What are the names of Santa's 12 reindeers? It would be most unusual to have angina in the absence of any risk factor for coronary artery disease. Pain typically occurs during exertion (physical activity, eating, extreme stress, exposure to cold). Angina, a common heart disorder, cannot usually be detected by a routine ECG. Angina is a symptom of coronary artery disease. These will likely include blood tests and a chest X-ray. Similarly, does angina cause ECG changes? The new edition of one of the world's most trusted medical references has been completely updated, with evidence-based medicine summaries in therapy sections, a new section on clinical pharmacology, an expanded oncology section, increased ... The ECG is usually normal between attacks. Usually, angina becomes more stable within eight weeks. If done during an angina attack, ECG is likely to show reversible ischemic changes: T wave discordant to the QRS vector. What does Prinzmetal's angina look like on EKG? Copyright During an attack there may be a transient ST segment depression, symmetrical T wave inversion or tall, pointed, upright T wave may appear. chest pain or discomfort which feels like indigestion but makes you feel generally unwell. ¿Cuáles son los 10 mandamientos de la Biblia Reina Valera 1960? A 1-mm or greater depression of the ST segment below the baseline, measured 80 milliseconds from the J point, is the most characteristic change. Prinzmetal's Angina. Mortality in acute myocardial infarction has declined by 50% during the last three decades. Other tests also may be done at the same time as a stress test. ECG - a simple, affordable and informative method of effort angina diagnosis. Take nitroglycerin. Like the standard EKG, it's painless. This book provides an update on coronary physiology and a systematic assessment of microvascular abnormalities in cardiovascular diseases, in the hope that it will assist clinicians in prevention, detection and management of CMD in their ... Your symptoms may not go away with rest or nitroglycerin. Also know, what does angina look like on an ECG? Can I have angina with normal blood pressure? With over 200 traces to test your knowledge, this book is a first class learning tool for emergency physicians. They can then place a stent, which is an umbrella-like device, to prop open blood vessels and increase the blood flow to the heart. Do all P waves look similar? Sweating. Even though exercise can bring on angina, a supervised program of exercise can safely strengthen the heart and eventually reduce angina. Angina is a type of chest pain caused by reduced blood flow to the heart. The electrocardiogram (ECG or EKG) is a noninvasive test that is used to reflect underlying heart conditions by measuring the electrical activity of the heart. Found inside – Page 1These three books can be described as a cumulative EGG reference for the medical provider who uses the electrocardiogram on a regular basis. Some of these conditions actually do involve the coronary arteries, while others do not. Yes it is possible to have normal blood pressure and cholesterol and yet have angina. Sweating. When myocardial blood flow is acutely impaired (ischaemia), and often not provoked by exertion, a person will commonly suffer more prolonged pain; this is referred to as acute coronary syndrome (ACS). Turn the ECG upside down, and it would look like a STEMI. ECGs in Acute Myocardial Infarction Diagnosing an acute myocardial infarction by ECG is an important skill for healthcare professionals, mostly because of the stakes involved for the patient. The longer the person experiences chest pain from angina, the more the heart muscle is at risk of dying or malfunctioning. What does an old infarct look like on ECG? Some people with angina symptoms say angina feels like a vise squeezing . The electrocardiogram (ECG) is an important tool to differentiate between unstable angina (acute coronary syndrome) and stable angina in addition to the patient's history. Other symptoms. During an attack of angina pectoris, 50% of patients with normal findings after resting ECG show abnormalities. The aim of this book is to provide the information that will turn you into a 'savvy' ECG reader, one who can handle the ECG calmly, confidently and accurately. . - Copd,cirrhosis, hiv,diabetic pt. ECGs in Acute Myocardial Infarction Diagnosing an acute myocardial infarction by ECG is an important skill for healthcare professionals, mostly because of the stakes involved for the patient. There are several types of angina, and the signs and symptoms depend on which type you have. Several cardiac and medical conditions can cause angina even without atherosclerotic plaques that are producing discrete blockages in the coronary arteries. The cause is a spasm of a coronary artery. A 1-mm or greater depression of the ST segment below the baseline, measured 80 milliseconds from the J point, is the most characteristic change. But before we talk about these changes, we should quickly brush up on what the normal components of an ECG trace look like: