Online Phonics Games Phase 3 Phonics Games Phase 1 Games Phase 2 Games Phase 3 Games Phase 4 Games Phase 5 Games Phase 6 Games Online Phonics Games Phase 3 Expansion Fishy Phonics Race against the clock to see how quickly you can finish this game Click the start button and choose a word set and difficulty level To play read the word in the cloud at the top of the screen and look at the picture cards moving along the bottom of the screen from right to left Fish for the correct card by clicking the top of the picture that matches the word in the cloud If you are correct the cloud shows a new word The timer stops when you finish matching all the cards Skills taught Visual discrimination graphemephoneme correspondence reading speed reading fluency reading 2syllable words fine muscle control Flash Cards This game is designed for a child to play with a teacher or family member The child and adult sit together and start the game You will see a pirate ship lowering a sail that shows a grapheme The child says the sound that the grapheme represents If the child is correct the adult clicks on the tick If the child is wrong the adult clicks on the x Note In Phase 5 set 15 only an underscore stands for consonant For example a_e means a consonant e Adding e to bit making it bite changes the sound of the i This is the vowel lengthening rule The correct readings are a_e sounds like ay e_e sounds like ee i_e sounds like eye o_e sounds like oh u_e sounds like you Skills taught Grapheme recognition graphemephoneme correspondence Flash Cards Time Trial This is for a beginning reader to play with an adult Click the start button choose a word set and game time 1 or 2 minutes You will see a phoneme in the middle of the screen between a cross and a tick The child reads the phoneme aloud The adult shows whether the child has read it correctly by clicking the cross or tick When the timer finishes you will see how many graphemes the child read correctly Replay using the same graphemes the ones the child read wrongly or new graphemes Skills taught Grapheme recognition graphemephoneme correspondence sounding out vowel digraphs recognizing the vowel consonant e pattern consonant digraphs ph and wh Match Cards You will see a word card at the top of the screen and three picture cards underneath The child sounds out the word on the top card then looks at the bottom three cards and says what he or she sees on each card They can check if they are right by clicking on each picture card and listening to the word They should then move the correct picture onto the word that it matches Skills taught Grapheme recognition sounding out blending NEW Odd And Bob Click the play button and choose a grapheme set then select a grapheme from the list You will see Odd the green alien on the left and Bob on the right A spaceship drops a sweet Read the word written on the sweet wrapper If it sounds like a real word drag the sweet down to the right to give it to Bob If it sounds like a fake word drag the sweet down to the left to give it to Odd Skills taught Grapheme recognition graphemephoneme correspondence sounding out blending Sentence Substitution Adults can show children how to play this game on their own At the bottom of the screen you will see a sentence and four words at the top You can replace a word in the sentence with any of the words at the top simply by dragging it down over the word you want to replace If you read the new sentence out loud does it still make sense How many of the words at the top can you use to make a new sentence In some cases you can use all the words In others one of the words will make the sentence quite funny Skills taught Sounding out blending groups of consonants reading 23 syllable words developing reading fluency Tricky Trucks This game is for a child to play with a teacher or family member The child and adult sit together When the game starts you will see a big lorry truck with a word on its side The child sounds out the word If the child is correct the adult clicks the tick If the child is wrong the adult clicks the x Skills taught Grapheme recognition sounding out blending recognizing tricky exception words Word Pairs When you start the game you see a set of cards face down The object of the game is for the child to match pairs of cards by clicking on two cards to see what is on the other side Some are picture cards and some are word cards Match a picture to the correct word and that pair will disappear The game ends when the child successfully matches all the card pairs Skills taught Grapheme recognition sounding out blending visual memory auditory memory YesNo Yeti When you start the game you will see the Yetis question at the top of the page On one side of the Yeti is the word Yes and on the other side is the word No The child reads the question by sounding out and blending the words and then answers the question by clicking on either yes or no Skills taught Grapheme recognition sounding out blending

