Re: Re: Opinions on Labs

[Guest guest]

Yes you read this right I would not do a do an MRI until I seen my Estradiol

levels but if your Health Care plain pays for this go for it. When you test

Estradiol levels the best range is said to be between 10 to 30 pg/ml best around

20 read this link it's in this.

Here is a cut and paste you could show this link to your Dr.

http://www.griffinmedical.com/male_hormone_modulation_therapy.html

==================================================

High serum levels of estrogen also trick the brain into thinking that enough

testosterone is being produced, further slowing the natural production of

testosterone. This happens when estrogen saturates testosterone receptors in the

hypothalamus region of the brain. The saturated hypothalamus then stops sending

out a hormone to the pituitary gland to stimulate secretion of luteinizing

hormone that the gonads require to produce testosterone. High estrogen can thus

shut down the normal testicular production of testosterone (1, 53, 54, 271-277).

--------------------------------------------------

Estrogen

Estrogen (measured as estradiol) should be in the mid- to lower-normal range. If

estradiol levels are in the upper one-third of the normal reference range, or

above the normal reference range, this excessive level of estrogen should be

reduced. Labcorp lists a reference range of between 3-70 picogram/mL for

estradiol while Quest states a reference range of between 10-50. For optimal

health, estradiol should be in the range of 10-30 picogram/mL for a man of any

age.

Co-Moderator

Phil

> From: marc200134470 <cfs38@...>

> Subject: Re: Opinions on Labs

>

> Date: Saturday, May 15, 2010, 12:22 PM

>

>

> OK,.......just so this is clear as mud to me! )

>

> I looked up the reference ranges on Quests site since I

> don't have the paper yet, only the numbers over the phone

> from yesterday.

>

> LH 1-15 range / Mine 3.7

> FSH 1-8 range / Mine 5.8

> Prolaction - under 20 for men / Mine 8.0

>

> Prolactin seems fine, FSH is over mid-range by a little,

> and LH is normal but in the lower end of range.

>

> Since my Total T is so low, the LH should be towards the

> high end of range, or even slightly elevated,.....is that

> correct?

>

> Also I was going to ask about the Estradiol myself, but

> Phil already mentioned it I see.

> I presume if those levels are high, my pituitary is looking

> at that as T and would not be sending the LH to tell my

> testes to release T?

>

> This leaves me thinking that I am either secondary, and my

> pituitary can't send the proper signals,.......or I have

> high Estradiol levels that are tricking my pituitary into

> thinking my T levels are normal, causing the normal test

> results I got back.

>

> Do I have this correct?

> I just want to have this down in my head clearly so I can

> fire off my thoughts when I see the doc next after the MRI.

>

> Also,.....the test I am looking for next is E2/Sensitive

> Estradiol for men, Quest #4021,.......correct?

> What range should this be in if estrogen is not my

> problem?

>

> I really appreciate the help, and the encouragement from

> you folks. I think I will get to the bottom of this soon,

> and feel confident my doc will work with me. He is one of

> those that doesn't mind people like me that do my own

> research and bring up questions. He actually likes it, and

> has said before that he is only human and sometimes forgets

> something that should be done.

>

> Believe it or not, he is a Cardiologist. I let him handle

> all that he will as my regular GP is not the greatest. He is

> ok for simple things but he doesn't even think my T levels

> should be of any concern to me. LOL

>

> My Cardiologist said immediately after seeing my T levels

> that I needed to find out the root of this and correct it

> one way or the other. Said that low T will increase my odds

> of heart disease as I get older as well as my feeling like

> crap. I don't have a heart problem now, but it does run in

> my family genes pretty bad,.....that is why I go to him to

> be watched for anything that might be changing.

>

> Just finished a stress test, and a MET test this past week.

> End of the month I get a carotid and renal ultrasound, and

> then a leg study.

> He rotates different tests on me every year to keep an eye

> on the whole picture. So far I have beat everyone in my

> direct family line by making it to almost 50 without any

> heart problems so far. I wish ALL docs were like this guy!

>

> Looks like I wrote another novel,....sorry.

>

>

>

>

>

>

> ------------------------------------

>

>

[Guest guest]

Well your just coming here you now know more then some Dr.'s.