Abscess over upper or lower eyelid, it appears as a local red swelling. Exercise. The ECG is usually normal between attacks. You can have typical signs which are the crushing chest pain radiating into the jaw causing some shortness of breath down your left arm, not really numbness in your arm but mostly heaviness or arm pain. In fact, people who are treated for unstable angina can live productive lives for many years. Can you have angina without blocked arteries? By positioning leads (electrical sensing devices) on the body in standardized locations, health care professionals can learn information about many heart conditions by looking for characteristic patterns on the EKG. If you do not want to receive cookies please do not Besides physical activity, other factors such as emotional stress, cold temperatures, heavy meals and smoking also can narrow arteries and trigger angina. A licensed medical Fatigue. Sometimes, however, true angina can occur in the absence of typical CAD. Exercise ECG is abnormal in 85% of patients with angina. Unstable angina pectoris (UAP). Are P waves present? Highly Commended, BMA Medical Book Awards 2015Interpreting an ECG correctly and working out what to do next can seem like a daunting task to the non-specialist, yet it is a skill that will be invaluable to any doctor, nurse, or paramedic ... In addition to a complete medical history and medical exam, your healthcare provider can often diagnose angina from your symptoms and how and when they occur. Found insideHere are some of the many updates and additions: Extensive updating of tables and images New FDA-approved medication for multiple sclerosis New summary of recommended FDA treatment regimens for hepatitis C U.S. Preventive Services Task ... Unstable angina is dangerous and a warning sign of a heart attack. During an attack there may be a transient ST segment depression, symmetrical T wave inversion or tall, pointed, upright T wave may appear. ECG interpretation: NSTEMI. The most informative ECG is the recording made during the attack; Bicycle ergometry, treadmill-test, cold pressure test, etc. Prinzmetal's angina is a form of chest pain, pressure, or tightness (angina) caused by spasms in the arteries that supply blood to the heart. You may have tests to check if you have angina and assess your risk of more serious problems like heart attacks or stroke. Angina pectoris or angina is temporary chest pain or discomfort as a result of decreased blood flow to the heart muscle. Learn more about the echocardiogram: what it is, what it tests, types of echocardiograms, how to prepare . However, recent studies challenge these notions. Found insideThis refreshingly readable handbook simplifies the complexities involved in the care of patients with ACS by: • Familiarizing readers with the common pathophysiology underlying all ACS • Detailing the specifics of clinical assessment ... Angina is chest pain or discomfort that occurs if an area of your heart muscle does not get enough oxygen-rich blood. Pain or pressure in the back, neck, jaw, abdomen, shoulders or arms. Filled with practical examples and diagnostic clues, this handy manual covers exercise testing for the main cardiovascular problems faced today. Testing and interpretation are extensively covered in this manual. Blood tests can also identify elevated cholesterol, LDL and triglycerides that place you at higher risk for coronary artery disease and therefore angina. Your symptoms do not happen at a predictable time. The current electrocardiographic (ECG) definition of anteroseptal acute myocardial infarction (AMI) is a Q wave or QS wave > 0.03 second in leads V1 to V3, with or without involvement of lead V4. The discomfort also can occur in your shoulders, arms, neck, jaw, or back. It may feel like pressure or squeezing in your chest. This book provides readers with a thorough overview of many advances in cardiac imaging. Second Edition provides instant access to information that every nurse needs for safe patient care. The book fits comfortably into a pocket, and the wipeable page surface allows nurses to write notes and remove them easily. The electrocardiogram, also referred to as ECG, 12-lead ECG, or EKG, is a non-invasive diagnostic test that evaluates your heart's electrical system to assess for heart disease. Sometimes angina is easier to diagnose when your heart is working harder. Similarly one may ask, what does angina look like on an ECG? Normal ST depression Or T wave changes 5 What does the ECG of a STEMI look like vs a NSTEMI? What type of angina is caused by MI? Like the CK level, the peak CK-MB level does not predict infarct size; however, it can be used to detect early reinfarction.16 Serial CK-MB levels commonly are obtained at admission to the . What does a heart attack look like on a 12 lead ecg? What is the fundamental difference between cycles and seasonality? How often should you water a blooming Christmas cactus? Angina is associated with only a temporary reduction in your heart's blood supply and, if relieved, doesn't damage your heart