O B I O O B I O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O


We Rely On Your Support Did you know that you can get Phoronix Premium for under 3 per month Try it today to view our site adfree multipage articles on a single page and more while the proceeds allow us to write more Linux hardware reviews ODROID Rolling Out New IntelPowered Single Board Computer After Trying With Ryzen Written by Michael Larabel in Intel on 20 October 2018 at 1200 AM EDT 53 Comments While ODROID is most known for their various ARM single board computers SBCs some of which offer impressive specs they have dabbled in x86 SBCs and on Friday announced the Intelpowered ODROIDH2 In the announcement they mentioned as well they were exploring an AMD Ryzen 5 2500U powered SBC computer which offered fast performance but the price ended up being prohibitive After the falling out with Ryzen over those cost concerns they decided to go ahead with an Intel Geminilake SoC Geminilake is slower than their proposed Ryzen board but the price was reasonable and it ends up still being much faster than ODROIDs earlier Apollolake SBC What they came up with is the ODROIDH2 and is powered by an Intel J4105 Geminilake 23GHz quadcore processor dual channel DDR4 memory via SODIMM slots PCIe NVMe storage slot dual Gigabit Ethernet dual SATA 30 ports and HDMI 20 DP 12 display outputs The ODROIDH2 board measures in at just 110 x 110 x 43 mm and is cooled by a large passive aluminum heatsink ODROID plans to begin shipping the H2 in late November Pricing information hasnt yet been announced The early launch details can be found via this forum thread About The Author Michael Larabel is the principal author of Phoronixcom and founded the site in 2004 with a focus on enriching the Linux hardware experience Michael has written more than 10000 articles covering the state of Linux hardware support Linux performance graphics drivers and other topics Michael is also the lead developer of the Phoronix Test Suite Phoromatic and OpenBenchmarkingorg automated benchmarking software He can be followed via or contacted via MichaelLarabelcom Latest Linux News Experimental Rockchip Video Codec Linux Driver Posted Google Devs Call OpenSource NVIDIA Driver Unstable Nouveau Blacklisted By Chrome Spotify Tops Ubuntus Snap Store Downloads While GIMP Tops Flatpaks Flathub iMX8 SoC Support Is Heading Into Linux 421 Along With Another ARM Platform Fedora 30 Aims To Use LUKS2 By Default For FullDisk Encryption The New ZFS on FreeBSD Implementation Can Now Be Tested With TrueOS Intel Graphics EngineReset Functionality Driver Work Revived GNOME On Wayland Is No Longer Frustratingly Slow With ASpeed Graphics Wine 40RC5 Released With Only A Handful Of Fixes Canonical Pulled In 110 Million Down To 440 Employees During Their Last Fiscal Year Support Phoronix The mission at Phoronix since 2004 has centered around enriching the Linux hardware experience In addition to supporting our site through advertisements you can help by subscribing to Phoronix Premium You can also use our NewEggcom shopping links when making online purchases or contribute to Phoronix through a PayPal tip

O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

odroid
single board computers
aluminum heatsink


System Hardening Windows Fixing SSLTLS Config Issues Windows Server IISCrypto Posted 15th March 2018 Phr33fall This post is all about the software IISCrypto and how to fix SSLTLS issues You can also find walk through video is here During the last 2 posts I covered how to fix certain SSLTLS issues using manually by using native Windows functionality These posts are linked below http1786212349ciphers http1786212349ssltlsissuesserver2012 Software is available which automates the whole process with just a few mouse clicks but the reason I first covered how to make the changes manually is twofold You understand the process of how to make the changes manually yourself and also understand what the software is changing in the Registry Editor If like me you prefer to keep the amount of 3rd party software within your environment to a minimum then you can do it manually IISCrypto IIS Crypto is a free tool that gives administrators the ability to enable or disable protocols ciphers hashes and key exchange algorithms on Windows Server 2008 2012 and 2016 It also lets you reorder SSLTLS cipher suites offered by IIS implement best practices with a single click create custom templates and test your website httpswwwnartaccomProductsIISCrypto Download IIS Crypto GUI The Windows Server 2012 used in this demonstration is straight out of the box Using sslscan to scan the 2012 machine you can see the multitude of SSLTLS issues highlighted Issues highlighted Rather than manually making changes to the Registry Editor IISCrypto does all of this work for you The GUI is easy to use and gives you plenty of options to chose from Selecting your options For the changes to take effect you first need to restart your Windows Server 2012 machine Upon rescanning the Windows Server youll now see that all the depreciated ciphers protocols and hashes have been removed The end result Ideally you can harden the configuration even further by removing support for SHA hashes Please remember to test these changes on a dev environment before pushing them onto your live systems Disabling Weaker Ciphers RC4 CBC and DiffieHellman

O O O O O O O B I B O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O


Working

with

the

Apache

configuration

file

If

you

want

to

install

Passenger

in

its

Apache

integration

mode

then

you

will

reach

a

point

where

you

have

to

edit

Apache

the

configuration

file

This

page

provides

information

for

those

who

are

not

familiar

with

how

the

Apache

configuration

file

and

its

related

directories

are

organized

The

location

of

the

Apache

configuration

file

On

most

systems

if

you

installed

Apache

with

a

package

manager

or

it

came

preinstalled

the

Apache

configuration

file

is

located

in

one

of

these

locations

etchttpdhttpdconf

etchttpdconfhttpdconf

If

you

installed

Apache

from

source

it

is

likely

located

in

usrlocal

or

opt

though

the

config

files

may

have

been

moved

to

etc

as

usual

Check

your

build

script

for

more

details

Furthermore

On

macOS

Server

Mountain

Lion

the

location

of

the

Apache

configuration

file

varies

Some

paths

are

listed

below

please

refer

to

the

macOS

Server

documentation

for

complete

information

Not

using

websiteswebservices

default

macOS

Server

webservices

macOS

Server

websites

modsenabled

and

sitesenabled

To

allow

better

organization

many

operating

systems

and

Apache

distributions

also

read

configuration

files

in

the

confd

modsenabled

and

sitesenabled

subdirectories

modsenabled

contains

symlinks

to

files

in

modsavailable

This

latter

subdirectory

contains

config

files

for

all

available

modules

while

modsenabled

contains

only

a

subset

namely

the

modules

that

should

actually

be

enabled

The

symlinks

are

created

using

the

tool

load

files

contain

LoadModule

directives

while

conf

files

contain

all

other

configuration

directives

Storing

Passenger

configuration

snippets

If

you

can

you

should

use

modsenabled

modsavailable

to

store

Passenger

configuration

Assuming

that

your

Apache

configuration

directory

is

Create

and

paste

the

LoadModule

directive

that

outputs

Create

and

paste

the

PassengerRoot

and

other

Passenger

options

Enable

by

running

sudo

passenger

If

the

modsenabled

mechanism

is

not

available

then

you

can

paste

configuration

snippets

into

httpdconf

or

directly

See

also

O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O B I I O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O


