the body. Varicose veins are a common condition.

What causes varicose veins?

Varicose veins are caused by leaky vein valves, which allow blood to pool within the veins causing them to stretch and become enlarged. Varicose veins can be an isolated finding, but the majority of the time, they are caused by underlying venous reflux disease. Venous reflux disease is also known as venous stasis, venous insufficiency or venous incompetence. Reflux may occur in the deep and/or superficial leg veins.

In our study, led by Dr. Nisha Bunke and published in the Journal of Vascular Ultrasound in 2018, we studied over 1,000 legs with varicose veins. Over 90% of the time, the source of the varicose veins were the great and small saphenous veins. The Great Saphenous Vein (GSV) courses up the middle of the thigh and calf and the small saphenous vein (SSV), which courses along the back of the calf. Normally, there are one-way valves within the leg veins, which help blood flow in one direction: toward the heart. This means blood is traveling against gravity. The calf muscle also helps move blood toward the heart. When vein valves are leaky, blood flows backward (reflux) towards the feet. Blood pools in the lower legs, causing bulging veins at the surface.

Varicose (VAR-i-kos) veins are enlarged veins that can be blue, red, or flesh-colored. They often look like cords and appear twisted and bulging. They can be swollen and raised above the surface of the skin. Varicose veins are often found on the thighs, backs of the calves, or the inside of the leg. During pregnancy, varicose veins can form around the vagina and buttocks.

What are spider veins?

Spider veins are the fine, thread-like reddish veins at the surface of the skin. Spider veins are not healthy. Spider veins are often considered a cosmetic issue, but they can be associated with underlying feeder veins, not visible to the naked eye.  Feeder veins are the ‘blue veins’ also known as ‘reticular veins,’ that give rise to spider veins. Spider veins may also be a sign of underlying venous insufficiency. For example, spider veins located in the inner ankles and inner thighs can indicate an underlying problem with the saphenous vein. As a result, an ultrasound examination may be recommended to identify and effectively treat the underlying source of the spider veins.

What are the symptoms?

Vein conditions affect people differently. For some, spider veins can be a painless cosmetic concern, and for others they may cause symptoms. The most common symptoms of spider veins are burning, throbbing, and localized pain. They can also feel hot and itchy and bleed.

What causes spider veins?

Spider veins in the legs are caused by the same condition that causes varicose veins. Leaky vein valves allow blood to pool within the veins causing them to stretch and become enlarged. They are on other areas of the body, such as the face, and chest can be caused by sun damage, hormone changes or liver disease. Hormones, such as with pregnancy, birth control or hormone replacement therapy can weaken the vein wall.

They are like varicose veins but smaller. Often, they are red or blue. They can look like tree branches or spiderwebs with their short, jagged lines. This patient had large clusters of bluish colored spider veins around the knee. 

If you experience any vein disease symptoms, please call our office at (858)-550-0330 to schedule a consultation with one of our knowledgeable doctors at La Jolla Vein and Vascular.

For more information on vein health please check out our Youtube Channel or visit our helpful guide of resources.

 

Varicose Veins vs Spider Veins2022-12-13T14:17:35-08:00

La Jolla Vein & Vascular Featured in a Fox 5 Segment

2022-12-13T13:25:29-08:00

At La Jolla Vein and Vascular, we are excited to share with you our FOX 5 Localist Segment where Dr Nisha Bunke shares what our clinic can offer. 

 “Bringing Experts Together for Unparalleled Vein and Vascular Care”

 

Check out our Fox 5 segment here 

fox5segment

 

La Jolla Vein & Vascular (formerly La Jolla Vein Care) is committed to bringing experts together for unparalleled vein and vascular care. As mentioned in the Fox 5 segment, La Jolla Vein and Vascular offers a variety of services for vein and vascular health. 

 

Nisha Bunke, MD, Sarah Lucas, MD, and Elliot DeYoung, MD are specialists who combine their experience and expertise to offer world-class vascular care. 

 

Our accredited center is also a nationally known teaching site and center of excellence. 