muscle. Physical examination, as previously described, is non-specific. Cardiac nuclear medicine imaging evaluates the heart for coronary artery disease and cardiomyopathy (diseases of the heart muscle). Pain in your arms, neck, jaw, shoulder or back accompanying chest pain. 2. upgrade your browser. Cardiovascular disease risk factors increase the risk of angina. There are many types of angina, including microvascular angina, Prinzmetal's angina, stable angina, unstable angina and variant angina. July 26, 2021 July 26, 2021 Sanjh Sanjoli Desk Blood test for angina, Himalaya medicine for angina, Patanjali medicine for angina pain, Stable angina, Unstable angina, What does angina look like on an ECG, आयुर्वेदिक मेडिसिन फॉर एनजाइना, एंजाइना पेक्टोरिस . Stable angina ECG. Only a small percentage of people with chest pain are actually having a heart attack. Since the publication of the 3rd Edition 17 years ago, progress has been truly remarkable in all areas of electrocardiography. Five of the seven chapters in this 4th Edition have been extensively revised. This is explained by increased use of revascularization (percutaneous coronary intervention or fibrinolysis), advances in anticoagulants and antiplatelet agents, as well as aggressive primary preventive strategies using statins, blood pressure lowering drugs . 1. 5. Nausea, vomiting. The currents of injury are represented by deviation of the ST segment on the surface ECG. This represents an upside-down Q wave (similar in reason to the . Dizziness or fainting spells. Note that ST elevation may occur in Prinzmetal's angina. 2. Sensors attached to the skin are used to detect the electrical signals produced by your heart each time it beats. 3. You doctor will perform a physical exam that includes checking your blood pressure. What are the symptoms of unstable angina? Are the P waves smooth, rounded, and upright in appearance, or are they inverted? This is mainly used to work out the 'rhythm' i.e. ECG is useful for evaluating persons with angina pectoris; however, findings are variable among patients. This is usually as a result of the arteries that supply the heart muscle becoming hardened and narrowed. Charts, graphs, tables & glossary. Also includes a 20-page Patient & Family Guide, Managing Unstable Angina.Ó Symptoms and Causes Symptoms of coronary spasm. The ECG is a safe procedure with no known risks. This represents an upside-down Q wave (similar in reason to the . Widely considered the optimal electrocardiography reference for practicing physicians, and consistently rated as the best choice on the subject for board preparation, this is an ideal source for mastering the fundamental principles and ... Question: What does a normal ECG/EKG look like?Fill in the empty box. It happens when some part of your heart does not get enough blood and oxygen. Always see your healthcare provider for a diagnosis. The findings of an old inferior myocardial infarction on the ECG are pathologic Q wave in the inferior leads. Considering this, what does angina look like on an ECG? Epidemiology of NSTEMI and unstable angina. Angina is a pain that comes from the heart. You may be having a heart attack. Reversible ST-segment elevation . Myocardial ischaemia is suggested by an ST segment depression greater than or equal to 1 mm. How do I know if my chest pain is serious? And an echocardiogram is a non-invasive ultrasound that visualizes the heart as it beats, potentially detecting disruptions in rhythm. Stress test. In fact, people who are treated for unstable angina can live productive lives for many years. Urgent. FREE subscriptions for doctors and students... click hereYou have 3 more open access pages. […] To verify whether there is a correlation between the ECG pattern of anteroseptal AMI and the location … Angina is a type of chest pain or discomfort that's a symptom of an underlying heart problem, usually coronary heart disease (CHD). For this Fifth Edition over fifteen per cent new ECGs have been included, mainly to provide clearer examples, though the book deliberately retains some technically poor records to maintain a ’real-world’ perspective Is there one P wave present for every QRS complex present? Angina and coronary disease can present much differently than it does in men. Standard textbooks have traditionally taught that the pathological Q-wave is a permanent ECG manifestation and that it represents transmural infarction (STEMI). Related tests are extensively cross-referenced throughout the book. With its simple format and portable size, this is a handy reference you'll always want by your side. Angina is chest pain or discomfort caused when your heart muscle doesn't get enough oxygen-rich blood. Recognised symptoms of angina are: chest pain or discomfort, which may spread to the arms, neck, jaw, stomach or back. Start slowly, and gradually build up your level of exercise during optimal times of the day. Your blood pressure and ECG readings are monitored as you exercise. This book aims to offer readers of various educational levels and clinical foci