Alevel Maths Papers C2 Solution Bank C2 Solution Bank You can find the solutions for the exercises in each chapter of the Heinemann Edexcel C2 textbook in pdf format below

O O O B I I B I I O O O O O O O O O O O O O O O O O O O O O


Crohns

Disease

DefinitionDescription

Gastrointestinal

Tract

in

which

Crohns

Disease

affects

Crohns

disease

is

a

form

of

inflammatory

bowel

disease

IBD

that

causes

inflammation

to

the

lining

of

the

digestive

or

gastrointestinal

GI

tract

and

may

be

a

result

of

an

immune

system

malfunction

The

immune

system

sees

the

bacteria

and

organisms

that

lie

within

the

GI

tract

and

intestines

and

mistakes

them

for

outside

invaders

to

the

body

In

response

to

this

the

body

produces

extra

white

blood

cells

to

the

GI

tract

to

fight

off

the

invaders

which

creates

inflammation

within

the

lining

of

the

tract

Chronic

inflammation

may

result

in

ulcerations

within

the

layers

of

the

tract

The

inflammation

can

occur

to

any

portion

of

the

GI

tract

from

mouth

to

anus

and

can

affect

all

layers

of

the

intestinal

tract

while

healthy

bowel

layers

may

be

interspaced

between

the

diseased

portions

of

the

bowel

The

most

commonly

affected

portion

of

GI

tract

affected

is

the

lower

portion

of

the

small

intestine

or

ileum

Due

to

the

inflammation

abdominal

pain

diarrhea

and

malnutrition

can

be

a

result

Crohns

disease

is

also

referred

to

as

granulomatous

enteritis

or

colitis

ileitis

regional

enteritis

or

terminal

ileitis

This

disease

is

similar

in

some

aspects

to

ulcerative

colitis

but

the

difference

lies

in

the

fact

that

ulcerative

colitis

produces

inflammation

only

within

the

colon

or

rectum

while

Crohns

disease

produces

inflammation

within

the

colon

rectum

small

intestine

stomach

mouth

and

esophagus

The

inflammation

caused

by

Crohns

disease

has

the

potential

to

affect

the

deeper

layers

more

than

ulcerative

colitis

While

these

two

conditions

are

very

similar

approximately

percent

of

individuals

are

unable

to

pinpoint

whether

the

disease

process

is

ulcerative

colitis

or

Crohns

disease

For

these

individuals

they

are

then

diagnosed

with

indeterminate

colitis

Prevalence

Crohns

disease

affects

approximately

to

two

million

people

in

the

United

States

equally

affecting

men

and

women

This

disease

may

occur

in

individuals

of

all

age

but

has

characteristically

affected

adolescents

and

young

adults

between

of

age

It

is

estimated

that

percent

of

individuals

affected

are

under

the

age

of

Crohns

has

been

found

to

affect

American

Jews

of

Euro

Geographic

Distribution

of

Crohns

Disease

pean

descent

four

to

five

times

more

than

the

general

population

The

prevalence

among

whites

is

per

with

a

steady

increase

in

incidence

among

African

Americans

Hispanics

and

Asian

have

a

lower

prevalence

than

do

African

Americans

and

whites

There

has

been

a

potential

link

between

living

environment

and

the

incidence

of

Crohns

disease

where

there

are

more

reports

amongst

urban

and

northern

climates

than

rural

and

southern

climates

Similarly

this

disease

tends

to

be

more

predominant

in

the

US

and

Europe

CharacteristicsClinical

Presentation

There

is

no

cure

for

this

condition

and

Crohns

disease

alters

between

periods

of

remission

and

relapse

Crohns

typically

appears

around

adolescence

and

early

adulthood

and

there

is

potential

of

Crohns

disease

to

run

in

families

About

of

individuals

affected

with

Crohns

disease

have

a

close

relative

who

is

affected

with

ulcerative

colitis

or

Crohns

disease

If

an

individual

has

a

relative

with

Crohns

the

risk

of

this

individual

is

times

higher

than

the

general

population

while

a

brother

or

sister

link

increases

the

risk

to

times

higher

than

the

general

population

Current

researchers

have

identified

an

abnormal

genetic

mutation

on

gene

which

reduces

the

ability

of

the

body

to

distinguish

harmful

bacteria

This

mutation

is

found

twice

as

often

in

individuals

affected

with

Crohns

versus

the

general

population

The

typical

symptoms

of

Crohns

disease

include

Your

browser

does

not

currently

recognize

any

of

the

video

formats

available

Click

here

to

visit

our

frequently

asked

questions

about

video

diarrhea

abdominal

cramping

generally

in

the

right

lower

quadrant

fever

potential

rectal

bleeding

The

rectal

bleeding

is

potentially

due

to

tears

or

fissures

within

the

anus

lining

fistulas

or

tunnels

leading

from

the

intestines

to

the

bladder

vagina

