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Open the Podcasts app and search for The Doctor’s Farmacy. If you’re viewing this site on your phone, you can just tap on the

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Episode 74
The Doctor's Farmacy: House Call

Is An Autoimmune Condition Driving Your Raynaud’s Syndrome?

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Autoimmune conditions are rising in prevalence and oftentimes if you have one, you are likely to have several. In some people who experience autoimmune conditions such as Sjogren’s, rheumatoid arthritis, or lupus, Raynaud’s Syndrome may be present. Raynaud’s is an uncomfortable vascular condition affecting the small arteries, prompting them to spasm, and can have a big impact on quality of life. Symptoms can include numbness and pain in fingers, toes, ears, or nose when exposed to cold weather or stress. Raynaud’s can also appear on its own in a milder form than if accompanied by another autoimmune condition.

In this episode, Dr. Hyman discusses Raynaud’s Syndrome with Dr. Cindy Geyer. They talk about who is at greatest risk of developing this condition and how it can lead to other more serious conditions such as high blood pressure, heart conditions, and stroke. They also explore the Functional Medicine approach to treating Raynaud’s, including healing the gut and incorporating stress management techniques.

Dr. Cindy Geyer received her Bachelor of Science and her Doctor of Medicine degrees, with honors, from the Ohio State University. She completed residency in internal medicine at Strong Memorial Hospital in Rochester, N.Y. and is triple board certified in internal medicine, integrative medicine, and lifestyle medicine. She joined The Ultrawellness Center in 2021 after practicing and serving as the medical director at Canyon Ranch for 23 years. She has served on the Board of Directors for the American College of Lifestyle Medicine and is a recently elected fellow of ACLM. Dr. Geyer has been a core faculty member at The Center for Mind-Body Medicine (CMBM) for 20 years, teaching physicians and other healthcare professionals how to use food and lifestyle to address health concerns in their own lives and those of their patients. A clinician, educator, and avid hiker, she is passionate about collaborative approaches to health and wellness: from the integrative team model in working with individual patients, to community partnerships that together can affect healthy changes in the places people live and work.

This episode is brought to you by Rupa Health and Athletic Greens.

Rupa Health is a place for Functional Medicine practitioners to access more than 2,000 specialty lab tests from over 20 labs like DUTCH, Vibrant America, Genova, Great Plains, and more. You can check out a free live demo with a Q&A or create an account at RupaHealth.com.

Athletic Greens is offering Doctor’s Farmacy listeners a full-year supply of their Vitamin D3/K2 Liquid Formula free with your first purchase, plus 5 free travel packs. Just go to athleticgreens.com/hyman to take advantage of this great offer.

In this conversation, Dr. Hyman and Dr. Geyer discuss:

  • Raynaud’s Syndrome in relation to other autoimmune conditions
  • What is Raynaud’s and who does it affect?
  • How the arteries are affected in Raynaud’s
  • How Raynaud’s is diagnosed
  • What to look for to identify the root cause of Raynaud’s and other autoimmune conditions
  • Treating Raynaud’s from a Functional Medicine perspective
  • Supplements that can be helpful in the treatment of Raynaud’s

I hope you enjoyed this conversation as much as I did. Wishing you health and happiness,
Mark Hyman, MD
Mark Hyman, MD

Guest

 
Mark Hyman, MD

Mark Hyman, MD is the Founder and Director of The UltraWellness Center, the Head of Strategy and Innovation of Cleveland Clinic's Center for Functional Medicine, and a 13-time New York Times Bestselling author.

If you are looking for personalized medical support, we highly recommend contacting Dr. Hyman’s UltraWellness Center in Lenox, Massachusetts today.

 
Dr. Cindy Geyer

Dr. Geyer received her bachelor of science and her doctor of medicine degrees, with honors, from the Ohio State University. She completed residency in internal medicine at Strong Memorial Hospital in Rochester, N.Y. and is triple board certified in internal medicine, integrative medicine and lifestyle medicine.