 

➡Vascular conditions we treat: 

 

-varicose veins and spider veins

 

 -chronic venous insufficiency 

 

-pelvic congestion and labial veins 

 

-varicocele (varicose veins in the scrotum) 

 

-uterine fibroids 

 

-deep vein thrombosis 

 

-May Thurner peripheral arterial disease 

 

-knee arthritis (genicular artery embolization) 

 

-leg ulcers 

 

-chronic leg swelling 

 

-lymphedema

 

If you experience any vein disease symptoms, please call our office at (858)-550-0330 to schedule a consultation with one of our knowledgeable doctors at La Jolla Vein and Vascular. 

 

For more information on vein health mentioned in our Fox 5 segment please check out our Youtube Channel or visit our helpful guide of resources. 

 

La Jolla Vein & Vascular Featured in a Fox 5 Segment2022-12-13T13:25:29-08:00

What you need to know about compression stockings

2022-07-20T13:10:20-07:00

At La Jolla Vein and Vascular, we suggest patients use compression stockings for better vein health. There are a few different types to choose from listed below. But first, knowing the benefits of using compression stockings for your vein health empowers you to decide with your physician which type is best for you. 

Benefits of compression stockings for vein and vascular health: 

  1. Wearing compression stockings or socks places pressure on the veins in the lower legs.
  2. The pressure helps improve blood flow
  3. The pressure helps prevent further spider veins and varicose veins
  4. Compression stockings also relieve leg swelling
  5. Reduces the risk of blood clots in the legs

 

Anti-embolism stockings, also known as TED hoses, are designed specifically for non-mobile patients or those confined to a bed. These are the white stockings used for hospital patients. They are low-cost temporary solutions commonly used for patients in nursing homes and post-surgery to prevent deep vein thrombosis (DVT).

 

Graduated compression therapy provides external support to the vein walls and works in conjunction with the calf muscle pump. Compression stockings improve circulation while helping to minimize and control leg and ankle swelling.

However, for ambulatory (walking patients who are not bed-bound), TED hoses do not offer sufficient support to counter the effects of gravity.  They have not graduated compression and only offer about 8-18mmhg compression. TED hose does not help the symptoms of venous disease and varicose veins. TED hose cannot be used for vein treatment and should not be used for daily support in walking patients.

In comparison, graduated compression stockings are medically therapeutic and designed for people who are mobile. Graduated compression means that they are tightest around the ankle and gradually ease as they go up. These can help reduce the risk of DVT in patients who travel by plane or car and reduce symptoms such as leg swelling (edema), aching, heaviness, fatigue, pain from varicose veins, and useful for pregnant women to reduce pain from varicose veins.

 

 For more information and to book a consultation, please give our office a call at 858-550-0330. 

 

For more information please check out our Youtube Channel at this link.

 

For more information on varicose veins and eliminating underlying venous insufficiency, check this link out full of resources. 

 

What you need to know about compression stockings2022-07-20T13:10:20-07:00

Tips to reduce discomfort from varicose veins

2022-07-19T18:14:43-07:00

How To Reduce Discomfort From Varicose Veins:

Varicose and spider veins may be treated with lifestyle changes or medical procedures.

The goals of treatment are to relieve symptoms, prevent complications, and for some to improve appearance.  Lifestyle changes can ease the symptoms but do not cause the veins to vanish.  These include:

  • Avoid standing or sitting for long periods of time:  To keep blood moving when you have to sit or stand for long periods, try these tips: at work, take walking breaks and try walking during your lunch hour. While sitting, try flexing your feet up and down 10 times an hour. When standing, raise yourself up and down on your toes or rock back and forth on your heels.
  • Exercise: Exercising is good for your veins because it improves blood flow. Walking, cycling or swimming are great exercises for vein health. But be sure to check with your doctor before starting any exercise program.
  • Weight loss or maintaining a healthy weight: Being overweight puts extra pressure on your veins.
  • Leg elevation: Use leg elevation three or four times a day for about 15 minutes at a time. Even elevating your legs on a step stool or ottoman is beneficial. If you need to sit or stand for a long period of time, flexing (bending) your legs occasionally can help keep blood circulating. If you have mild to moderate varicose veins, elevating your legs can help reduce leg swelling and relieve other symptoms.
  • Compression stockings: These elastic stockings squeeze or compress the veins and prevent blood from flowing backward. Compression stockings must be graduated, medical-grade compression to be beneficial. Over-the-counter support hose or TED hose are not adequate to reduce symptoms in venous disease for active patients.
  • Supplements such as horse chestnut and grape seed extract can help reduce symptoms of venous disease
  • Anti-inflammatory medications such as ibuprofen
  • ice packs can be applied to veins that are tender to reduce inflammation

 For more information and to book a consultation, please give our office a call at 858-550-0330. 