or

skin

may

also

occur

while

most

occur

around

the

anal

area

The

fistula

has

potential

to

produce

drainage

pus

mucus

or

stool

being

excreted

from

the

opening

These

symptoms

may

vary

between

individuals

and

may

not

all

be

present

at

the

same

time

weight

loss

fatigue

perianal

lesions

stunted

growth

in

children

extraintestinal

manifestations

While

Crohns

is

a

chronic

disease

the

patients

will

experience

bouts

of

flare

ups

and

remission

with

the

absence

of

symptoms

There

are

different

types

of

Crohns

Disease

dependent

upon

the

location

and

disease

pattern

within

the

GI

tract

Types

of

Crohns

disease

The

different

locations

of

Crohns

Disease

include

Gastroduodenal

Crohns

Disease

upper

GI

Crohns

Disease

This

is

uncommon

and

symptoms

occur

in

of

those

diagnosed

with

Crohns

This

affects

the

stomach

and

first

part

of

the

small

intestine

duodenum

The

symptoms

associated

include

Nausea

Los

s

of

appetite

Weight

loss

Vomiting

Pain

in

upper

abdomen

Jejunoileitis

inflammation

of

the

Jejunum

or

second

part

of

small

intestines

This

is

also

uncommon

in

the

general

population

of

those

diagnosed

with

Crohns

disease

The

symptoms

include

Diarrhea

Abdominal

pain

after

eating

Malnutrition

due

to

malabsoprtion

of

nutrients

Weight

loss

Ileitis

inflammation

of

last

part

of

small

intestine

or

ileum

This

is

affects

of

individuals

diagnosed

with

Crohns

disease

The

symptoms

include

Diarrhea

Abdominal

pain

right

lower

quadrant

Weight

loss

Ileocolitis

inflammation

of

the

ileum

and

colon

This

is

the

most

common

form

of

Crohns

disease

and

affects

of

those

diagnosed

The

symptoms

include

Diarrhea

Abdominal

pain

right

lower

quadrant

Weight

loss

Crohns

colitis

inflammation

of

colon

This

affects

of

individuals

diagnosed

with

Crohns

disease

The

symptoms

include

Diarrhea

Rectal

bleeding

Abdominal

pain

The

perianal

disease

and

extraintestinal

complications

are

more

commonly

associated

in

these

individuals

Perianal

disease

This

occurs

in

of

individuals

diagnosed

with

Crohns

disease

These

individuals

can

have

fistulae

fissures

abscesses

or

skin

tags

Skin

tags

fleshy

growths

outside

the

anus

Distribution

of

Crohns

Disease

within

the

Gastrointestinal

tract

About

of

individuals

with

Crohns

Disease

will

have

mild

symptoms

The

other

half

may

experience

more

severe

symptoms

and

pain

that

appears

to

come

and

go

These

patients

undergo

painful

exacerbations

and

potentially

symptom

free

remissions

The

remissions

might

last

for

months

to

years

but

the

symptoms

will

eventually

return

This

unpredictable

nature

is

part

of

what

makes

Crohns

so

complicating

Associated

Comorbidities

While

commonly

Crohns

disease

affects

the

GI

tract

there

have

been

instances

where

additional

complications

include

arthritis

skin

conditions

inflammation

of

the

eyes

andor

mouth

joints

kidney

stones

gallstones

and

liverbiliary

conditions

were

also

reported

The

most

common

associated

comorbidity

is

a

blockage

of

the

intestines

Continual

blockage

tends

to

thicken

the

walls

of

the

intestine

with

scar

tissue

which

further

reduces

the

size

of

the

passageway

Fistulas

are

also

common

due

to

sores

or

ulcers

that

develop

into

deep

ulcers

or

tracts

connecting

into

the

bladder

vagina

skin

or

anal

area

These

fistulas

are

then

exposed

to

infection

It

has

been

discovered

that

individuals

with

Crohns

disease

have

referred

pain

to

the

low

back

Approximately

of

individuals

with

Crohns

andor

irritable

bowel

disease

have

sacroilitis

polyarthritis

monarthritis

of

ankle

knee

elbows

andor

wrists

as

well

as

migratory

arthralgias

At

times

these

joint

conditions

may

even

present

initially

before

the

other

GI

related

symptoms

Since

this

disease

affects

the

absorption

of

nutrients

chronically

involved

individuals

commonly

have

deficiencies

of

protein

calories

and

vitamins

This

may

be

due

to

the

malabsorption

or

overall

inadequate

dietary

intake

secondary

to

the

patients

attempt

to

limit

the

pain

produced

with

eating

There

is

a

risk

of

colorectal

cancer

that

tends

to

increase

with

an

increased

length

of

time

with

the

disease

There

is

a

incidence

of

colorectal

cancer

after

years

diagnosis

incidence

after

years

diagnosis

and

incidence

after

years

of

diagnosis

of

Crohns

disease

A

mortality

rate

lies

within

the

first

years

of

diagnosis

in

the

presence

of

complications

Surgical

removal

of

the

Crohns

bowel

does

not

prevent