Show Notes

  1. Three Steps to Reverse Autoimmune Disease with Dr. Terry Wahls
  2. Top Healthy Foods that Prevent & Treat Autoimmune Disease with Dr. Elroy Vojdani
  3. What Really Causes Autoimmune Disease with Dr. Todd LePine
  4. How a Doctor Cured her Autoimmune Disease with Functional Medicine

Transcript

Dr. Cindy Geyer:
The first step I’m going to go is looking for celiac disease, including sensitivity. I mean, that is a do not miss in anybody with an autoimmune condition. I mean, if you just look at the overlap, you see higher prevalence of celiac disease and gluten sensitivity in anybody with any autoimmune condition.

Dr. Mark Hyman:
Welcome to the Doctor’s Farmacy. I’m Dr. Mark Hyman. That’s Farmacy with an F, a place for conversations that matter. And if you’ve ever had that weird feeling where your fingers go cold, numb, and turn blue and purple, it’s called Raynaud’s syndrome. It’s a associated with a lot of autoimmune diseases, then you might want to listen to this podcast. Or if you know anybody who has it, it’s kind of miserable. It means you can’t go out in the cold, and your fingers feel like they’re going to fall off. They get numb. And it’s pretty common and prevalent. And a general approach to medicine is a bunch of drugs that don’t really work that well.

Dr. Mark Hyman:
We’ve got today on our special episode of the Doctor’s Farmacy, my friend and colleague, Dr. Cindy Geyer, who was recently the medical director at Canyon Ranch for a long time after I left there in 2004. And has just been a leading light in the field of integrative and functional medicine, has been teaching all over the world. And we’re just so happy to have her on the show. And today, we’re going to talk about all things Raynaud on this special episode of Doctors Farmacy called House Call. So welcome, Sydney.

Dr. Cindy Geyer:
Thanks, Mark. Good to be here.

Dr. Mark Hyman:
Okay. So this thing called Raynaud named after some guy Dr. Raynaud or something, such a powerful ego driven medicine. You got all these Hashimoto’s and this one, and this one, Sjogren’s. Everybody’s got a name for their disease. So I’m glad no one named a disease after me. That’s all I can say. So tell us about Raynaud’s. How common is this problem? What are the symptoms? And what is a general approach with traditional medicines?

Dr. Cindy Geyer:
Sure. So you talked a little bit about the symptoms that it’s typically fingers, sometimes toes, sometimes nose turning white or blue in the cold, and it can be very painful. And then you come inside and as it warms up, they can turn beet red. So it’s small arteries that react to the cold, and there are two types of Raynaud’s. There’s primary Raynaud’s which is just the Raynaud’s by itself. And then there’s secondary Raynaud’s which is associated with autoimmune conditions like rheumatoid arthritis and progressive systemic sclerosis.

Dr. Cindy Geyer:
And the second component tends to be more severe. It can even lead to ulcers on the tips of the fingers and things. It’s more common in women. It’s more common in lean women, interestingly enough, and it can significantly affect quality and quantity of life. And if it’s the primary source, it’s usually reassurance where mittens stay out in the cold. If it’s the more serious issues, sometimes they’ll use topical nitroglycerin, calcium channel blockers, even medications like Viagra.

Dr. Mark Hyman:
Wow. So Viagra, which it increases blood flow. So that makes sense, right?

Dr. Cindy Geyer:
Yeah. Isn’t that interesting? Yeah, with some benefit. Right. But I think the important thing is to say, well, what does it actually mean either if you have small arteries that tend to react to cold, or if you’ve got an autoimmune condition, because that opens the door into thinking about things from a much broader, comprehensive way.

Dr. Mark Hyman:
Yeah. And so from the perspective of the biology of it, you’re getting these sort of contracted vessels. What is the cause of that?

Dr. Cindy Geyer:
Well, we don’t know 100%, but those arteries, if we think of the importance of artery elasticity. So your arteries are dynamic. They can dilate, and they can constrict when needed. Sometimes it’s a way to kind of maintain core body temperature, but those small arteries in particular, we think of that inner lining, the endothelium that’s responsible for regulating the tone. It is another one of those proverbial canaries in the coal mine. It’s affected by a lot of other things besides cold.

Dr. Cindy Geyer:
In fact, it’s affected by many of the other factors that increase our risk of cardio-metabolic disease. We know that arteries can spasm in response to an unhealthy diet or hydrogenated oils. We know that arteries can spasm in response to stress or sleep deprivation. Arteries can spasm in response to air pollution. So there are many, many other factors that will make maybe a predisposition become more significant and more relevant. And the other piece is there’s some evidence that if you have arteries that are prone to spasm, it may be a marker that you are at higher risk down the road of developing high blood pressure, heart risk, and stroke. So it’s really a time to pay attention to the health of your arteries.