Co-Moderator

Phil

> From: marc200134470 <cfs38@...>

> Subject: Re: Opinions on Labs

>

> Date: Saturday, May 15, 2010, 2:05 PM

>

>

> Thanks for that info Phil, I will print it off and take it

> with me.

> I am going forward with the MRI since it is already set for

> 9:15 AM Monday.

>

> My insurance requires no approval for diagnostic testing as

> long as it is ordered by one of my doctors. With the cardiac

> stuff I am having done this year my deductible of 1K will

> easily be met,.....probably already is! )

>

> I am choosing to do this because of my headaches, and

> visual disturbances at this point mainly. If not for that I

> would do the Estrogen test first, and go from there.

>

> The info here is invaluable to folks like us. Without it, I

> would have thought that everything was fine and I simply

> needed T gel for life due to testicular failure. Once you

> learn how things work, you quickly see that what appears

> normal on a blood test, is not necessarily the case.

>

> I understand that I may still be primary,......but without

> this site I would not have even known the difference between

> primary and secondary, nor all of the things that can go

> wrong even if your T levels get back in line.

>

>

>

>

>

> ------------------------------------

>

>

[Guest guest]

Hi Bstee and Welcome,

I am not a Dr. but feel you have a Pituitary Problem I say this because your

Total Testosterone is very low at 44 I don't care what time of the day you did

labs. And the message from your Pituitary that tells your Testis to make

Testosterone is very low. Also your not on Thyroid meds and your TSH is very

low most are at about 2.

What is going on here can be you have a tumor on your Pituitary don't get upset

about my saying this it is rare to be Cancer or a life and death problem.

You need an MRI on your Pituitary to rule this out some of us like myself have a

Pituitary Problem mine is due to a head injury from an Auto Accident.

If and when you treat this your going to feel like your old self. Dr.'s that

are up on this are few and fare between. In your case if I were you I would

find a Dr. that knows how to test you and treat you.

A lot of men see Dr. in MI. he only needs to see you once the rest he dose

by phone or Email.

He is one of the best there is for male hormones and your levels are the worst I

have seen I don't understand how your walking around.

Go to Dr. 's site and read TRT: A Recipe for Success and in this are labs

you need and why. He will also work with your Dr. over the phone if you can get

him or her to do this.

www.allthingsmale.com

Or find a new better Dr. Endo's and Uro's are not good at this find a good DO

Dr.

http://forums.realthyroidhelp.com/viewtopic.php?f=12 & t=15451

What I have is called Hypopituitary go to this link and read all the links there

so you understand about this problem.

is not there anymore but all his info is he helped me a lot and reading

this site will help you.

http://forums.realthyroidhelp.com/viewforum.php?f=12 & sid=c81889bf7ee9a8d434b1710\

fec3239dd

Also to to the home page hear at and read in the Links and Files section

about low T. In the Files section read the file " Finding a New Male Hormone

Dr. " make dam sure you make calls before seeing a new one that we don't know.

As a lot of Questions like how many men dose the Dr. treat for low T dose he

test to find out why one is low. Will he treat men with a Pituitary Problem

with HCG dose he test for High Estradiol and will he treat it with Arimidex.

You will know if you have a good one.

If your near this Dr. go see him they are very good.

Overbeck hardasnails1973@... 484-868-0916 contact 1100 fayette

st Conshohocken Internal medicine Male and female hormone disorders and

metabolic disorders 610-828-2026

If you live near CA. this Dr. is dam good.

Romeo no, M.D. (831) 375-6655 395 Del Monte Ctr #305 Monterey, CA 93940

262 Eldorado Street #100 physician, psychiatrist,Behavioral Neuroendocrinology

and Immunology (831) 626-9094 fax

Here are some links to read to get you going the more you learn that better off

you will be seeing a Dr.

http://answers.google.com/answers/threadview?id=450553

http://www.griffinmedical.com/male_hormone_modulation_therapy.html

If you need more just ask.