 

For more information please check out our Youtube Channel at this link.

 

For more information on varicose veins and eliminating underlying venous insufficiency, check this link out full of resources. 

 

Tips to reduce discomfort from varicose veins2022-07-19T18:14:43-07:00

What you need to know about leg ulcers

2022-07-19T18:05:28-07:00

A leg ulceration is the most severe form of chronic venous insufficiency.  This is referred to as a ‘venous leg ulcer.’  Venous leg ulcers make up 70% of all chronic leg wounds.  Therefore, a venous leg ulcer is much more common than a diabetic or arterial ulcer.  It is caused by long-standing pressure within the leg veins, resulting from 1) venous reflux through faulty valves, 2) a blockage within the deep veins or 3) from the inability to use the calf muscles or a combination.  Venous reflux is the most common cause of a venous leg ulcer.  The increased pressure within the leg veins (we call this venous hypertension) causes an inflammatory response. Inflammation then causes changes in the skin, usually around the ankles (this is where pressure is the greatest).  The inflammatory process will cause the skin around the ankles to become brown or discolored, and eventually, the skin will break open.  The leg wound can be healed by treating the underlying vein condition.  Venous leg ulcers can also be prevented by early intervention with non-invasive procedures.  If you have signs of chronic venous insufficiency (such as skin discoloration around the ankles) you should address your underlying vein condition to prevent the skin from breaking open.

 

What is chronic venous insufficiency?

Chronic venous insufficiency (CVI) is an inflammatory condition caused by long standing, untreated venous reflux disease.  Commonly, venous reflux disease causes a collection of symptoms such as leg swelling, heaviness, fatigue and varicose veins. But, over time, when blood is no longer circulating properly in the leg veins, skin changes can also appear. When skin changes appear, this is termed, chronic venous insufficiency (CVI). Venous stasis is another term used for this condition.   Chronic inflammation from CVI causes the skin around the ankles to darken, become dry, itchy, and firm. In severe cases, the skin can start to break down and ulcerate. The ulcer (wound) occurs in the inner or outer ankle and is also referred to as a stasis ulcer or venous ulcer.

Venous stasis skin changes associated with venous insufficiency include:

  • Darkening of the skin along the ankles
  • Itching and dry skin around the ankles (venous eczema)
  • Development of wounds around the ankles, called venous leg ulcers

How are leg ulcers treated? 

Venous leg ulcers, depending on the severity, can be healed with a combination of correction of the underlying venous reflux, wound care clinic referral, and compression therapy. A detailed ultrasound will determine what specific treatment is needed depending on where the underlying reflux lies (for example, in the saphenous veins, perforator veins and tributaries). Deep vein reflux is also present in many individuals with ulcers.

 

 

For more information please check out our Youtube Channel at this link.

 

For more information on varicose veins and eliminating underlying venous insufficiency, check this link out full of resources. 

 

What you need to know about leg ulcers2022-07-19T18:05:28-07:00
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© Copyright 2010-2025, La Jolla Vein & Vascular | All Rights Reserved

CONTACT INFORMATION

La Jolla/UTC

Vista

Patient Privacy Practices

Privacy Policy

Hippa Privacy Practices
HIPAAOneTM Certified Seal 2

Use the search features below to find articles and insights for the diagnosis and treatment of vascular disease

TWO CONVENIENT LOCATIONS THROUGHOUT SAN DIEGO

La Jolla/ UTC

North County San Diego/ Vista — Endovascular Center
Now Open! Call/Text for Appointments

© Copyright 2010-2024, La Jolla Vein & Vascular | All Rights Reserved

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