Dr. Mark Hyman:
So it can be found in isolation just as a random condition or random, or it can be associated with other autoimmune diseases like Sjogren’s or Lupus or other conditions. Essentially, it’s almost an autoimmune disease of the blood vessels. Right?

Dr. Cindy Geyer:
Right.

Dr. Mark Hyman:
And it creates inflammation. So then the question is, how do we think differently? If you’re just giving drugs like Viagra or you’re giving drugs to increasing blood flow, like blood pressure pills and so on, what do we do differently in functional medicine? How do we think differently about this problem? What are the diagnostic approaches we use to test and figure out what the cause is? And what do we do in terms of treatment?

Dr. Cindy Geyer:
Well, I think it’s important, number one, to really do a deep dive into vascular risk measurements. We want to know somebody’s quality and quantity of cholesterol. We want to know their glucose and insulin and how they’re able to manage glucose. We want to know their inflammatory markers like their C-reactive protein, and do they have evidence of oxidative stress. Anybody with an autoimmune condition, Mark, I mean, you’ve talked about this for such a long time, we want to figure out what the underlying cause is that’s up regulating the reactivity and leading to or chipping into the autoimmune condition. So we want to look for food triggers. We want to look at the health of the gut lining and all of the other things that people are familiar with. So it’s really looking for upstream to see from a vascular standpoint, how healthy that is and what’s driving it and from the driving and upregulating the immune system, what we can identify, remove, and address.

Dr. Mark Hyman:
Yeah. I mean, from the functional medicine perspective, I approach autoimmune disease really in a very consistent way, which is going down the framework of the matrix and looking where the imbalances are in the body and what are the potential drivers and causes of an inflammation disease. And so I would say, what are the things that you look for. Cindy, when someone comes in with an autoimmune disease like Raynaud’s? And by the way, there’s 80 million people with autoimmune disease. It’s three times as much as diabetes or heart disease or cancer. It’s massive, but they’re all sub categorize in their specialties.

Dr. Mark Hyman:
You’ve got Raynaud’s which is a blood vessel disease. You’ve got rheumatoid arthritis which is a joint disease. You’ve got MS which is a neuro disease. You’ve got celiac bowel which is a GI disease. And so you’ve got all these separate specialists, nobody’s saying, “Whoa, why is there so much autoimmune disease? And what do we look at to understand the root causes?” What are the things in your mind that you go through as a checklist, if someone comes in with an autoimmune disease?

Dr. Cindy Geyer:
The first step I’m going to go is looking for celiac disease including sensitivity. I mean, that is a do not miss in anybody with an autoimmune condition. I mean, if you just look at the overlap, you see higher prevalence of celiac disease and gluten sensitivity in anybody with any autoimmune condition. I mean, we’ve talked about this before with Cindy Baker’s TAC rules. If you’re trying to control the auto-immune condition, but you’re sitting on that gluten tack, it’s going to be really hard to quiet everything down and feel good. You have to remove the driver of the inflammation and the auto immune upregulation. So that is the first place that I go.

Dr. Mark Hyman:
Before you go on from that, I want you to explain the rest, but I just want to emphasize that because when someone comes with an autoimmune disease, getting a celiac panel is like checking a blood pressure. It’s just the most basic thing you can do. And often people misinterpret it because the levels are “normal.” But they might be in the continuum, so what if normal is up to 20, but your level’s 18 or 17 or 15 or 10, is it relevant? And the answer is yes. It’s relevant because it means your body’s having an immune response to an antigen or foreign protein in the gluten that you’re absorbing across your gut and your immune system is seeing and then getting pissed off about and creating a systemic reaction around. Now, how bad is that reaction? Will it cause symptoms ? Do you feel bad? Maybe, maybe not, but it is causing some low grade level of inflammation. And it’s a low grade hidden inflammation that’s driving so many chronic diseases.

Dr. Cindy Geyer:
Right. I think that’s a really important point. And it’s another one of those that sometimes doing more in depth testing, somebody might say, “Well, I don’t have celiac disease.” But every single other glial or gluten protein is showing up elevated, that might be a big motivator to say, “All right, I guess I do need to stop eating the bread and remove the gluten from the diet.” So sometimes we do more testing to convince people or really engage them because it’s hard. Those are foods you love. It’s hard to get people to give up what they’re used to eating.

