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What does research reveal about the most common contributing factors of post-ICU PTSD? Does sedation prevent or inflict trauma? Dr. Jackson shares with us his decades of research and experience with post-ICU PTSD.

Episode Transcription

Kali Dayton 0:27
Hello, and welcome back. This episode, we’re going to discuss what truly traumatizes our patients during their ICU stay. We know that post ICU PTSD is a significant problem for survivors. I’ve had clinicians tell me that they sedate patients on ventilators for the purpose of preventing PTSD. So our culture of automatically sedating patients on ventilators for the past few decades, has been done with intentions rooted and compassion. We have believed that while patient’s eyes are shut and they are still that their reality is as neat and tidy as their bedsheets.

Yet, last episode, Spencer Freeman shared with us how his time with delirium while in a medically-induced coma, has deeply scarred him and changed his life. How misguided have our assumptions about prolonged sedation been? Do we prevent trauma with sedation? Or do we inflict it? Dr. Jackson joins us now to set facts vs fallacy straight with his decades of experience and research on post ICU PTSD. Dr. Jackson, thank you so much for joining us. Can you tell us a little bit about your career timeline and where you’re at currently?

Dr. Jim Jackson 1:47
I’d be happy to do that. And and yes, you’re welcome. I’m really delighted to be here. So I’m a professor. I’m a research professor of medicine at Vanderbilt University Medical Center where I work at the SIB center. That’s the critical illness, brain dysfunction and survivorship center. And at the SIB Center, where I’ve been for about 20 years, we have been studying ICU survivors and exploring outcomes like post traumatic stress disorder, depression, cognitive impairment, really a range of things, researching that at the CIB center. And then crucially, since 2012, we’ve been trying to treat those conditions in a clinical context at the ICU Recovery Center at Vanderbilt. So I’m coming to you as one who has interacted with many, many hundreds, I suppose 1000s of ICU survivors over the years to someone who has heard the stories of people who struggle often quite mightily with the mental health consequences, in particular, of having been critically ill.

Kali Dayton 2:49
And what led you to take that special interest in ICU survivorship, specifically?

Dr. Jim Jackson 2:56
it’s really quite interesting how we get to where we are. You know, how we find ourselves and for me, certainly not a not a linear path. We had moved to Nashville. In the year 2000, I was doing a psychology residency at Vanderbilt, and hadn’t really thought about a career in research, necessarily, I was a little conflicted about that.

And we were at a Chinese restaurant one day, believe it or not August Moon, which I think is now since closed, and I got a fortune cookie, I’m not a superstitious guy, particularly, but I got a fortune cookie. And it said, you will prosper in the field of medical research. And I thought, how strange is that? Very different than the than the typical fortune cookie for sure. So that didn’t make me decide to, to jump in with both feet into research. But it did make me wonder a bit if there were larger forces in play.

And later that year, I met my colleague, West Ely, pulmonary critical care intensivist, who I think you’ve had on your podcast, who’s this ICU outcome space, and he was starting a program didn’t really exist yet. And we hit it off got along well, and he said, “Why don’t you be the psychologist to join our team?” And I didn’t know exactly what the future would look like. But I understood that there was a lot of value in trying to explore the the cognitive and the psychological dimensions of medical illness.

And as I began to interact with ICU survivors, visiting them in their homes, often getting to know them around a kitchen table in the context of our research, it was obvious that they had very significant needs. I had struggled as a younger man about whether I wanted to go into the pastor it I came close to, to go into the ministry, if you will, and at some point realize that becoming a psychologist is also holy work, if you will. It’s also really important work and the sense of mission and purpose that I found at the SIB center. Working with ICU survivors has really been motivating.

Kali Dayton 5:10
Well, I love that. And I also feel very called the specialty as well. So I can completely relate to that. So now you have decades of research and experience under your belt, and I have so many questions for you. In the previous episode, we talked with Spencer Freeman, about his journey with post-ICU PTSD. And he talked a lot about his delirium, and how that has not fully left as far as the vivid reality of his hallucinations. So can you tell us a little bit more about what causes delirium, and what is happening to the brain when a patient is experiencing delirium?