colorectal

cancer

thus

putting

importance

on

prevention

and

screening

for

early

detection

of

colorectal

cancer

Osteopenia

can

occur

in

of

patients

diagnosed

with

Crohns

Disease

and

osteoporosis

can

occur

in

of

those

diagnosed

It

is

thought

these

complications

may

be

due

to

the

steroid

therapy

smokers

those

with

a

more

active

disease

as

well

as

those

individuals

with

low

calcium

and

vitamin

D

intake

Due

to

this

all

patients

diagnosed

with

Crohns

Disease

should

be

informed

of

this

potential

complication

and

should

be

advised

to

take

supplemental

calcium

and

vitamin

D

Stones

of

the

kidney

and

gallbladder

are

potential

comorbidities

Kidney

stones

may

occur

due

to

the

fat

malabsorption

and

diarrhea

in

individuals

with

Crohns

Disease

These

patients

may

experience

extreme

flank

or

lower

lateral

back

pain

as

well

as

blood

in

the

urine

Gallstones

may

occur

due

to

the

bile

acid

malabsoprtion

These

patients

may

experience

right

sided

abdominal

pain

Medications

There

are

a

few

classifications

of

drugs

that

can

be

used

to

help

relieve

the

symptoms

of

Crohns

disease

These

include

antiinflammatory

cortisone

or

steroids

immune

system

suppressors

Infliximab

Remicade

antibiotics

and

antidiarrhealfluid

replacements

Antiinflammatory

drugs

are

generally

the

initial

step

in

relieving

the

symptoms

which

can

include

Sulfasalazine

which

is

better

for

conditions

within

the

colon

and

is

the

most

common

An

additional

type

includes

agents

such

as

Mesalamine

which

has

fewer

side

effects

but

is

not

as

effective

at

treating

the

small

intestine

Cortisone

or

corticosteroids

can

be

very

effective

by

reducing

inflammation

within

the

body

but

their

side

effects

are

vast

including

night

sweats

high

blood

pressure

osteoporosis

bone

fractures

excessive

facial

hair

increased

susceptibility

for

infection

and

cataracts

Prednisone

is

typically

prescribed

when

the

disease

is

beginning

and

typically

worse

Immune

system

suppressors

suppress

the

immune

system

which

targets

the

immune

system

to

reduce

the

inflammation

within

the

body

Some

types

include

Imuran

or

Azathioprine

and

Purinethol

which

are

the

most

commonly

used

for

IBD

and

conditions

These

may

also

help

to

heal

the

fistulas

It

should

be

noted

that

the

use

of

immunosuppressive

drugs

may

increase

the

effectiveness

of

corticosteroids

Infliximab

Remicade

is

the

first

medication

to

block

the

inflammation

response

by

the

body

This

was

approved

by

the

FDA

for

the

treatment

of

moderate

to

severe

Crohns

disease

that

has

failed

to

respond

to

prior

conservative

treatments

This

medication

is

an

antiTNF

substance

or

antitumor

necrosis

factor

and

neutralizes

this

protein

that

is

produced

by

the

immune

system

The

TNF

is

targeted

and

removed

before

there

is

the

chance

for

inflammation

to

occur

in

the

GI

tract

The

FDA

has

declared

a

warning

to

children

and

adolescents

taking

this

medication

or

other

TNF

inhibitors

are

at

an

increased

risk

for

developing

cancer

Antibiotics

are

used

to

treat

and

heal

fistulas

and

abscesses

associated

with

Crohns

disease

Medications

such

as

these

may

also

reduce

the

amount

of

harmful

bacteria

within

the

GI

tract

that

suppresses

the

intestinal

immune

system

Common

antibiotics

include

Flagyl

and

Cipro

Additional

medications

that

are

used

to

help

relieve

symptoms

in

individuals

with

Crohns

disease

include

antidiarrheals

to

relieve

the

diarrhea

laxatives

pain

relievers

iron

supplements

vitamin

shots

calcium

and

vitamin

D

Nutrition

supplements

are

also

very

important

especially

in

children

whose

growth

may

be

slowed

This

nutrition

might

be

in

the

form

of

highcalorie

liquid

formulas

feedings

tube

or

parenteral

nutrition

injected

into

the

vein

This

will

help

to

overall

improve

the

nutrition

of

the

individual

and

allow

their

bowel

to

rest

which

may

reduce

inflammation

for

a

short

period

of

time

Diagnostic

TestsLab

TestsLab

Values

The

diagnosis

of

Crohns

disease

is

made

by

ruling

out

other

potential

causes

to

explain

the

patients

signs

and

symptoms

Some

of

the

tests

include

blood

tests

fecal

occult

blood

test

FOBT

colonoscopy

flexible

sigmoidoscopy

barium

enema

or

small

bowel

imaging

CT

of

the

GI

tract

or

a

capsule

endoscopy

The

blood

tests

are

used

to

check

for

anemia

which

would

indicate

inflammation

within

the

body

infection

and

antibodies

that

might

be

present

with

individuals