Co-Moderator

Phil

> From: Bstee <bstee@...>

> Subject: Re: Opinions on Labs

>

> Date: Saturday, May 15, 2010, 10:53 PM

>

>

> Brand new here and looking for help with test results as

> well.  I have all the symtoms of low testosterone

> except the ED.  Also, while I have asked to be tested

> over the years due to extreme fatigue the closest I came was

> with my throid being tested an suggesting I was hypertyroid

> which makes no sense (TSH <.17) so the docs just tell me

> to get up amd move around.  This has gone on for years

> - I am now 42 and finally got tested due to fertility

> issues.  Winds up I have a great sperm count too but

> that doc still decided to test my Testosterone and this is

> what I have:

>

> FSH = <0.7 (range is 1.6-8.0)

> LH  = <0.2 (range is 1.5-9.3)

> Testoserone Total 44 (range is 241 - 827)

>

> I understand that maybe I threw it off by testing in the

> afternoon and it could be higher in the morning.  Any

> chance that it would go up 200 points and make me

> normal?  I would love to hear that my issues are

> related to some type of chemical issue but I am guessing

> that the doc will say it is nothing to worry about. 

> That seems really low though.  Do you think a doc will

> do anything based on these results or the fact that I did an

> afternoon test mean that it really is nothing to worry

> about.  I would love to cut down on the 20 cups of

> coffee I drink just to function. 

>

>

>

> ------------------------------------

>

>

[Guest guest]

I think that's the lowest " Total T " number I have seen! You need some help....

________________________________

From: Bstee <bstee@...>

Sent: Sat, May 15, 2010 10:53:18 PM

Subject: Re: Opinions on Labs

Brand new here and looking for help with test results as well. I have all the

symtoms of low testosterone except the ED. Also, while I have asked to be

tested over the years due to extreme fatigue the closest I came was with my

throid being tested an suggesting I was hypertyroid which makes no sense (TSH

<.17) so the docs just tell me to get up amd move around. This has gone on for

years - I am now 42 and finally got tested due to fertility issues. Winds up I

have a great sperm count too but that doc still decided to test my Testosterone

and this is what I have:

FSH = <0.7 (range is 1.6-8.0)

LH = <0.2 (range is 1.5-9.3)

Testoserone Total 44 (range is 241 - 827)

I understand that maybe I threw it off by testing in the afternoon and it could

be higher in the morning. Any chance that it would go up 200 points and make me

normal? I would love to hear that my issues are related to some type of

chemical issue but I am guessing that the doc will say it is nothing to worry

about. That seems really low though. Do you think a doc will do anything based

on these results or the fact that I did an afternoon test mean that it really is

nothing to worry about. I would love to cut down on the 20 cups of coffee I

drink just to function.

[Guest guest]

I feel you did make the right choice if nothing shows up great then work on your

Pituitary.

Co-Moderator

Phil

> From: marc200134470 <cfs38@...>

> Subject: Re: Opinions on Labs

>

> Date: Monday, May 17, 2010, 1:55 PM

>

>

> Well for any interested, I just finished my MRI at 11:00

> AM.

> I had to show at 9:15 to sign all the garbage of course.

> Then they x-rayed my eyes to be sure I had no metal in them

> from the type of work I do. After that a blood test to check

> for renal function before contrast.

>

> After reading about what a horror one of these MRI's was I

> had myself pretty worked up last night anticipating it.

> What a waste of sleep, as it was a walk in the park IMHO.

> About 40 minutes in the machine total, and short of one

> noise pattern that became really annoying after a 5 minute

> run of the same thing, it was all fine. It was like a

> musical rhythm of bangs and clicks for that one segment, and

> made you want to move a little, which is a big no no.

>

> They left me in the machine for a few minutes while they

> scanned the images quickly to be sure they were of high

> quality, and took me out.

> Said I did an exceptional job of keeping totally still, and

> not breathing in a panicked pattern,......so I hope it

> yields some excellent images.

>

> Only thing I was confused by was the fact that they have

> another MRI that only targets the pituitary, and mine was

> ordered for the entire head/brain. They tried to call my doc

> but I told them he was not in on Mondays,.....he does

> invasive procedures and testing. They told me that I could

> of course refuse the test and come back another time, but I

> went through with it.

>

> Hope I made the right choice!

> Now the waiting begins.

>

>

>

> ------------------------------------

>

>

[Guest guest]

Please get some help right away.  Be well.....

________________________________

From: hardasnails1973 <hardasnails1973@...>

Sent: Tue, May 18, 2010 11:37:05 AM

Subject: Re: Opinions on Labs

 

Lowest testoterone recorded for me was 40.

It was confirmed by repeat analysis because dr could not believe it

His response 2.5 mgs of androgel. I was like you goto be kidding me.