Dr. Jim Jackson 5:54
I’m glad to speak to that. Delirium is a is a topic of high interest to many researchers and clinicians. If you were to do a PubMed search with the term delirium, and you were to do that by year, you would find that ICU delirium was talked about hardly at all in 1999, or 2000. It was talked about increasingly in 2005, 2010. If you look at how often it is discussed or engaged today, it really is on the tip of everybody’s tongue, particularly during COVID, where patients are often ventilated for extended periods of time.

And in that context, they’re very delirious. So the shorthand term that people often use is is confusion, delirium is confusion. It’s not exactly that. And it’s much more than that it is a neurologic, it is a neuro psychiatric condition. It is marked by a variety of features. It’s marked by inattention, it’s marked by things like a rapid shift from baseline smart by significant changes in cognition, things of that sort. And it occurs at one time or other, to probably most patients who were seriously critically ill in the way that Spencer was.

There are a lot of things that drive the development of delirium, we’re still learning about what the neurobiological drivers are. But probably the thing that contributes to it the most than the ICU. His medication is things like heavy sedation. I think before the show, when you and I were talking about the fact that there has been a certain orthodoxy for a long time in the ICU, that’s certainly changing due to things like the ABCDEF bundle.

But then orthodoxy once upon a time suggested that patients were better cared for when they were heavily sedated. And so that was the that was the approach it was a was a well meaning and tended to be loving approach that is to sedate patients very heavily. And many people thought that when they were sedating patients heavily, they were doing them a favor, because what that meant was that they would not have any memory of their experience, which is to say, no memory of their traumatic experience.

But what we know and what I think Spencer referenced is that often, it is true that they don’t have much memory, under sedation of their actual experience. Instead, unfortunately, they have vivid memories of other things. These are delusions, these are hallucinations. These are often distortions of things that are actually happening. So I often talk about patients I’ve interacted with who were being moved into an MRI machine, for example, to get to get their brain imaged. And those patients have said things like, I felt sure I was being moved into an oven, you’ll hear people talk about having a catheter removed. And in the throws of this sedation driven delirium, they often will say, “I’m quite sure someone was trying to sexually assault me” someone has a trach placed and someone will say, “someone was trying to cut my head off, someone was trying to slice my throat.”

So what you see is often a kernel of truth, and then a lot of real perceptual distortions of the environment. And these things are incredibly vivid. I think Spencer probably alluded they’re incredibly vivid. They are they’re tattooed, if you want to think of it that way into the memories of people. And these disturbing hallucinations, which often seem very real to patients, even when they’re in their right mind, so to speak. These disturbing vivid images, they often form the basis for PTSD. And long after the fact, people are having nightmares about their delusions. They’re having nightmares about their hallucinations. They’re very concerned about things that seem unlikely to have happened even as they’re convinced that they have happened. And many of these dynamics develop up within the boundaries of delirium.

Kali Dayton 10:06
And so as a psychologist, how do you respond or what is it like to meet with these people talking about how real these unreal experiences were to them?

Dr. Jim Jackson 10:18
It is it is quite fascinating. I think until the last 20 years or so there wasn’t a lot of attention paid to the prevalence of delusions and hallucinations. Often people call them “delusional memories” in ICU survivors. So it’s a fairly new phenomenon that has been described, I’m sure it’s been going on. For a long time, it is jarring to hear these stories and to see how disturbed patients are by these things, it often is quite a task, to even coax patients.

And this is, I think, really important clinically, so often quite a task to coach patients to even talk about these things. Because these are things that in their mind should not be uttered. They’re they’re often terrified that people will view them as crazy that people think we’ll think they were insane. If they share their belief that they were sexually assaulted, if they share their bizarre belief that an alien abducted them, or whatever it might be, they often are quite strange these memories on the continuum, one of the most helpful things we can do.

And one of the things we really try hard to do during the sport group we lead is we try to take patients like Spencer, the one that you interviewed, and we try to connect them with other ICU survivors who have had similar experiences. And when we do that, it’s really like magic, it really is, you can see the expressions on the faces of these ICU survivors who have who have never met, perhaps, someone from their tribe. And when they start talking about frightening vulnerable things, and they see that there are people caring for them who really get it, they feel embraced and accepted.

And it’s really wonderful. If you look at the number of ICU survivors, who survive and leave the ICU in North America each year, that number is way in the millions depending on the research, you reference, it’s 3 million or 4 million, 5 million. It’s it’s a, it’s a huge number Kaylee. And despite that being a huge number. There is not an advocacy group for ICU survivors like there is for breast cancer survivors like there is for patients with Alzheimer’s disease or MS. A lot of other obviously worthy conditions.