with

inflammatory

bowel

disease

The

FOBT

assesses

an

individuals

stool

sample

for

the

presence

of

blood

A

colonoscopy

allows

the

doctor

to

take

a

biopsy

or

tissue

sample

to

determine

if

there

is

a

presence

of

any

granulomas

which

are

common

with

Crohns

disease

and

not

ulcerative

colitis

Normal

small

bowel

and

Crohns

Disease

small

bowel

through

colonoscopy

The

flexible

sigmoidoscopy

allows

the

doctor

to

assess

the

last

portion

of

the

colon

for

any

biopsy

samples

This

allows

the

doctor

to

determine

if

there

is

any

inflammation

or

bleeding

amongst

the

intestines

Barium

enemas

allow

the

doctors

to

assess

the

intestines

via

xray

The

barium

coats

the

inner

lining

of

the

GI

tract

to

allow

the

lining

to

be

visible

on

the

xray

Barium

enema

study

showing

arrows

narrowing

in

the

small

bowel

from

Crohns

Disease

A

CT

of

the

GI

tract

allows

a

quick

look

at

the

entire

bowel

in

a

way

that

can

not

be

seen

in

other

diagnostic

tests

This

helps

to

assess

for

blockages

abscesses

or

fistulas

The

capsule

endoscopy

consists

of

a

capsule

with

a

small

camera

inside

that

is

swallowed

by

the

individual

The

camera

takes

pictures

every

second

as

it

travels

along

your

GI

tract

The

pictures

are

then

sent

to

a

wireless

computer

belt

worn

by

the

patient

that

can

then

be

taken

into

the

doctor

and

downloaded

for

view

An

outcome

measure

has

been

created

to

track

the

progress

or

lack

of

progress

for

individuals

affected

with

Crohns

disease

called

Crohns

Disease

Activity

Index

CDAI

A

score

below

indicates

a

better

prognosis

than

higher

scores

This

measure

helps

to

track

an

individuals

progress

from

week

to

week

to

determine

if

the

symptoms

are

better

or

worse

This

is

more

of

a

gauge

of

progress

and

not

a

prognosis

tool

Causes

The

initial

cause

of

Crohns

disease

is

unknown

but

was

previously

thought

to

be

caused

by

a

persons

stress

and

diet

Now

it

is

believed

that

factors

such

as

these

are

just

aggravating

components

while

hereditary

and

a

malfunctioning

immune

system

may

be

a

part

of

the

development

of

Crohns

disease

The

immunological

explanation

believes

that

immune

system

attempts

to

fight

off

organisms

while

inflaming

the

GI

tract

In

those

affected

with

Crohns

disease

there

may

be

an

abnormal

response

to

the

bacteria

that

produces

the

large

extent

of

inflammation

The

hereditary

explanation

believes

there

is

a

genetic

mutation

that

Some

research

has

indicated

that

Crohns

disease

is

very

similar

to

a

condition

called

Johnes

disease

that

occurs

in

cattle

The

difference

between

the

two

is

that

Johnes

disease

has

a

known

etiology

which

is

a

bacterium

called

Mycobacterium

avium

subspecies

paratuberculosis

or

MAP

It

is

believed

that

MAPs

presence

in

the

intestines

of

individuals

with

Crohns

disease

could

be

a

common

characteristic

It

is

believed

that

the

MAP

comes

from

the

pasteurized

milk

consumed

from

cows

that

are

infected

with

Johnes

disease

The

pasteurization

does

not

remove

this

organism

and

potentially

is

reasoning

for

the

connection

Individuals

with

Crohns

Systemic

Involvement

Erythema

Nodosum

Crohns

disease

may

have

extraintestinal

symptoms

or

symptoms

that

occur

outside

of

the

intestines

This

can

occur

in

up

to

of

patients

diagnosed

with

Crohns

Disease

These

can

include

any

or

all

of

the

following

Musculoskeletal

Osteoporosis

Arthritis

most

commonly

peripheral

joints

Low

back

pain

Integumentary

Erythema

nodosum

or

painful

red

bumps

on

the

skin

surface

Pyoderma

gangrenosum

or

skin

ulcerations

Extraintestinal

manifestations

of

Crohns

disease

Genitourinary

Kidney

stones

Liver

involvement

Hepatitis

Cirrhosis

Primary

sclerosing

cholangitis

PSC

or

inflammation

of

liver

ducts

Oral

Sores

within

the

mouth

Ophthalamic

Redness

and

itching

of

the

eyes

uveitis

eye

pain

andor

vision

changes

Psychiatric

Emotional

distress

Medical

Management

current

best

evidence

The

mail

goal

of

medical

therapy

is

to

better

regulate

the

patients

immune

system

Additional

goals

for

treatment

in

Crohns

Disease

include

inducing

remission

maintain

remission

improve

the

patients

quality

of

life

and

minimize

toxicity

The

specific

treatment

of

Crohns

Disease

is

dependent

upon

several

factors

including

the

location

severity

of

disease

type

of

disease

complications

of

Crohns

and

the

individuals

response

to

prior

medical

treatments

There

is

a

current