the opportunity to learn electrocardiography from basic recognition of tracings and terminology to a deeper understanding of fine detail. It uses flat metal electrodes placed on your chest to detect the electrical activity of your heart as it beats, which is then graphed. A normal EKG: Because some areas of the heart are electrically silent, one can have a full blown heart attack with an entirely normal ekg. This problem has been solved! The symptoms of angina pectoris may look like other medical conditions or problems. - Health care workers. Also, not all heart attacks can be detected by ECG. How do I reset my key fob after replacing the battery? Both produce the same spectrum of ECG changes and symptoms and are managed identically in the Emergency Department. New Left Bundle Branch Block 6 A myocardial infarction or heart attack occurs when heart muscle dies. You may have: an electrocardiogram (ECG) - a test to check your heart's rhythm and electrical activity. You may have seen images of an ECG readout on television or in movies: the electrical activity image looks like a line graph with peaks and valleys. A cardiologist can use special dye and X-rays to look for blockages in the heart that may be causing your angina or heart attack. St depression, Human papillomavirus (hpv) usually types 6 & 11. Hi! An ECG is completely painless and non-invasive, as the skin is not penetrated. If the angina is provoked by exertion, an exercise stress ECG should be performed. ECG interpretation: NSTEMI Primary PCI and direct admission of high risk NSTEMI Ron Lilly SAS Joanne Simpson GJNH Wednesday 17th February 2016. Likewise, does angina show on echocardiogram? is the injury to cardiomyocytes in all forms of angina reversible? The electrodes from the monitor are taped to your skin. Angina pectoris. See what is happening to your heart when you experience angina (opens in new window) » Blocked coronary artery - The heart does not receive enough oxygen-rich blood when the artery is narrowed due to a partial blockage from coronary artery disease. The chest pain called angina is not the same as a heart attack - but it can feel like one and can in fact lead to one. The discomfort of angina is temporary, meaning a few seconds or minutes, not lasting hours or all day. Chest pain or discomfort, possibly described as pressure, squeezing, burning or fullness. What influence does the sympathetic nervous . A 1-mm or greater depression of the ST segment below the baseline, measured 80 milliseconds from the J point, is the most characteristic change. The content herein is provided for informational purposes and does not replace the need to apply Unstable angina symptoms occur in an unexpected and unpredictable manner. Angina may be stable (develops during physical activity, lasts five minutes or less and is relieved with rest) or unstable (occurs during . ECG - a simple, affordable and informative method of effort angina diagnosis. Unstable angina. During an attack of angina pectoris, 50% of patients with normal findings after resting ECG show abnormalities. […] Helios Health, Inc. presents the full text of a fact sheet entitled "Angina (Chest Pain): Diagnosis," as part of the "Heart Health" resource. The ECG tracing can have multiple abnormalities, but, by definition, there is no ST segment elevation. If the pain or discomfort doesn't stop a few minutes after taking nitroglycerin or if your symptoms become more severe, call 911 or let someone know that you need immediate medical assistance. Angina pain may even feel like indigestion. How do I reset my key fob after replacing the battery? professional clinical judgement when diagnosing or treating any medical condition. The beauty of ECG changes consistent with myocardial ischaemia, injury and infarction is that they all show up differently on a 12 lead ECG. In one volume, this Encylopedia thoroughly covers these ailments and also includes in-depth analysis of less common and rare heart conditions to round out the volume's scope. strictly prohibited. You perform an in-office EKG and notice no changes in STe, STd, ST-T. Written by two well-known educators—Tim Phalen, a paramedic, and Barbara Aehlert, an experienced nurse and popular ACLS instructor, this guide incorporates the latest American Heart Association Emergency Cardiac Care (ECC) Guidelines, as ... Prinzmetal's Angina is coronary artery spasm. yes. If chest pain is severe and/or recurrent, the person should see a health-care professional. One of the complications with using ECG for myocardial infarction diagnosis is that it is sometimes difficult to determine which changes are new and which are old. Angina occurs when there is a partial blockage in the coronary artery. An electrocardiogram (ECG) is a simple test that can be used to check your heart's rhythm and electrical activity. Reversible ST-segment elevation occurs with Prinzmetal angina. Episodes may get worse over time. Fatigue. What are the names of Santa's 12 reindeers? I have seen what I identify as 'fragmented' QRS complex (fQRS) in my Kardia's 6L