Scotland emergency and out of hours radiology

Emergency and out of hours radiology Meeting organised by the Scottish Branch of The British Institute of Radiology Wednesday 20 May 2015 New Lister Building, Glasgow Royal Infirmary, Glasgow 09:00

Registration and refreshments

09:30

Trauma head imaging Dr Susan Kealey, Consultant Neuroradiologist, Department of Clinical Neuroscience, Edinburgh

10:00

Spinal trauma Dr Jon Foley, Consultant Musculoskeletal Radiologist, Glasgow Royal Infirmary

10:30

Acute stroke imaging Dr Ahmed Iqbal, Consultant Neuroradiologist, New South Glasgow University Hospital

11:00

Headache Dr Leighton Walker, Consultant Neuroradiologist, Glasgow Royal Infirmary

11:30

Refreshments

11:50

What’s new in VTE? Dr Giles Roditi, Consultant Cardiovascular Radiologist, Glasgow Royal Infirmary

12:20

Suspected acute aortic syndrome Dr John Dreisbach, Specialist Trainee in Radiology, West of Scotland Radiology Training Scheme

12:50

Emergence of cardiac CT Dr Michelle Williams, Specialist Trainee in Radiology, South East Scotland Radiology Training Scheme

Incorporated by Royal Charter Patron - Her Majesty The Queen

President Dr David Wilson MBBS BSc MFSEM FRCP FRCR Chief Executive Ms Jacqueline Fowler BA, MInstF(Cert)

The British Institute of Radiology 48-50 St John Street London EC2M 4DG

T : +44(0)20 3764 5710 E : admin@bir.org.uk www.bir.org.uk

Registered Charity No. 215869 VAT Registration No. GB 233 7553 63

13:20

Lunch

14:05

Lessons from Glasgow polytrauma Dr Ross MacDuff, Consultant Radiologist and Clinical Lead, Glasgow Royal Infirmary

14:35

Thoraco–abdominal trauma Dr Chris Hay, Consultant Interventional Radiologist, Royal Infirmary of Edinburgh

15:05

Lessons from the Rad Cave Dr Laura Thomson, Specialist Trainee in Radiology, West of Scotland Radiology Training Scheme

15:35

Refreshments

15:50

Acute female pelvis Dr Yee Ting Sim, Consultant Radiologist, Ninewells Hospital Dundee

16:20

Acute small bowel and appendix Dr Hedvig K’arteszi, Consultant Gastrointestinal and Abominal Radiologist, Glasgow Royal Infirmary

16:40

Abdominal bleeding Dr Andrew Downie, Consultant Interventional Radiologists, Victoria Infirmary and New South Glasgow University Hospital

17:10

Close of meeting This meeting has been awarded 6 RCR category I CPD credits.

Your certificate of attendance will be emailed to you within the next two weeks once you have completed the online survey at: https://www.surveymonkey.com/s/emergencyandoutofhours We are most grateful to

for supporting this event

Speaker profiles Dr Andrew Downie, Consultant Interventional Radiologist, Victoria Infirmary and New South Glasgow University Following radiology training in Guy’s and St Thomas’ Hospitals in London, and a fellowship in abdominal and GI imaging and intervention in Vancouver, Canada, Dr Downie has worked in Glasgow for 17 years with interests both in diagnostic abdominal imaging and in interventional radiology.

His experience in dealing with acute intra abdominal bleeding emergencies has been greatly widened in recent years through participation in the pan Glasgow Interventional Radiology On Call rota, one of the first comprehensive 24 hour interventional radiology services in the UK. Dr John Dreisbach, Specialist Trainee in Radiology, West of Scotland Radiology Training Dr John Dreisbach completed his MBChB at the University of Aberdeen in 2010 and is currently a specialist registrar in clinical radiology in Glasgow with an interest in cardiovascular imaging.

Dr Jon Foley, Consultant Musculoskeletal Radiologist, Glasgow Royal Infirmary Dr Jon Foley is currently a consultant radiologist at Edinburgh Royal Infirmary with a special interest in musculoskeletal radiology. He completed his radiology training in Glasgow and worked as a consultant in Glasgow Royal Infirmary for two years after doing a one year fellowship at the Royal National Orthopaedic Hospital in London.

He also worked as a volunteer radiologist at the Glasgow Commonwealth Games in 2014.

