lice infestation

The Facts of Lice, and How To Treat Them

It’s back-to-school time, and one thing you may not be prepared for is your child coming home from school with a lice infestation. If the very thought is making your skin crawl, our concierge family doctors at MD 2.0 in Jupiter want to assure you that, while head lice are annoying and distasteful, they are not dangerous.

The facts

According to the Centers for Disease Control and Prevention (CDC), an estimated six million to 12 million infestations occur each year in the U.S. among children ages three to 11. And, although creepy, head lice are not known to spread disease.

• Head lice are found worldwide. In this country, infestation with head lice is most common among pre-school children attending child care, elementary schoolchildren, and the household members of infested children.

• Head lice are found in three forms: the egg (also called a “nit”), the nymph, and the adult.

• Personal hygiene or cleanliness in the home or school has nothing to do with getting head lice, the CDC says. Head lice move by crawling; they cannot hop or fly. They are spread by direct contact with the hair of an infested person. Anyone who comes into head-to-head contact with someone who already has head lice is at greatest risk.

• Despite the old myths, it is very uncommon to pick them up by sharing hats, scarves, coats, combs, brushes, towels, headphones, or any other personal items, although it can happen. Dogs, cats, and other pets do not play a role in the spread of head lice.

• Head lice and their nits soon die if they have no human host to feed on; nits need temperatures close to that found on the human scalp in order to hatch.

• The CDC, the American Academy of Pediatrics, and the National Association of School Nurses all take issue with the “no nits” policy of many school systems nationwide, which prevent children with head lice from attending school; these organizations contend that head lice are not a public health risk.

How to spot head lice

Often parents have little warning about an infestation of head lice until they’re combing or styling their child’s hair.

Head lice and their nits are found almost exclusively on the scalp, particularly around and behind the ears and near the neckline at the back of the head. Less commonly, head lice can also be found on the eyelashes or eyebrows.

The nits can range in color from white to brown and may look like dandruff, scabs, or droplets of hairspray. A fully grown, developed adult louse is about the size of a sesame seed, has six legs, and is tan to grayish-white in color.

Other signs and symptoms include:

• a tickling feeling of something moving in the hair;
• itching caused by an allergic reaction to the bites of the creature;
• irritability and difficulty sleeping (head lice are most active in the dark); or,
• sores on the head caused by scratching, which can sometimes become infected with bacteria found on the person’s skin.

How to treat them

The adult female head louse lays her eggs at the base of the hair shaft nearest the scalp, and are firmly attached there. They hold tightly to the hair with hook-like claws at the end of each of their six legs. Nits are so firmly cemented to the hair shaft that they can be difficult to remove even after they hatch and the empty casings remain.

Most home remedies have been found not to work. The most dangerous of these is gasoline, which the CDC emphatically warns against using.

The CDC recommends treatment with either an over-the-counter (OTC) preparation or a prescription medication known as a pediculicide, following the instructions on the label carefully. It also warns against using a combination shampoo/conditioner or conditioner alone prior to treatment, and advises not to re-wash hair for one to two days after treatment.

If a few live lice are still found eight to 12 hours after treatment, but are moving more slowly than before, do not re-treat. If live lice are still evident after this period, talk to us for the best way to proceed. Some head lice have developed a resistance to OTC treatments and may require a prescription product.

Also, if you’re still not sure whether your child has an infestation, we can make a definitive diagnosis; we can also tell you whether the infestation is still active and recommend ways to treat it.

jellyfish stings

How To Treat Jellyfish Stings

Approximately 150 million people worldwide are victims of jellyfish stings each year. And yes, while rare, you can die from their stings.

Because August is prime season for jellyfish, our concierge family doctors at MD 2.0 in Jupiter want to offer you some tips on how to treat this common seaside scourge.

Background

Jellyfish aren’t actually fish, but invertebrates that have been around for more than 500 million years. Also known as “jellies” or “sea jellies,” their long, stinging tentacles are used to catch, immobilize, and digest prey. They exist in every ocean.

The most dangerous type of marine animal is the box jellyfish, whose venom is one of the world’s deadliest. Its sting is so painful that swimmers have been known to have a heart attack or drown before being able to reach the shore. Fortunately for us, they are mainly confined to the Indo-Pacific region and northern Australia.