There’s not that for ICU survivors. So the upshot of that is that these folks often really do suffer in silence. They don’t know other ICU survivors, they think their story is unique, they’re afraid to share it. And so when we can be the, you know, when we can be the midwives, if you will, that that, that help these patients help these patients deliver their stories, if you will. And when we can see them embraced by, by other survivors who are thriving and winning, conquering their obstacles. It’s a very special thing. And it makes me really proud to be a clinician and a researcher working in the space that resonates

Kali Dayton 13:18
So much with what I am seeing on these survivor groups, when patients or survivors, sometimes newly out of the ICU. Come on, and they go to these groups because they’re wanting validation. And people jump in and say, “yes, this is normal. Yes, we’ve had that too.” You can almost see even in text, the relief and the comfort that people find and knowing that they’re not alone.

Spencer Spencer mentioned that there was no reference to PTSD when he was leaving the ICU that tried to prepare him to staff and it from alcohol and physically recover. But nothing was mentioned if PTSD and I completely understand that because I as I talk to other clinicians around the country, even world there is very little understanding of the reality of post ICU PTSD. And when that is brought up, the assumption is reaffirmed that the PTSD is from certain procedures or that we’re giving sedation to prevent the PTSD.

But what you’re saying and what survivors have said is one of the main contributing factors for post ICU PTSD is the delirium, the hallucinations, the vivid distortion of those experiences and in research and I’ll add some of the links on the blog. But there’s research that shows correct that actual recall of ICU stay, and what happened in the ICU is protective against post ICU PTSD, depression and anxiety. Is that correct?

Dr. Jim Jackson 14:47
That is correct. So the notion would be you know, there’s an old saying the devil you know, is better than the devil you don’t know. I don’t know if you’ve, you’ve heard that with. With my team at Vanderbilt. I tried out old fashioned things like that occasionally. And some of the some of the younger members of the team roll their eyes, they don’t quite know what I’m talking about.

But the devil, you know, is better than devil, you don’t know. So. So the idea, I think, is that the actual trauma that is happening to the patient in the world right there in the ICU at that moment, that is upsetting. But there’s a fair bit of evidence that would say that exposing them to that, in the main is healthier than exposing them to the two years, the example, then exposing them to the trauma that you don’t know, you know, to these delusional, vivid memories that they have that didn’t actually happened. So given the choice, we would rather have people orient toward reality and find a way to support them, even as their challenge in the fear of that, then to, you know, leave them on their own in this in this heavily sedated state to grapple internally with these demons that are, you know, kind of swirling around in their memory.

So I think that’s a, that’s a really good point that the comment I would make about education that you alluded to, is that, I think it still continues to be quite a problem. If you talk to a sample of ICU clinicians. And I would say even a fair number of psychologists around the world, there are a surprising number of them, who are not really aware of this dynamic that we might call medical PTSD, PTSD is often associated correctly with combat, sexual assault, of childhood trauma, things of that sort.

But often people don’t have categories, even some professionals for the way that that medically driven dynamics, including the one that we’re talking about, can themselves be traumatic stressors, I think if you interact with people like Spencer, or, you know, 101 other survivors that I could, that I could name, you hear their stories, and you leave thinking, wow, there’s no doubt, you know, this is this is compelling, frightening and horrible. There’s no doubt these symptoms are PTSD. And and I think as it relates to education, if the question is, you know, “Will education prevent the development of these symptoms?”

I think the answer is “no”, but but if the question is, “Will education probably relieve a considerable amount of stress and distress for these patients?” I think the answer is, “yes”. Because what tends to happen, Kali, is these patients go home from the hospital, they start having problems sleeping, they start having nightmares, start having upsetting reminders, whatever the symptoms are.

And they don’t have any point of reference, they don’t know, there’s a phenomenon called ICU related PTSD. So they really think and this is what they say, you know, that they’re losing their minds. And, and they double down often, and they don’t want to share those concerns with with family or friends. So we have found that a simple conversation, which is, “You know, Mr. Johnson, we hope this doesn’t happen, but but there’s some things that you could expect when you go home, you may have some problems with your memory and your thinking, you know, you may be physically weak, and you may have really upsetting memories, you may have vivid dreams, upsetting memories, if that happens, just be aware of those are symptoms of anxiety and, and perhaps PTSD. And, and there’s a way to treat that we can help that.”