Dr Chris Hay, Consultant Interventional Radiologist, Royal Infirmary of Edinburgh Dr Chris Hay undertook clinical radiology training in the Peninsula training scheme South West England with subspecialty interventional training in Glasgow and interventional fellowship in Perth, Western Australia.

He has been a clinical and interventional radiologist at the Royal Infirmary Edinburgh for four years. His interests are vascular and nonvascular intervention, trauma imaging and clinical education.

Dr Ahmed Iqbal, Consultant Neuroradiologist, Institute of Neurosciences, New South Glasgow University Hospital Dr Ahmed Iqbal has been a consultant neuroradiologist at the Institute of Neurological Sciences, New South Glasgow University Hospitals since 2012 after completing his fellowship training in Newcastle. He has a subspecialist interest in academic and clinical stroke imaging conducting the weekly mutli-disciplinary stroke meeting in the largest thrombolysis centre in Scotland. He has been invited to

national meetings to teach stroke imaging since becoming a consultant.

Dr Hedvig K’arteszi, Consultant Gastrointestinal and Abdominal Radiologist, Glasgow Royal Infirmary Dr Hedvig K’arteszi started her career as a consultant radiologist in Hungary’s largest University Department in Budapest. She has been working in Glasgow Royal Infirmary since 2008 as gastrointestinal radiologist with special interest in pancreatobiliary and small bowel imaging. She is the lead radiologist of the Scottish HepatoPancreatoBiliary Network.

Dr Susan Kealey, Consultant Neuroradiologist, Department of Clinical Neuroscience, Edinburgh Dr Susan Kealey graduated from University College Dublin and completed radiology training in Dublin and the USA. She currently works as a consultant neuroradiologist in Edinburgh.

Dr Ross MacDuff, Consultant Radiologist and Clinical Lead, Glasgow Royal Infirmary Dr Ross MacDuff trained on the West of Scotland Radiology Training Scheme. He then took up a consultant post at Glasgow Royal Infirmary and Stobhill Hospital with a subspecialty interest in cardiothoracic imaging and intervention. Since 2014 he has also been the clinical lead for imaging for the North Sector of NHS Greater Glasgow and Clyde.

Dr Giles Roditi, Consultant Cardiovascular Radiologist, Glasgow Royal Infirmary Dr Giles Roditi is a consultant radiologist, working at Glasgow Royal Infirmary since 1997. He has a clinical and research interests in cardiovascular and thoracic radiology, including publications in cardiac MRI and body MRA techniques since 1994. His particular interests are in cardiac MRI, cardiac CTA, venous thromboembolism, renovascular imaging, lower limb MRA techniques, carotid MRA and venous imaging.

He is the current chair of the BIR Scottish Branch, treasurer of the British Society of Cardiovascular Imaging (BSCI) and chair for Contrast Procurement in Scotland and Northern Ireland. He has been an active member of the Venous Thrombosis Committees of Glasgow Royal Infirmary and NHS Greater Glasgow and Clyde since inception and involved in both education regarding VTE as well as audit and patient safety initiatives.

In the last year he has reviewed and updated the Royal College of Radiologists Guidelines on contrast administration (Standards for Intravascular Contrast Administration to Adult Patients, Third Edition). With colleagues on the committee of the BSCI he has also been involved with the recently published RCR Guidelines for CTCA performance (Standards of Practice of CT Coronary Angiography in Adult Patients).

He is active in cardiovascular imaging research and has been involved in several recent and on going trials, most notably on the trial steering committee for the recently reported SCOT-HEART study and is participating in the early start up phases for Rapid CTCA and DISCHARGE. He has been involved in promoting non-invasive cardiovascular imaging at all levels in the UK and internationally and is currently part of the programme development for the cardiac imaging stream for ECR 2016. He is Level 3 accredited in both Cardiac CT and Cardiac MRI. Dr Laura Thomson, Specialist Trainee in Radiology, West of Scotland Radiology Training Scheme Dr Laura Thomson is a ST5 registrar on the West of Scotland training scheme, having commenced training in 2007. She is currently the Less than Full Time training representative on the West of Scotland Educational Sub committee and has been involved in the negotiations and implementation of the new Radiology Centralised Reporting Centre for NHS Greater Glasgow and Clyde.

Dr Yee Ting Sim, Consultant Radiologist, Ninewells Hospital Dundee Dr Yee Ting Sim studied medicine at Edinburgh and completed foundation training in Tayside. She trained in radiology in West of Scotland, gaining the FRCR in 2012.