Dr. Mark Hyman:
Absolutely, absolutely.

Dr. Cindy Geyer:
And of course there are other foods that could be culprits too, but gluten is the number one in my list.

Dr. Mark Hyman:
So go through now the rest of the kinds of things you think about with an autoimmune disease.

Dr. Cindy Geyer:
Yeah. So I also think about gut health and the health of the intestinal lining because anything that disrupts the health of that lining creates more input to those antibody producing cells. And I think if we quote Alessio Fasano, unlike Las Vegas, what happens in the gut, doesn’t stay in the gut. If it’s not healthy, if that wall is more permeable, and there’s more bacterial proteins getting into the bloodstream or more food proteins getting into the bloodstream, there’s that immune system just going ahh. It’s not just acting at the gut level. It can start cross reacting to organs that we should normally be tolerant to hence an autoimmune condition. So we really want to understand the health of the gut microbiome, the integrity of the intestinal lining, how well are we digesting and absorbing our food? Do we have an overgrowth of bacteria in the small intestine? That’s the second priority.

Dr. Mark Hyman:
Yeah. So you’ve got gluten, you’ve got the gut microbiome, you’ve got leaky gut. What else goes through your mind when you see someone with an autoimmune disease?

Dr. Cindy Geyer:
Well, so you also think about whether there could be a toxic insult to toxic exposure that could be upregulating the immune system. We know that. And I won’t say that stress per se necessarily causes an autoimmune condition, but it can certainly perpetuate the cycle of inflammation.

Dr. Mark Hyman:
Makes it worse, for sure.

Dr. Cindy Geyer:
Makes it worse just like sleep deprivation, the same thing.

Dr. Mark Hyman:
Yeah. So toxins, like you said, are actually immunogenic, and there’s a word for the role of toxins in autoimmune disease. They’re called autogens. They literally cause an auto-immune response in the body, whether it’s pesticides, heavy metals, and I’ve seen this and I’m sure you have, Cindy, many times in your practice. And you never know if it’s that. Or so we’ve gone through the gluten. And we’ve gone through the microbiome. We’ve gone through toxins. And there’s a few other things I think about like food sensitivities, besides gluten, that can play role, which just goes along with the leaky gut. And then the last thing I think about are infections that are [inaudible 00:00:12:11] because we often ignore those. And the body’s, you’re living as a host to all sorts of bugs, right? And when you have Aids or HIV, you don’t die from the Aids virus.

Dr. Mark Hyman:
You die from all the latent infections that you actually have already living in your body like pneumocystis or candida or CMB or tuberculosis or whatever you’ve got kind of laying around, your body’s handling. It’s, that what kills you. And then in the autoimmune disease, I think there’s an unrecognized role of infectious disease. And there is some literature about this, for sure.

Dr. Cindy Geyer:
Absolutely.

Dr. Mark Hyman:
But what’s interesting to me is that nobody chases it down. So even though if you look at the PubMed National Library Medicine, and you’ll get all the data on autoimmune disease. You can type in autoimmune system and toxins and diet and gluten and allergens and Lyme disease. And you’ll find all these papers, but what’s striking to me, is that when you go see the rheumatologists, they don’t go, “Oh, we should look for these things.” They just don’t. Sometimes they’ll check a celiac panel. That’s actually more common now, but they don’t really look at diet. They don’t look at toxins. They don’t look at allergens. They don’t look at latent infections. And you’ll often see dramatic improvements when you actually help people with those issues.

Dr. Cindy Geyer:
Well you know, Mark, it’s interesting. When we were in medical school way back in the day, we learned about Reiter’s syndrome, right? Reiter’s syndrome where people would show up with symptoms like rheumatoid arthritis, swollen joints and positive rheumatoid markers. And that either came after a gut infection like Shigella or Yersinia or it came after a genital urinary infection like chlamydia. So we knew even 30 years ago that those infections can actually trigger an autoimmune reaction more. And more recently there’s been a link with porphyromonas gingivalis so an oral bacteria in rheumatoid arthritis. So absolutely.