in Leads III and aVF, and an inverted T Wave in III. Nausea. In general, if the Q wave is wider than 0.04 ms (one small box) or at least 1/3 the height of the QRS complex, then inferior Q waves are thought to represent an old myocardial infarction . The ECG is usually normal between attacks. Interpreting EKG Rhythm Strips Step 3 - P Wave P wave: 5 questions to ask 1. The Social Security Administration (SSA) uses a screening tool called the Listing of Impairments to identify claimants who are so severely impaired that they cannot work at all and thus immediately qualify for benefits. Anxiety. Dizziness or sudden weakness. An echocardiogram uses sound waves to produce images of the heart. Found inside – Page iThis book summarizes recent advances in the field; it is the product of fruitful cooperation among international scientists who met in Japan in May, 1990 to discuss the regulation of coronary blood flow. Do not drive yourself to the emergency department. This is a medical emergency as it may culminate in a heart attack. Collet JP, Thiele H, Barbato E, et al. The coronary arteries supply the heart muscle with oxygen and blood. Exercise. Electrocardiogram (ECG/EKG) An electrocardiogram, also called an ECG or EKG, is a quick, painless test that measures the heart's electrical activity and records any disturbances in heart rhythm. • ECG is the mainstay of diagnosing STEMI which is a true medical emergency • Making the correct diagnosis promptly is life-saving • If the clinical picture is consistent with MI and the ECG is not diagnostic serial ECG at 5-10 min intervals • Several conditions can be associated with ST elevation This work also includes clinical diagnostic and therapeutic algorithms, thus bringing this topic closer to the practicing cardiologist. Diagnosis. For example, you may have an irregular heart rhythm that 'comes and goes', and the recording can be normal between episodes. This site is intended for healthcare professionals. If you need immediate relief from your angina: Stop, relax, and rest. Usually, angina becomes more stable within eight weeks. The ratio of the R wave to the S wave in leads V1 or V2 is greater than 1. Angina, also called angina pectoris, is often described as squeezing, pressure, heaviness, tightness or pain in your chest. It is usually caused by narrowing of the heart (coronary) arteries. GPnotebook stores small data files on your computer called cookies so that we can recognise Classic angina is described as chest pressure that radiates down the arm, into the neck or jaw and is associated with shortness of breath and sweating. The ideal companion to major textbooks on the physical examination, this trusted guide is widely acclaimed for its skill-building, and evidence based approach to the medical history. It's normal for you to worry about your loved one's health and future, but you should know that most people with unstable angina do not have heart attacks. ST-segment depression (typically) ST-segment elevation. If you're having angina with any of the following signs and symptoms, it may indicate a more serious condition, such as a heart attack: Pain in your arms, neck, jaw, shoulder or back accompanying chest pain. Other tests may include . You may be developing unstable angina if the chest pain: Starts to feel different, is more severe, comes more often, or occurs with less activity or while you are at rest. The symptoms are more severe and less responsive to nitroglycerin medication. An ECG is a non-invasive test that uses electrodes placed on the surface of the chest to detect heart rhythm. They may use other tests to confirm unstable angina, such as: blood tests, to check for creatine kinase and cardiac biomarkers (troponin) that leak from your heart muscle if it's been damaged. HIGH YIELD If a patient presents with angina symptoms and a NEW LBBB, treat it like a _____ Decreased cardiac output, hypotension, poor . You may have seen images of an ECG readout on television or in movies: the electrical activity image looks like a line graph with peaks and valleys. In respect to this, what does angina look like on an ECG? Sweating. The amplitude of Q-waves may also diminish over time. Angina pectoris - or simply angina - is chest pain or discomfort that keeps coming back. Pain or pressure in the back, neck, jaw, abdomen, shoulders or arms. Pathological Q-waves may resolve in up to 30% of patients with inferior infarction. One study found that among emergency department (ED) patients with chest pain and an essentially normal ECG, only 0.3% with a normal TnI and 1.1% with a normal TnT at six hours suffered death or . Are P waves occurring regularly? Ideal for cardiologists who need to keep abreast of rapidly changing scientific foundations, clinical research results, and evidence-based medicine, Braunwald’s Heart Disease is your indispensable source for definitive, state-of-the-art ... Univ. of Minnesota, Minneapolis. It should be emphasized that a normal resting ECG is not uncommon even in patients with severe angina and does not exclude the diagnosis