She currently works as a consultant radiologist in Ninewells Hospital Dundee and Perth Royal Infirmary. Her subspecialty interests are in breast and gynaecological imaging.

Dr Michelle Williams, Specialist Trainee in Radiology, South East Scotland Radiology Training Scheme Dr Michelle Williams trained in Edinburgh and recently completed a British Heart Foundation Clinical Research Fellowship at the University of Edinburgh. She is currently a radiology trainee at the Royal Infirmary of Edinburgh. Her research interests include CT coronary angiography, CT myocardial perfusion, PET myocardial perfusion and molecular imaging of atherosclerotic plaque.

She is also research fellow for the SCOTHEART study, a multicentre randomized control trial of the role of CT imaging in patients attending the Rapid Access Chest Pain Clinic. She is the radiology trainee representative for the British Society of Cardiovascular Imaging committee, member of the British Society of Cardiovascular Magnetic Resonance trainee committee and secretary of the Society of Cardiovascular Computed Tomography Fellows and Residents in Training committee. In her spare time she is a computed programmer developing apps for doctors and patients

Abstracts (where supplied) Trauma head imaging Dr Susan Kealey This session will review the radiology of acute blunt and penetrating cranial trauma.

Typical imaging patterns of parenchymal and extraxial intracranial haemorrhage with be covered, included diffuse axonal injury. The appropriate choice of imaging techniques will be discussed.

Participants should be able to recognise the typical patterns of traumatic intracranial haemorrhage and identify secondary complications of cranial trauma. Participants should be able to discuss the choice of appropriate imaging in the acute setting.

Spinal trauma Dr Jon Foley This presentation will focus on the radiological investigation of patients with suspected spinal trauma from the craniocervical junction to the sacrum. It will cover the criteria that have been established for deciding if clinical clearance of the cervical spine is appropriate or if imaging is required. Plain films, CT and MRI will be used to illustrate the injuries described and the functional anatomy of the spine.

Particular attention will be paid to multidetector CT and the scanning protocols used. Specific injuries of the upper cervical spine will be addressed and the concept of spinal stability will be discussed, with emphasis on the subaxial spine. Established models and classification systems will be covered and a more recent classification system will be advocated, with emphasis on the radiological morphology of the injury and the integrity of discoligamentous structures rather than the mechanism of injury. Pitfalls and normal variants will also be addressed.

By the end of the presentation, delegates’ knowledge of common injury patterns should have been refreshed: They should also have an improved understanding of the concept of spinal stability and the spectrum of injury severity with a view to facilitating communication with referrers regarding the need for neurosurgical intervention or otherwise.

Acute stroke imaging Dr Ahmed Iqbal Stroke can be defined as an acute central nervous system injury with an abrupt onset. Acute ischaemia constitutes approximately 80% of all strokes and is a leading cause of mortality and morbidity in the developed world. The goals of an imaging evaluation for acute stroke are to establish a diagnosis as early as possible.

Unenhanced CT is widely available and can be performed quickly. It not only helps identify haemorrhage (a contraindication to thrombolytic therapy) but it can also identify early stage acute ischaemia by depicting features such as the hyperdense vessel sign, insular ribbon sign and obscuration of the lentiform nucleus.

Unenhanced CT plays an important role in the identification and quantification of parenchymal involvement for thrombolysis. Stroke mimics such as tumours are important to distinguish from acute ischaemia and the imaging differences will be

discussed. CT angiography is a widely available technique for assessment of both intracranial and extracranial vasculature and its role in acute stroke lies in its capabilities for demonstrating thrombi within intracranial vessels and demonstration of a significant thrombus burden which can guide the appropriate form of intravenous or intraarterial therapy.

Aims • The radiological findings of acute ischaemia on CT • Stroke mimics • Role of CT angiography in hyperacute stroke What’s new in VTE? Dr Giles Roditi Venousthromboembolism (VTE) remains a significant healthcare issue and a focus of patient safety efforts. Although the imaging diagnostic tests for DVT (ultrasound) and pulmonary embolism (predominantly CT pulmonary angiography - CTPA) are now very routine in every UK radiology department there still seems to be much we can learn.

For DVT diagnosis there is increased awareness of the importance of superficial venous thrombosis and MR angiography with venous phase imaging is leading to new insights. Recent advances in CT technology should help us minimise the risks of CTPA by reducing radiation and contrast doses while also improving specificity through motion-free imaging. The benefits of iterative reconstruction, low kVp imaging and ECG gating will be explored.