step

up

therapy

that

is

used

for

individuals

with

Crohns

disease

This

approach

involves

Patients

first

treated

with

medications

with

fewer

side

effects

that

may

not

be

as

effective

as

the

stronger

medications

As

the

disease

progresses

the

treatment

becomes

more

intense

involving

medications

that

are

more

powerful

with

potentially

more

toxicity

levels

Traditional

Crohns

treatment

pyramid

It

is

estimated

that

of

individuals

affected

with

Crohns

will

need

surgery

at

some

point

within

their

lives

This

becomes

a

necessary

treatment

plan

when

medications

and

conservative

treatment

has

failed

The

surgery

is

used

either

to

relieve

the

symptoms

or

correct

complications

secondary

to

perforation

abscess

blockage

or

bleeding

into

the

intestines

The

surgery

can

often

times

improve

the

symptoms

but

may

never

treat

or

heal

the

condition

Crohns

disease

often

reoccurs

after

surgery

so

the

benefits

and

complications

should

be

weighed

appropriately

by

the

patient

when

choosing

the

course

of

action

Some

indications

for

surgery

include

Perforation

of

intestines

Fistula

that

can

not

be

medically

managed

Abcess

Uncontrollable

bleeding

from

intestine

Cancer

or

precancer

Toxic

magacolon

a

potentially

lethal

form

of

acute

colitis

Failure

of

medical

therapy

There

are

multiple

surgical

processes

that

can

be

used

for

individuals

with

Crohns

Disease

These

include

Bowel

resection

in

which

the

affected

parts

of

the

intestines

are

removed

and

the

healthier

portions

are

then

reattached

Proctocolectomy

and

Ostomy

where

the

individual

may

need

the

whole

colon

and

rectum

removed

These

patients

will

need

a

stoma

where

the

stool

can

then

exit

the

body

via

pouch

or

bag

Stricturoplasty

is

the

removal

of

the

strictures

or

scarred

narrowings

of

the

intestines

This

will

widen

the

portions

and

will

allow

intestinal

contents

to

pass

through

Physical

Therapy

Management

current

best

evidence

Crohns

disease

is

associated

with

periumbilical

pain

and

referred

low

back

pain

Individuals

may

also

experience

pain

in

the

lower

right

quadrant

and

potential

associated

iliopsoas

abscess

due

to

an

inflammatory

mass

that

may

create

hip

buttock

thigh

or

knee

pain

When

a

patient

presents

to

physical

therapy

with

unknown

origin

of

low

back

sacroiliac

or

hip

pain

it

is

vital

for

the

therapist

to

screen

for

potential

organic

sources

of

the

pain

and

is

even

more

important

in

patients

with

a

history

of

inflammatory

bowel

disease

Since

individuals

with

Crohns

disease

might

also

have

associated

low

bone

mineral

content

and

a

high

potential

for

osteoporosis

it

is

important

for

the

therapist

to

provide

education

on

osteoporosis

and

its

prevention

Hydration

is

very

important

in

patients

with

Crohns

disease

so

the

therapist

should

be

aware

of

signs

of

dehydration

including

headache

dry

lips

brittle

nails

and

hair

dry

hands

and

disorientation

Due

to

the

complexity

of

Crohns

Disease

patients

might

be

predisposed

to

emotional

stress

that

could

exacerbate

the

prior

symptoms

In

knowing

this

the

therapist

has

the

availability

to

accept

the

patients

feelings

validate

the

disease

to

the

patient

as

well

as

prescribing

an

exercise

program

to

better

the

outcome

for

the

patient

These

exercises

have

the

ability

to

boost

the

immune

system

reduce

depression

and

improve

the

body

image

of

the

patient

In

addition

to

providing

this

exercise

program

therapists

can

better

create

coping

mechanisms

as

well

as

techniques

to

manage

the

unexpectedness

of

Crohns

Disease

Dietary

Management

current

best

evidence

An

elemental

diet

that

includes

food

broken

down

into

basic

components

like

amino

acids

vitamins

sugars

etc

can

help

improve

the

symptoms

associated

with

Crohns

disease

There

has

also

been

improvements

found

in

individuals

who

are

placed

on

diets

free

of

dairy

gluten

and

yeast

products

Herbs

have

also

been

studied

to

determine

effectiveness

of

relief

of

symptoms

Additional

ways

to

better

manage

the

symptoms

may

include

changes

to

your

diet

Some

key

points

include

Eating

smaller

meals

and

at

more

frequent

intervals

Reducing

the

amount

of

greasy

fatty

foods

that

may

produce

diarrhea

and

gas

Limit

consumption

of

milk

and

dairy

products

Reduce

the

amount

of

carbohydrates

that

are

poorly

digested

that

may

cause

diarrhea

gas

bloating

cramps

Restrict

the

intake

of

highfiber

foods

such

as

nuts

seeds