Dr. Mark Hyman:
Yeah. So if you have bad teeth, that can also be a source, right?

Dr. Cindy Geyer:
Yeah, which I didn’t mention, so absolutely.

Dr. Mark Hyman:
Yeah. So someone comes in with Raynaud’s you’re thinking about all these things in the back of your head. And you’re wondering, oh, what’s this person’s story? And you go into their story, and you can usually ferret out, what the issues are for them. And then you can start to chase down the things that are really abnormal. So how do we assess people? Is there a test for Raynaud’s or is it just sort of looking at the symptoms?

Dr. Cindy Geyer:
It’s primarily a symptomatic diagnosis, to be honest. There are tests you can do to look at artery elasticity in general. They’re not widely available, but some places will do them. They’re usually done in the context of cardiovascular disease to look at how resilient the small arteries are. There’s one by a company called Itamar based out of Israel called an endoPAT. I don’t know if you’re familiar with that one. It’s not very comfortable. It basically put a little probe on your finger and pump up a blood pressure cuff to block the blood flow for two minutes. And then measure how quickly it takes for the blood to get back to your finger when they let it down again. So they can tell you about the small arteries.

Dr. Mark Hyman:
It’s like medical torture.

Dr. Cindy Geyer:
Yeah, medical torture.

Dr. Mark Hyman:
Well, that’s fine. So that’s good. But then it doesn’t really tell you why. It just tells you they’re not working. We’re really good at in medicine is figuring out what’s not working, but we don’t know how to figure out why it’s not working. We know what’s not working, but not why it’s not working. And I think that’s the beautiful thing about functional medicine. So when I’ve seen patients with Raynaud’s, and we start to dig down on these issues. We look at toxins. We look at gluten. We look at their microbiome. We look at allergens. We look at food sensitivities. We look at infections. We can even start to figure out what the issues are and get these people a lot better. So what is the approach then from a functional medicine perspective for Raynaud’s syndrome?

Dr. Cindy Geyer:
Yeah. So from a diagnostic standpoint, as I mentioned before, we want to look at all those cardio-metabolic risk factors. We want to look for the underlying tax that are upregulating the immune system, whether it’s gluten or food sensitivities or something going on in the gut microbiome or an infection. And then from a treatment standpoint, a lot of the same lifestyle things that we normally want to do specifically help those arteries be more resilient, less reactive. So we know, for example, that studies on meditation, yoga, biofeedback can show improvements in Raynaud’s and artery elasticity after six weeks of a regular consistent practice.

Dr. Mark Hyman:
Wow, just yoga and meditation.

Dr. Cindy Geyer:
Right, it’s great.

Dr. Mark Hyman:
So you can basically meditate your blood vessels healthier right? That’s good.

Dr. Cindy Geyer:
What was that story years ago of somebody meditating, and they could change the temperature in one hand versus the other by five degrees or something incredible? Yeah. So we have more control over that autonomic nervous system than what we thought.

Dr. Mark Hyman:
I’ve often found other things you do around diet or supplements helpful for these patients.

Dr. Cindy Geyer:
Yeah, there’s a lot. So again specific food components, omega-3 fatty acids have benefits on artery elasticity, whether that’s fish, fish oil, nuts, and seeds. Arginine is an interesting amino acid. It’s used by the arteries to make their own version of nitroglycerin. So it’s a precursor of nitroglycerin, which of course dilates blood vessels.

Dr. Mark Hyman:
Nitric Oxide.

Dr. Cindy Geyer:
Yes. Thank you. Nitric oxide. So getting nuts and seeds, or maybe even supplementing Arginine. The deeply pigmented foods that are rich in bioflavonoids a lot of those polyphenolic foods also relax the arteries, things like resveratrol, for example. Folate rich foods, dark leafy greens, another powerhouse for the arteries. So if we think of that extra Virgin olive oil, another food that has natural benefits on relaxing the arteries.

Dr. Mark Hyman:
Okay. That’s really a lot of what I use, Cindy. And often I’ll supplement with our Arginine. They’re very symptomatic if they’re going out and often even Ginkgo, which is another product. But I think the nitric oxide is interesting. You can increase nitric oxide by your breathing too. Just meditating practices. We had Louie Narro on our podcast who won the Nobel Prize for his discovery of nitric oxide and its role in improving overall health, reducing inflammation. And it’s incredibly important for lung health as well. And with COVID, they’re finding nitric oxide being very effective in treating COVID patients. And he talks a lot about that on a podcast, but the nitric oxide can also be increased by Viagra or Cialis or any of those drugs that are used for sexual enhancement, but they actually actually work by increasing blood flow and circulation. So that’s a good thing.