That simple conversation really cuts things off at the past. And it is incredibly helpful and empowering to these patients, when it shows up and they’re expecting it. Versus it really catches them out of the blue, which often is quite devastating for them and their families.

Kali Dayton 18:45
I keep thinking if we inside the ICU understood this big picture. How much would that change our practices? Would we be as quick and willing to give sedation as deeply and as much as we do if we understood what that would mean for the patient in the long run? And then yeah, like you said, :Would it change our conversations with them as they’re leaving? Would we have a different level of understanding and empathy and prepare them for what may come right now.”

If any of my patients ever experienced delirium, I am in constant communication with the family saying this may result in cognitive deficits and post-ICU PTSD. This may be what this is like for them. Trying to prepare the family to be a support system. I hear survivors say that they struggle to talk to their family members about it because it sounds so crazy or because they can’t understand. They think that once they reaffirm that it wasn’t a real experience, that it’s gone. So if the family members can be prepared to empathize, maybe they’ll be able to be more of a support system. But I think we in the ICU first of all, have to understand what the patient’s reality is.

Dr. Jim Jackson 19:59
I think that’s a great point. And and there’s a lot to respond to in in what you said. So it’s certainly the case that these conversations, conversations about what happened, conversations about fears about what will happen, those are conversations that families need to have, right. Because when patients survive the ICU, a couple things are happening, patients are impacted in whatever way they are.

But their family systems are impacted. Also, you know, sometimes they’re impacted minimally, often, they’re impacted profoundly, there’s a new normal in the household, you know, everything is different. And, and sometimes what happens, interestingly, is, survivors would love to have conversations with their spouses, let’s say, and spouses would love to have conversations with their ICU survivor, but never the twain will meet, you know, each of them sometimes thinks this would be too emotional, to be too upsetting. I don’t want to broach it with them. When we see people in the ICU Recovery Center, our encouragement always is try not to avoid those conversations.

Will those be emotional? Yes. You know, will they be uncomfortable? Yes. But they’re important conversations to have. And if you have those conversations, from the vantage point of a survivor, for instance, if you’re able to talk about how scared you are, you’re able to talk about very, very private things that are bothering you. That is upsetting thoughts you had in the ICU that were quite personal. Usually, instead of getting worse, the anxiety associated with those thoughts actually usually gets better, at least over time, it gets better. So we’re very big about discouraging avoidance about encouraging people to lean into things, a phrase that I find myself using a lot these days as very relevant during COVID, where it seems like the whole world’s on fire is this simple phrase, you can do hard things, right, you can do hard things.

And my take on ICU survivors is, if you have been, you know, on a vent for 62 days, you know, you’ve been in the hospital for 80 days, you’ve had 14 surgeries, whatever. Well, I’m sorry. But above all, you can do hard things, you know, even really hard things. So you’re gritty and resilient, you’re stronger than you know. And you and your family, with guidance for professionals, you can lean into these things. And when you lean into them, is it scary it is but they actually can get better. pushing back against this avoidance cailli is so important, partly because if PTSD is left untreated, it leads to a lot of adverse outcomes.

But for patients in this space, one adverse outcome that leads to that always concerns us is it sometimes leads to what you might call medical avoidance. So patients say, I don’t want to go back to the ICU. I certainly don’t want to get on the ventilator. Again, you often will hear people say, “I’d rather die before that happens again.” Yeah. So how do they go about doing that? How do they go about avoiding, they decide not to go to the ER when they should, right, they decide to wait it out, they decide not to go to the doctor when they need to, because they think you know this infection is going to take care of itself or whatever.

There was a study done some years ago that looked at cardiac surgery survivors with and without PTSD, track them over time. And what that study found was that, for the people with PTSD, when they had chest pain, they took about two to three times longer to go to the ER than their counterparts without PTSD, so that that medical avoidance concerns us. And we try to tackle that appropriately with our ICU survivors.

Kali Dayton 23:50
And with coping with his level of PTSD, I would imagine all your faculties are really important. So what role does physical capacity play in PTSD? I’d seen a study showing that the more debilitated someone was physically the more likely they were to have poor psychological outcomes as well.