I would have the dr re run the labs in 2-3 weeks to see if it hidden infection

or trama to the body. Most likely this would be due to excessive cortisol and

low DHEA levels in the blood. Please check 24 hour salivary cortisol to catch

this now before it cascades into something that goes out of control. Need to

identify what stage of adrenal imbalance you are in pronto. As well as proper

evaluation of ft3 ft4,tsh and rt3, ferritin for thyroid. This help practioner in

the proper in what direction to treat next.

>

> I think that's the lowest " Total T " number I have seen! You need some help....

>

>

>

>

>

> ________________________________

> From: Bstee <bstee@...>

>

> Sent: Sat, May 15, 2010 10:53:18 PM

> Subject: Re: Opinions on Labs

>

>

>

>

> Brand new here and looking for help with test results as well. I have all the

symtoms of low testosterone except the ED. Also, while I have asked to be tested

over the years due to extreme fatigue the closest I came was with my throid

being tested an suggesting I was hypertyroid which makes no sense (TSH <.17) so

the docs just tell me to get up amd move around. This has gone on for years - I

am now 42 and finally got tested due to fertility issues. Winds up I have a

great sperm count too but that doc still decided to test my Testosterone and

this is what I have:

>

> FSH = <0.7 (range is 1.6-8.0)

> LH = <0.2 (range is 1.5-9.3)

> Testoserone Total 44 (range is 241 - 827)

>

> I understand that maybe I threw it off by testing in the afternoon and it

could be higher in the morning. Any chance that it would go up 200 points and

make me normal? I would love to hear that my issues are related to some type of

chemical issue but I am guessing that the doc will say it is nothing to worry

about. That seems really low though. Do you think a doc will do anything based

on these results or the fact that I did an afternoon test mean that it really is

nothing to worry about. I would love to cut down on the 20 cups of coffee I

drink just to function.

>

>

>

>

>

>

>

>

[Guest guest]

Wow Marc you and I have a similiar story, I care for both my parents I'm sorry

about your father.

We also have the same name and live in FL.

Good luck with everything.

Marc

Sent via BlackBerry from T-Mobile

Re: Opinions on Labs

I appreciate the info,.....but honestly can't say I understand it all.

Right now I simply have to wait to see my doc again on June 1st. after some

other cardiac testing this week, and next.

So far I have not received a phone call from anyone concerning my MRI, but then

again I have no idea how long it takes for them to read them and fax the outcome

to my doc. They said if something really bad was seen I would get a call.

My life has been full of stress for the last 6 years especially so there is

nothing for me to tie it to that way. My step-father that was a retired

physician died a horrible death that took almost 2 years from start to end.

During that time I was running my business of 18 years, taking care of my home,

as well as theirs, along with bills for both places, and my usual business

paperwork. I also had to bring my mothers pooch here to care for him.

After that my mother has had several health issues, one which almost killed her.

I basically lived over there for several months doing the same,........back and

forth and trying to keep up with work.

After all this started is when I began 'over consumption' of beer to try and

calm myself down. I am now cutting way back on that, and intend to quit totally

soon.

I posted in another thread about my diet,.....it is good. No junk food and all

that garbage.

I feel like I have been running on adrenaline for a long time actually, and that

may have something to do with this,.....I don't know. My own doc has said that I

am a very strong person to have gone through all that I have and still be

standing.

All I can do is take it one step at a time, and report it here. I am very

hopeful that I will be guided in the right direction by doing this. Some of

these doctors you guys mention are not available to me as I live in Florida, so

my best hope is to work with the one I have.

He is open to thoughts and theories, and I don't think he will hesitate to order

tests that might be needed.

My understanding is when I see him again on the first, he is going to check my T

again, and I will ask for the E2 test as well,......I know he will order it.

Until then it is a waiting game for me.

Simply trying to keep myself going right now, but I do appreciate all of the

help to date.

>

> Yes ruling out pituitary issues is a wise thing to due. Some times nothing

may be found but still have problems with something either interrupting the

signal or do not have the right nutients to help creat the signal in the first

place which can mimic pituitary issues.

> The next thing would to evaluate the pathology of the issue as well as other

hormonal markers to try to come up with some kind of scenerio on WHY this

occured and then start proper treatment to take care of the cause as well as

help bridge the symptoms.