Dr. Mark Hyman:
So maybe if you have Raynaud’s that might help as well. So arginine you can take or you can do that those drugs. Or you can actually use Ginkgo and other things. Bioflavonoids I used to use quite a bit. And combining that with the root cause medical detective piece, because you can’t just give those, oh, give them arginine. No. Well, why is it they have Raynauds? What is the cause? What is the root cause? And I think that’s what often people miss. Even in integrative medicine, they’ll say, “Oh, well you have Raynaud’s. Use Arginine.” I’m like, “No, no, no, no. Why do you have Raynaud’s? What is the root cause?” And this is the part that we often miss in medicine. And that’s why the UltraWellness Center we really have such a robust practice because we are the medical detectives looking for the root cause.

Dr. Mark Hyman:
And I just tell you an anecdote of a patient I just had this week. It’s one of those stories. He’s a really awesome guy. And he developed a ticks when he was… Not tick bites, but he developed motor ticks when he was eight. And I started asking him about his story. And the doctor was nothing you can do, take these drugs, whatever. So I said, “Well, what was it like? What was happening? Did you get infections? Did you have this, you have that?” So I started digging into his story. He had tons of infections and slap and all kinds of things. We know there’s a syndrome called PANDAS, which is pediatric autoimmune disease of neurologic blah, blah, blah. I forget what it stands for, it’s been so long. And that is associated with strep infections that cause behavior issues, OCD, ticks.

Dr. Mark Hyman:
And when I checked his labs, he had super high antibodies to strep. And on the Cunningham panel, he had really high antibodies against some of the components in his brain related to strep. And yet no one had even thought to ask the question of why. And so whether it’s tick disorders or what it’s Raynaud’s or whatever, if you get into the habit of thinking, which is what I love about functional medicine, because it makes you think as opposed to just sort of rote, memorization, and knee-jerk reaction that’s sort of what we get in medicine, which is we make the diagnosis. And then we don’t have to think anymore. We just basically say, here’s the cookbook protocol that is in 2021 for XYZ disease. And functional medicine is different. We have to start thinking. We call it thinking and linking. We know why your fingers get cold and turn white, and you have no circulation. It’s because you have Raynaud’s.

Dr. Mark Hyman:
No, that’s just the name of what it looks like. That’s just the name of the problem. It’s not the cause of the problem. Right? And so that’s what’s so beautiful about functional medicine is you get to actually go into thinking and linking. It’s what Sid Baker talks about this whole idea of thinking and linking and changing the way that we actually approach diseases by once we get the diagnosis, that’s the beginning of the process of thinking and connecting the dots and being a medical detective.

Dr. Mark Hyman:
And that’s what we do in functional medicine. It’s what we do at the Ultra wellness center here in Lenox, Massachusetts. And we are in full swing. We have five doctors, 4 nutritionists. We’re doing virtual visits. We help you from all over. Although we do have a waiting list so stay tuned for that. We’re trying to figure out how to break that down and get you in maybe even in groups. So stay tuned, and we’ll get back to you about whether or not we’re going be offering group programs. A lot of the stuff we do in functional medicine can be done virtually and even in groups. So anyway, if you love this podcast, please share your friends and family. You know someone with Raynaud’s, I’m sure they need to hear this. And subscribe wherever you get your podcasts. And we’ll see you next week on the Doctor’s Farmacy.
Speaker 1:
Hi everyone. I hope you enjoyed this week’s episode. Just a reminder that this podcast is for educational purposes only. This podcast is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical or other professional advice or services. If you’re looking for help in your journey, seek out a qualified medical practitioner. If you’re looking for a functional medicine practitioner, you can visit ifm.org and search their find a practitioner database. It’s important that you have someone in your corner who’s trained, who’s a licensed healthcare practitioner, and can help you make changes, especially when it comes to your health.

If you are looking for personalized medical support, we highly recommend contacting Dr. Hyman’s UltraWellness Center in Lenox, Massachusetts today.

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