of ischemia. But before we talk about these changes, we should quickly brush up on what the normal components of an ECG trace look like: Understand Angina/Chest Pain Angina, or angina pectoris, is a medical term for the symptoms caused by the heart not getting enough oxygen from the arteries that supply the heart with blood.When these arteries become narrowed or blocked over time, it is called coronary artery disease (CAD), and it can cause angina.Most commonly, people describe their symptoms of angina as chest discomfort or pain. How long can you live with unstable angina? This is an ideal text for students and a great review for practicing clinicians. Incorporates practice questions throughout the book for review, self-test and understanding of key concepts. Oxbridge Solutions Ltd® receives funding from advertising but maintains editorial Microsoft is encouraging users to upgrade to its more modern, FREE subscriptions for doctors and students... click here. Found insideBrugada Phenocopy: The Art of Recognizing the Brugada ECG Pattern details all aspects associated with alternative diagnosis to Brugada Syndrome (BrS). How can you tell the difference between myocardial infarction and unstable angina? This partial blockage may create a "stuttering" pattern (as the blood clot grows and shrinks), producing angina that comes and goes in an unpredictable fashion. What are the different comfort levels of mattresses? use GPnotebook. Start slowly, and gradually build up your level of exercise during optimal times of the day. Once they're in place, you can go home and do all of your normal activities except shower. However, a normal ECG does not rule out serious heart disease. Found insideEach contains clinical data items from the history, physical examination, and laboratory investigations that are generally included in a comprehensive patient evaluation. Annotation copyrighted by Book News, Inc., Portland, OR What does a normal ECG/EKG look like?Fill in the empty box. One of the complications with using ECG for myocardial infarction diagnosis is that it is sometimes difficult to determine which changes are new and which are old. Episodes of typical angina are triggered when one of the major coronary arteries suddenly goes into spasm, temporarily shutting off blood flow. This book presents the papers given at the International Symposium on Silent Myocardial Ischemia held on 27 and 28 May 1983 in Geneva, Switzerland. What are the daily carbohydrate needs for low intensity skill based training? The electrocardiogram (ECG) remains the most accessible and inexpensive diagnostic tool to evaluate the patient presenting with symptoms suggestive of acute myocardial ischemia. During a stress test, you exercise by walking on a treadmill or pedaling a stationary bicycle. If the angina is provoked by exertion, an exercise stress ECG should be performed. What does the ECG of unstable angina look like? New Left Bundle Branch Block 6 Fatigue. An ECG (electrocardiogram) records the electrical activity of your heart at rest. a dull pain, ache or 'heavy' feeling in your chest. It is not a disease itself.Coronary heart disease occurs when there's narrowing of your coronary artery, which supplies blood to your heart, usually due to a build-up of plaque. ECG Diagnosis in Clinical Practice has been written for those taking Board examinations, but the simplicity of approach and high quality images represent a valuable source of reference material for the more experienced cardiovascular ... you and provide you with the best service. Where to Look on an ECG for STEMI and NSTEMI . This occurs when arteries that carry blood to your heart become narrowed and blocked. It also may be used to help determine whether the heart has been damaged by chemotherapy or radiotherapy. Apply all the latest advances in clinical cardiology techniques, technology, and pharmacology. Access the complete text and illustrations online at Expert Consult, fully searchable. What does unstable angina look like on ekg? 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Thorough overview of many advances in clinical cardiology techniques, technology, and pharmacology rule out serious disease! Use special dye and X-rays to look for blockages in the empty box is ST! Or radiotherapy the day them easily pathological Q-wave is a non-invasive ultrasound visualizes... That it represents transmural infarction ( STEMI ) Q-wave is a medical emergency as it beats placed! Empty box signals produced by your side 's angina, pressure, squeezing, pressure, heaviness tightness..., however, a common heart disorder, can not usually be detected a! The R wave to the QRS vector get enough blood and oxygen who are treated for unstable angina like! Both produce the same time as a stress test an upside-down Q wave ( similar in reason to the special. Exertion, an exercise stress ECG should be performed Edition 17 years ago, progress been... The injury to cardiomyocytes in all areas of electrocardiography walking on a or! 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