>

> How I would. handle this

> 1. Look for potential stressors- when did this occur what occured with in 3-6

months of experiencing symptoms. Some kind of dramam can eventually be isolate.

Working on lifestyle modification, sleep patterns, eating balanced meals would

be the first line.

> 2. proper hormone evlaution of thyroid, testosteone, adrenals, estrogen with

complete blood work, salvia cortisol test,

> 3. If the person has insurance running nutra eval has been a huge asset into

looking into the potential cause of the prolbem giving vital clues that may be

hidden

> 4. Gather the data and come up with some type of logical scenerio explaining

the information that was found.

> 5. implement proper protocol then retest in 5-6 weeks till symptoms get better

then goto every 12 weeks then once every 6 months.

>

> if nothing comes back with MRI then i would do a clomid challenge and then to

see if you are able to start up. if this was positive run clomid protocol as

same time back fill it with proper nutrient needed to make testosterone it self

and supporting the adrenal and thyroid if needed.

>

[Guest guest]

I live in Daytona.

There is a place in Lake called Eterna MD.

The doc is Mercado. He seemed experienced but not like Dr . If you go by Dr

Crislers protocal it seems to work.

Since I went to Mercados I don't have baselines of my E2, prolactin, and some

others.

I'm actually seeing him this Sat to pick up someblood. I'm not on TRT but I

wouldn't recomend him unless he agrees to work with Dr . I never mentioned

Dr to him. I should.

But I'm going to go see Dr June 3rd. I figured he is one of the best in the

country and that's the help I need.

PS. Mercado charges 2600 a year.

Sent via BlackBerry from T-Mobile

Re: Opinions on Labs

Stress is a killer for sure,....watch out for too much of it.

I have lived in Florida since I was about 3 years old. Used to live in Ft.

Lauderdale, then WPB and Boca.

Now in Central Florida about an hour north of Orlando since 1991. Name is the

same but mine is spelled with a k actually. I used an old sign-in to join

this group instead of setting up a new one.

If any folks in Florida know of good TRT docs be sure to post about them.

Take care of yourself as well.

>

>

> Wow Marc you and I have a similiar story, I care for both my parents I'm

sorry about your father.

>

> We also have the same name and live in FL.

>

> Good luck with everything.

>

> Marc

> Sent via BlackBerry from T-Mobile

>

[Guest guest]

That's good you found a Doc.

I'm not sure about your insurance covering it. How old are you?

Sent via BlackBerry from T-Mobile

Re: Opinions on Labs

Marc,......I am in Ocala, not really that far away. Used to do work in Daytona

for a few clients years ago, but have not been over there for awhile.

I found a D.O. here that seems to be into this stuff, but I only want to use him

if it's needed. I have no clue if my insurance will cover a D.O. or not, and I

do believe they will pay for most of this stuff as long as it is ordered by one

of my regular docs.

I say they pay for it! LOL

I pay about 6200 bucks a year for my insurance, so I figure that I am paying for

most of it. This year it appears that they will lose money on me for the first

time in over 12 years.

I have read a lot of the articles about Dr. Crisler,....seems pretty impressive.

I don't have the time to fly around the country seeing a doc though.

I truly hope it works out well for you!

>

>

> I live in Daytona.

>

> There is a place in Lake called Eterna MD.

>

> The doc is Mercado. He seemed experienced but not like Dr . If you go by

Dr Crislers protocal it seems to work.

>

> Since I went to Mercados I don't have baselines of my E2, prolactin, and some

others.

>

> I'm actually seeing him this Sat to pick up someblood. I'm not on TRT but I

wouldn't recomend him unless he agrees to work with Dr . I never mentioned

Dr to him. I should.

>

> But I'm going to go see Dr June 3rd. I figured he is one of the best in

the country and that's the help I need.

>

> PS. Mercado charges 2600 a year.

> Sent via BlackBerry from T-Mobile

>

[Guest guest]

There is one he is high on Dr. 's list.

http://www.jeffreydach.com/

Co-Moderator

Phil

> From: marc200134470 <cfs38@...>

> Subject: Re: Opinions on Labs

>

> Date: Tuesday, May 18, 2010, 1:56 PM

>

>

> Stress is a killer for sure,....watch out for too much of

> it.

> I have lived in Florida since I was about 3 years old. Used

> to live in Ft. Lauderdale, then WPB and Boca.