As the imaging of VTE has become a part of daily routine and diagnoses more secure then, in part, our efforts must focus on outcomes through continued audit, particularly at a regional level learning the lessons regarding cases of HAVTE which are becoming increasingly important in an ever more litigious society. In Scotland this is being taken forward through the Scottish Patient Safety Programme which aims to improve delivery of evidence based care in both prevention and management of VTE including reliable recognition and assessment.

Suspected acute aortic syndrome Dr John Dreisbach Acute aortic syndrome (AAS) is a relatively rare but frequently life-threatening condition, which may require emergency radiological intervention or surgery. Due to the significant overlap in clinical presentation with multiple other conditions, the initial diagnosis and detection of complications typically depends on prompt and accurate interpretation of CT images. It can potentially affect multiple body systems and not uncommonly manifest subtle and complex radiological appearances.

Furthermore, challenges in interpretation are often confounded by suboptimal CT images relating to contrast timing, scan coverage and motion artifact from the heart.

A recent local retrospective review of the accuracy of CT reports in AAS demonstrated a 31% rate of major discrepancies in the radiological interpretation.

Major errors related to failure to correctly identify and/or characterize the AAS itself and/or the major haemorrhagic and malperfusion complications.

This lecture will review recommended CT protocols for investigating suspected AAS, the typical and atypical appearances of aortic dissection, intramural haematoma and penetrating atherosclerotic ulcer, and the major haemorrhagic and malperfusion complications. Review will also be made of classification systems and controversies, an outline of the radiological and surgical interventions, and the potentially confusing radiological appearances and complications after treatment. Throughout the talk, particular focus will be given to recognizing and avoiding the pitfalls and common errors in interpretation reported in the literature and experienced locally.

Emergence of cardiac CT Dr Michelle William Computed tomography coronary angiography (CTCA) is now an established technique for the diagnosis of coronary artery disease. CTCA has an excellent diagnostic accuracy as compared to invasive coronary angiography, with the major strength being the high negative predictive value. In addition, the ability to identify non-obstructive coronary atherosclerosis can guide appropriate medical management and primary prevention therapies. Recent studies have established the role of CTCA in patients with stable chest pain (SCOTHEART, PROMISE). In the emergency department CTCA can reduce time to diagnosis and hospital costs (ROMICAT, CT-STAT). New research studies will assess the outcomes of patients undergoing CTCA in the emergency department in a UK setting (RAPID). CTCA is an exciting and useful technique that will become an important component of emergency CT workload in the future.

Lessons from Glasgow polytrauma Dr Ross MacDuff Imaging polytrauma patients presents a radiology department with specific radiographic and reporting problems. When these patients come from a major incident the need to rapidly evaluate multiple casualties adds to the pressure placed upon the radiographic and radiology staff. We will draw on the recent experience at Glasgow Royal Infirmary of imaging patients from two major incidents.

In this talk we will review imaging protocols for polytrauma patients and discuss how best these patients can be imaged. Once the images have been acquired rapid but accurate reporting is key to allow clinical colleagues to prioritise patient management. We will discuss how to optimise the reporting of these examinations and the communication of the results to the clinicians.

Major incident planning is vital to allow a co-ordinated response by medical services to such an incident. We will discuss where a radiology department sits within a coordinated response and how best to plan for imaging multiple polytrauma patients. Finally we will discuss the importance of post incident debriefing to shape the response to future events.

Thoraco–abdominal trauma, Dr Chris Hay Imaging has revolutionised the management of the severely injured patient.

Increased ease of access to imaging, speed of image acquisition and advances in

reporting has placed imaging in an essential role in the assessment of patients with thoraco-abdominal trauma. Where appropriately utilised, extensive imaging with computed tomography and ultrasound may improve survival and streamline the patient journey. However clinical diagnostic uncertainty, increasing pressure on trauma services and waiting times may result in injudicious requests for imaging, raising concerns over increasing workload, incidental findings and radiation dose.

In this session we will consider the current available evidence and guidelines which may help guide imaging strategies and inform service provision in your institution.