Dr. Jim Jackson 24:11
There’s no doubt and and I think when we talk about and I’ll introduce the term but it’ll be familiar to your to your listeners, when we think about post intensive care syndrome, often referred to as “PICS”. PICS refers to this notion that ICU survivors following critical illness have deficits in cognition, or they have deficits in physical functioning, or they have deficits in mental health.

Well, the truth is, these are not three separate silos, right? Like they all intersect. And when you’re struggling in one, not always but often, you’re struggling in all or in several years ago, we had a patient come to our clinic, and he was a big mountain biker that was his. That was his avocation. That was his activity of interest. And he was so physically debilitated following critical illness. He couldn’t do that.

Well, the problem was, that was probably his main coping strategy against anxiety against depression. So this. So the reality is, if you’re physically debilitated to use that as just one example, it isn’t just that you’re physically debilitated it often is that you can’t do the things that distract you in a healthy way, right, you can’t do the things that have been part and parcel of your coping. So it’s all related, we’re integrated. We are, we are people who rely on our brains and our bodies, all of these things. And when when one one part of his, if you will, is affected, I think all our which is why better approaches to treatment of post intensive care syndrome, better approaches to care of ICU patients are not siloed. They are necessarily multidisciplinary. They involve physical therapists, they involve physicians, they involve psychologists, they involve occupational therapists, I don’t want to leave anybody out, because deficits in any area, any domain, necessarily affect deficits and another.

Kali Dayton 26:16
And with that, any pleadings to the inpatient side of ICU care that you would give from the other side?

Dr. Jim Jackson 26:25
So it’s a particular challenge during COVID, as you’re aware, but but but some of the themes that we hear during COVID are some of the themes that we’ve heard before, you know, people were pleading for family centered care before, people are pleading for family centered care. Now, admittedly, that is one area where there are huge challenges now, right, there’s a different paradigm now.

But but we’re certainly seeing patients who are affected, you know, apart from delusional memories, apart from those dynamics, they’re greatly affected and really harmed by not being able to see family members, let’s say during this long, tough slog. Equally, we’re seeing family members who are greatly traumatized by the fact that, you know, perhaps they hadn’t spent a day apart, you know, from their spouse. In the last many years, there’s a country song or two that talks about that.

But having spent a day or two apart from their spouse, and now their spouse is languishing, you know, with COVID, in a hospital, and they’re lucky if they can see them on FaceTime. So I think it’s hard to overstate what the impact of this dynamic is on them. And also, I would say, on nurses, many of whom I’ve talked to who have said, “Oh, my gosh, you know, one of the most difficult things I’ve ever done is tell family members that they cannot come and visit their loved one, you know, because it’s against protocols.”

So I think their unique challenges at work now, particularly related to family centered care, but I think we need to, we need to prioritize integration of families as much as we can. The other quick thing I would say, and we’ve highlighted before, even in this talk, education, education is so important. It’s easy, and it’s cheap, right? It’s, it’s what we like to call low hanging fruit, you can saddle up beside a patient and a family, you can take two minutes to explain to them what they might expect. It’s not hard to do. And yet it makes a huge impact.

The other quick thing I would say if if patients and their families are listening, and they’re struggling, the other quick thing I would say, and I don’t want to be flippant about it at all, I’m not a Pollyanna, but I would say, you know, if you’re battling the effects of being critically ill, there’s hope for you, you know, there is help for you, there is hope for you. We know how to treat PTSD. And we, as a mental health community, we often can do it quite effectively. And there’s help for you. So find a mental health professional, get a proper referral, connect with people who have walked down the same road, you have their support groups available. Help is available if you have the resilience and persistence and a community of people around to help you pursue it.

Kali Dayton 29:19
And an additional question came to mind. How much would your field or your work or what you’re seeing change if our ICU community was really dedicated and focused to preventing delirium?

Dr. Jim Jackson 29:35
So this this is a great question. Probably a million dollar question. So Wes Ely, who who has been on this podcast previously, he often in the grants that he writes that we all write talks about delirium as being important, because it is a modifiable risk factor right meaning, it is something that can be acted upon, right, it can be impacted in a way that a lot of other variables cannot be.