corn

and

popcorn

Differential

Diagnosis

The

symptoms

above

are

not

specific

to

Crohns

disease

and

have

potential

to

be

seen

in

other

conditions

Differential

diagnoses

can

include

the

following

Infectious

causes

bacterial

viral

or

parasitic

infection

Ischemia

low

blood

flow

to

the

small

intestine

or

colon

usually

seen

in

older

patients

Medication

nonsteroidal

antiinflammatories

antibiotics

birth

control

pills

Diverticulitis

infection

of

a

diverticulum

outpouching

of

colon

that

can

present

with

left

lower

quadrant

pain

and

fever

Appendicitis

usually

presents

with

right

lower

quadrant

abdominal

pain

and

fever

Irritable

bowel

syndrome

can

cause

severe

diarrhea

and

abdominal

pain

Lactose

intolerance

can

cause

diarrhea

bloating

and

abdominal

pain

Patients

with

Crohns

disease

can

also

have

lactose

intolerance

Celiac

disease

sensitivity

to

gluten

wheat

which

can

cause

diarrhea

and

bloating

Gallstones

Cancer

lymphoma

Diseases

that

affect

other

organs

in

the

abdomen

also

need

to

be

considered

such

as

Endometriosis

pelvic

inflammatory

disease

ectopic

pregnancy

ruptured

ovarian

cyst

Kidney

stones

bladder

or

kidney

infections

Case

Reports

Crohns

Disease

Case

Study

Barlow

S

Case

study

A

year

old

male

with

bone

density

losses

resulting

from

Crohns

disease

Synergy

serial

online

January

Available

from

ProQuest

Nursing

Allied

Health

Source

Accessed

April

Document

ID

Case

studyA

year

old

male

with

bone

density

losses

resulting

from

Crohns

disease

Arumugam

R

Brandt

ML

Jaksic

T

Gilger

M

Crohns

disease

presenting

as

chronic

constipation

A

case

report

Clinical

Pediatrics

serial

online

Available

from

Health

Module

Accessed

April

Document

ID

Crohns

disease

presenting

as

chronic

constipation

A

case

report

Holaday

M

Smith

KE

Robertson

S

Dallas

J

An

atypical

eating

disorder

with

Crohns

disease

in

a

fifteenyearold

male

A

case

study

Adolescence

serial

online

Available

from

Research

Library

Core

Accessed

April

Document

ID

An

atypical

eating

disorder

with

Crohns

disease

in

a

fifteenyearold

male

A

case

study

Ogram

AE

Sobanko

JF

Nigra

TP

Metastatic

cutaneous

Crohns

disease

of

the

face

a

case

report

and

review

of

the

literature

Cutis

Available

from

Pubmed

Acessed

April

Metastatic

cutaneous

Crohns

disease

of

the

face

a

case

report

and

review

of

the

literature

Resources

Crohns

Colitis

Foundation

of

America

Crohns

Colitis

Foundation

of

America

Living

with

Crohns

Disease

Living

with

Crohns

Disease

National

Digestive

Diseases

Information

Clearinghouse

NDDIC

Crohns

Disease

CDAI

Calculator

Crohns

Disease

Activity

Index

Calculator

Recent

Related

Research

from

Pubmed

Failed

to

load

RSS

feed

from

httpeutilsncbinlmnihgoventrezeutilsersscgirss_guid1

There

was

a

problem

during

the

HTTP

request

Internal

Server

Error

Presentations

Crohns

Disease

Pt

of

View

the

presentation

Crohns

Disease

Pt

of

View

the

presentation

References

Crohns

Disease

Answers

What

is

Crohns

Disease

accessed

April

National

Digestive

Diseases

Information

Clearinghouse

NDDIC

Crohns

disease

httpdigestiveniddknihgovddiseasespubscrohns

accessed

March

Living

with

Crohns

Disease

Inside

Crohns

disease

httpswwwlivingwithcrohnsdiseasecomlivingwithcrohnsdiseasecrohns_diseaseinside_crohnshtml

accessed

March

MayoClinic

Crohns

Disease

accessed

March

MedicineNet

Crohns

Disease

accessed

March

Crohns

and

Colitis

Foundation

of

America

CCFA

About

Crohns

Disease

httpccfaorginfoaboutcrohns

accessed

March

Thomas

Craig

A

Frank

discussion

on

Crohns

Disease

Available

at

last

accessed

Cheifetz

Adam

Moss

Alan

Peppercorn

Mark

Crohns

Disease

Knol

Beta

Available

at

httpknolgooglecomkcrohnsdisease

Accessed

April

Crohns

Disease

Introduction

John

Hopkins

Medicine

Available

at

accessed

April

Goodman

CC

Snyder

TEK

Differential

Diagnosis

for

Physical

Therapists

Screening

for

Referral

ed

St

Louis

MO

SaundersElsevier

Goodman

CC

Fuller

KS

Pathophysiology

Implications

for

the

Physical

Therapist

ed

St

Louis

MO

SaundersElsevier

Susman

E

SONIC

gives

boost

to

infliximab

for

Crohns

Medical

Post

serial

online

November

Available

from

Health

Module

Accessed

March

Document

ID

Crohns

Disease

Activity

Index

CDAI

calculator

CDAI

Online

Calculator

ltref

httpwwwibdjohncomcdai

Crohns

Disease

Activity

Index

CDAI

accessed

March

Bone

K

Using

Herbs

and

Diet

to

Beat

Crohns

Disease

Dynamic

Chiropractic

O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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