Aims: • • • • • • •

Review of up to date imaging strategies for the thoraco-abdominal trauma patient Overview of medical literature regarding whole body CT versus focused directed imaging Guidance from the Royal College of Radiologists Consider clinical pathways for management of thoraco-abdominal trauma Look at the RIE protocol Issues with Audit and QIP Briefly touch upon the application/indications for interventional radiology

Learning outcomes: • • • • •

Develop an awareness of the various imaging strategies available for the trauma patient Appreciate the current issues with regards to evidence for the available strategies Know where to find the best evidence and guidelines to help structure a protocol fit for purpose in your institution Understand the need to agree local guidelines and where to find them in a hurry Be sensitive to the problems of audit and quality control in trauma imaging

Lessons from the Rad Cave Dr Laura Thomson The out of hours radiology provision in Greater Glasgow and Clyde has been under review for a number of years, due to increasing demand on out of hours services and introduction of rules and regulations on working times for junior doctors.

The previous model utilised registrars from ST2 onwards as a ‘first on call from home’, with three separate rota covering the six Glasgow hospitals. The three hospitals outwith Glasgow operated a consultant only on call system with teleradiology links.

A board wide team was established to come up with a new model for working to provide a EWTD compliant rota for the registrars on the west of Scotland rotation, and a centralised reporting centre was proposed. Following extensive rota modelling, amenity evaluation and discussions with the registrar body, a month long

trial ran in November 2013. This flagged up several issues, particularly with respect to IT. Once these problems were addressed the new centralised reporting hub (dubbed the Rad Cave by the registrars) reopened for business as of February 2015.

This talk will discuss the process of developing the new system and our feedback from radiographers, radiology and clinical staff, problems we have identified and lessons we have learnt.

Acute female pelvis Dr Yee Ting Sim Acute gynaecological diagnoses may not be clinically straightforward to unsuspecting surgeons. Ultrasound is the preferred first-line imaging for many female patients, particularly of reproductive age. Despite this, radiologists not infrequently encounter gynaecological conditions in patients who undergo CT scanning in emergency and out-of-hours setting for “acute abdomen�.

The aims of the presentation are to discuss a spectrum of common acute gynaecological entities, such as infection, torsion, endometriosis and fibroid complications; to illustrate and review their typical features on cross-sectional imaging (CT and MRI). Examples from various clinical cases will be shown, highlighting helpful pointers and potential pitfalls in scan interpretation, correlating with ultrasound and pathological findings where available.

Acute small bowel and appendix Dr Hedvig K’arteszi Acute appendicitis is the most common abdominal emergency. Most of the radiologists are familiar with the typical radiological signs of appendicitis. This review focuses on understanding the role of different imaging modalities (US, CT, MRI) in clinical management of patients with suspected appendicitis to achieve best clinical outcome.

Acute abdomen represents the rapid onset of severe symptoms that may indicate potentially life-threatening intra-abdominal pathology. Abnormal small bowel is often seen on imaging but interpretation of the findings might be difficult.

Radiologists should be familiar with appearances of the normal small bowel and various pathologies in order to make correct diagnosis. MDCT plays a primary role in evaluation of patients with acute small bowel diseases as it can provide answers to specific questions that have a major effect on the clinical management of the patient. A systematic approach to interpretation of CT findings and consideration of clinical information are the key for a correct diagnosis. This presentation aims to provide a guide to radiological diagnosis of small bowel diseases that cause acute abdomen with a particular focus on differential diagnostic challenges.

Abdominal bleeding Dr Andrew Downie When a clinician calls about a patient with acute intra-abdominal bleeding, the best course of management is not always clear, and handling the call can be stressful.

• Has the clinician exhausted their own approaches to the problem before calling?

• Does the patient need investigating out of hours at all?

• Which investigation is best?

• How should it be performed?

• What will the interventional radiologist ask me if I ring them at home?

• Should the clinician be ringing the interventional radiologist direct?

While each case needs to be considered on its own merits, some basic principles can guide us.

Aims: • • • • • • •

Consider the common causes of acute intra-abdominal haemorrhage Classify them by source Consider the various possible investigation pathways, according to source, including the respective roles of endoscopy, CT angiography (CTA) and conventional angiography Describe the indications for CT angiography, and preferred CT protocols Consider the role of the interventional radiologist Describe embolisation techniques and agents Discuss the relative merits of CTA and conventional angiography as the next step in managing a bleeding patient; CTA or IR?

Learning outcomes: • • •

Understand how interventional radiologists manage bleeding patients Understand how diagnostic radiology can have a vital role in directing care appropriately How to improve one’s confidence in dealing with the next on call emergency referral

NOTES ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

NOTES ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

NOTES ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________