So treating delirium and managing it is a huge priority from from my vantage point for two reasons. One, because there’s no question and we haven’t discussed this, but but at some point, maybe we can, there’s no question it is a key driver of the cognitive impairment. That itself is such a bane in the lives of ICU survivors to because it props up and drives the development of these delusional memories, which we mentioned are often a culprit in the development of PTSD. So if there were a way to eradicate it, I think that would be welcome, as I’m sitting here, looking over the horizon here, in this podcast, I’m looking at some poison ivy in my garden, I’d like to be rid of it. But if I get rid of it, I’m not sure it will make much of an impact on anyone other than me. If we can find a way to get rid of delirium, though, or at least reduce it, make it a priority to reduce it. The benefits are going to be writ large in the lives of people and the quality of life for people. And it’s a really important endeavor, Kali.

Kali Dayton 31:12
Thank you so much. Oh, that’s so validating, I think we have a lot of discussions as far as why to implement early mobility and why to reduce or avoid sedation and ICU. And we talk a lot about reduced length of stay and reduce time on the ventilator. And we can bring up dollar signs and a lot of things. But I think those of us at the bedside, got into this work because we want to save lives as a whole. And we want to restore quality of life. And so what you shared with us is so insightful as to how to do that. And I think your research your work. And that is, along with dozens of other researchers can be so insightful to help us know how to better treat and better prevent delirium, and therefore improve total quality of care in every aspect for patients lives.

Dr. Jim Jackson 32:08
I agree with that this is really important before we went live, today on the podcast, I was I was sharing with you a mental image that someone shared with me. And that’s the image of someone climbing a ladder that is leaning against a building, and they’re climbing the ladder quickly. And they get to the top and they’re so happy, they feel triumphant. And then they look around and they say, “Ru-row, uh-oh, the ladders leaning against the wrong building.”

And you know, you and me and others, our desire is to vote to devote our lives to meaningful quests right to pursuit that make a difference in the lives of patients. And I think none of us want to be climbing a ladder that is leaning against the wrong building, and delirium to use this metaphor, delirium is the it’s the right building, you know, it’s something important that we need to be tackling along with the other parts of what people refer to as the ABCDEF bundle, because that drives the improvement of care.

You know, as a younger man, in my 30s. And then early 40s, I spent long hours practically day’s driving around the world, Tennessee, Kentucky, Northern Alabama, sometimes northern Mississippi, to get to know the lives and to get to know our patients in our in our research studies. Breaking bread with them at dinner table sitting on the front porch, you know, really just hearing their stories and learning about how impacted and in some ways how utterly broken they were and their families were, by the impact of critical illness and fixing that, quote, unquote, fixing it obviously completely is is beyond our reach.

But finding a way to engage in behaviors that reduce the burden on these patients substantially. That I think is a realistic goal. And that’s accomplished partly by, as you said, making sure there is a connection between active ICU providers and these patients so they can understand the magnitude of suffering that these patients are having. And and also leveraging hard and prioritizing what we know, which is that patients do better in an ICU context, when they are activated. When they are made alert, when they are well cared for when they are engaged by their family. They do better, and that we know. And we just need to build on that.

Kali Dayton 34:40
I think as we understand the research that you’ve done, we’ll have our why and I as we understand this reality, we can realize that sedation in a lot of contexts and a lot of cases in the ICU is actually the wrong ladder, that we’re doing more harm than good. But until we know what that harm is like we have No reason to change, especially when you have the misconception that it is that it is compassionate to. Someone said, put them into oblivion.

Dr. Jim Jackson 35:10
Yeah, well, thank you. I agree. And I thank you with with all sincerity, I thank you for giving me a chance to shine a little bit of a light into the lives of these patients and then forgiving my friend and our ICU survivor group member Spencer, a great opportunity to talk thoughtfully about his compelling experience, because I think it’s those stories that people can begin to understand and relate to, and they will drive behavior change at the end of the day.

Kali Dayton 35:39
Yeah, we can talk about the how for weeks and months, and we do and try to implement these protocols. But unless we know the why. There’s no heart behind it. And there’s no real drive to do it. So thank you for all that you’ve done. And we’ll put links to a lot of your research and everything we’ve referenced during this episode onto the blog so that everyone can read all of your good work.

Dr. Jim Jackson 36:03
Thank you so much. It’s been my pleasure. Thank you.

Transcribed by https://otter.ai

 

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