>

> Now in Central Florida about an hour north of Orlando since

> 1991. Name is the same but mine is spelled with a k

> actually. I used an old sign-in to join this group

> instead of setting up a new one.

> If any folks in Florida know of good TRT docs be sure to

> post about them.

>

> Take care of yourself as well.

>

>

> >

> >

> > Wow Marc you and I have a similiar story, I care for

> both my parents  I'm sorry about your father.

> >

> > We also have the same name and live in FL.

> >

> > Good luck with everything.

> >

> > Marc

> > Sent via BlackBerry from T-Mobile

> >

>

>

>

>

> ------------------------------------

>

>

[Guest guest]

Both Androgel and Testim are fine products. I sit on the Speaker's Bureau

for both companies, and I would not were same not true.

Some do better on one, the rest on the other.

ANY change in a prescription medication takes FDA approval (years and

$millions). I seriously doubt you will get them to change anything.

BTW, the FDA just rejected Solvay's application for a 1.62% (or something

near that) gel. The rocket scientists at your friendly Federal government

felt it was an invitation to steroids.

They did, however, approve a chemotherapy drug which has shown absolutely no

benefit whatsoever.

Be afraid. Be very afraid.

Be well!

Regards,

Crisler, DO

Anti-Aging Medicine

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From: [mailto: ]

On Behalf Of hardasnails1973

Sent: Tuesday, May 18, 2010 7:58 PM

Subject: Re: Opinions on Labs

Then i would look into androgel instead of testim.

its been around longer and much more convient. I'm going to battle with the

rep on thursday to see if they could some how better improve the delivery

system for it. She actually really hot and loved it when I got up in her

face because she was not expecting some one to give her a challenge. She was

totally hitting on me and when she left looked back and gave me a wink and

sexy smile saying " bring it on thursday " Componding stuff is too much hit or

miss where androgel is a regulated by FDA for potency.

> >

> >

> > That's good you found a Doc.

> >

> > I'm not sure about your insurance covering it. How old are you?

> >

> >

> > Sent via BlackBerry from T-Mobile

> >

>

Internal Virus Database is out of date.

Checked by AVG - www.avg.com

Version: 8.5.437 / Virus Database: 271.1.1/2828 - Release Date: 04/22/10

06:31:00

[Guest guest]

Maybe all us Florida folks can get together. We can storm the doctors

office and hold all the nurses hostage until we get what we want! Now

that'll fixum! LOL

Brett in the Ocala National Forest, Florida.

Re: Opinions on Labs

>

>

> Stress is a killer for sure,....watch out for too much of it.

> I have lived in Florida since I was about 3 years old. Used to live in Ft.

> Lauderdale, then WPB and Boca.

>

> Now in Central Florida about an hour north of Orlando since 1991. Name is

> the same but mine is spelled with a k actually. I used an old

> sign-in to join this group instead of setting up a new one.

> If any folks in Florida know of good TRT docs be sure to post about them.

>

> Take care of yourself as well.

>

>

>>

>>

>> Wow Marc you and I have a similiar story, I care for both my parents I'm

>> sorry about your father.

>>

>> We also have the same name and live in FL.

>>

>> Good luck with everything.

>>

>> Marc

[Guest guest]

Just remember that Cat that crossed the RR tracks and a Train cut of his Tail he

turned to see what happened and then lost his Head.

Co-Moderator

Phil

> From: hardasnails1973 <hardasnails1973@...>

> Subject: Re: Opinions on Labs

>

> Date: Tuesday, May 18, 2010, 7:58 PM

>

> Then i would look into androgel instead of  testim.

> its been around longer and much more convient. I'm going to

> battle with the rep on thursday to see if they could some

> how better improve the delivery system for it.  She

> actually really hot and loved it when I got up in her face

> because she was not expecting some one to give her a

> challenge.  She was totally hitting on me and when she

> left looked back and gave me a wink and sexy smile saying

> " bring it on thursday "    Componding stuff is

> too much hit or miss where androgel is a regulated by FDA

> for potency. 

>

>

> > >

> > >

> > > That's good you found a Doc.

> > >

> > > I'm not sure about your insurance covering it.

> How old are you? 

> > >

> > >

> > > Sent via BlackBerry from T-Mobile

> > >

> >

>

>

>

>

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