Scientists can’t prove that jellyfish are more numerous than in years past, but it is clear that they are expanding their territory. Theories as to the reason include climate change, agricultural runoff, and overfishing of their predators, which include tuna, swordfish, and sharks.

How to avoid stings

As with any wild creature, the best way to keep from being attacked is to avoid them.

One way to do that is to ask the lifeguard on duty whether jellyfish are prevalent where you’re planning to swim. Also, look for signs or a purple warning flag posted on the beach. These indicate that either jellyfish or other dangerous sea creatures have been spotted in the water. If so, stay out of the water!

You can also identify them yourself: They look like clear or white plastic bags or balloons, either floating on the water or on the beach.

If you do see them on the beach, do not touch them. Jellyfish tentacles can sting for up to two weeks after they’ve died. Wear some type of protective footwear when walking on the beach, because jellyfish—as well as any detached tentacles—can be difficult to spot.

Don’t depend on a wetsuit or coating your body with petroleum jelly to protect you. These may help, but they are not sting-proof. If you must go into the water, special “stinger suits” for sale at some dive shops may offer some protection.

What not to do

Because jellyfish have plagued humans since the first time we set foot in the ocean, many home remedies have sprung up over the millennia regarding the best way to treat their stings.

Many of them, in fact, will not only not help, but can actually exacerbate a sting. These include applying:

• ice
• fresh water
• baking soda
• urine
• ammonia
• meat tenderizer
• alcohol

All of these can make the sting worse by triggering the release of more venom, as can applying ice or a pressure bandage, or rubbing the site briskly with a towel.

What to do instead

The most recent research finds that the best ways to treat jelly fish stings is to immediately douse the site of the sting with vinegar (always bring some with you to the beach).

Then carefully pluck out any visible tentacles with fine point tweezers. Save these for later identification in case a dose of antivenin is required.

Soak affected skin in hot water between 110 to 113 degrees Fahrenheit for a minimum of 20 minutes; 45 minutes is better. If you don’t have a thermometer available, test the water with your hand. It should be hot but not scalding.

A mild hydrocortisone cream or an oral antihistamine can help relieve itching and swelling.

Finally, clean open sores three times daily, finishing with antibiotic ointment.

When to seek medical treatment

The following situations require immediate emergency care following a jellyfish sting:

a sting on or near the eyes;
• the sting is from a box jellyfish (identifiable by its boxy shape);
• the sting covers more than half an arm or leg; or,
• the victim displays signs of a severe allergic reaction (i.e., trouble breathing or swallowing, coughing, wheezing, chest pain or tightness in the lungs, low blood pressure, weak or rapid pulse, dizziness, confusion, or fainting, or any other unusual symptom).

For less serious reactions, such as severe pain, if the area looks infected or the victim feels unwell, feel free to contact us at any time for advice and/or treatment.

get the best sleep

Get a Good Night’s Sleep On a Hot Summer Night

The concept of air conditioning was first proposed by Florida physician and inventor Dr. John Gorrie in the 1840s. Gorrie believed that cooling was the key to avoiding diseases like malaria and making patients more comfortable, but his rudimentary system for cooling hospital rooms required ice to be shipped to Florida from frozen lakes and streams in the northern United States.

To get around this logistical challenge, Gorrie began experimenting with the concept of artificial cooling. He designed a machine that created ice using a compressor powered by a horse, water, wind-driven sails, or steam, and was granted a patent for it in 1851.

But it wasn’t until 1902 that Willis Carrier perfected the process and introduced it at the St. Louis World’s Fair in 1904.

Nowadays, most Americans, especially here in Florida, have air conditioning in their homes. But if you’re one of those who prefer not to use it, or if your power goes out, or you travel somewhere that lacks it, our concierge family practice doctors at MD 2.0 in Jupiter want to offer some tips on how to get a good night’s sleep in the summer heat.

The only thing worse than having insomnia is having insomnia on a hot summer night. To keep your cool, try the following.

 

Cool the room

According to the National Sleep Foundation (NSF), if you are sleeping and the temperature rises above 75 degrees Fahrenheit, it can wake you up. So be sure to keep the room as cool as possible by:

• closing the blinds and windows during the day to prevent heat buildup during the hottest part of the day;

• using a fan to keep the air circulating and supply “white noise” to block out street sounds;

• placing a bowl of ice or ice packs in front of the fan, which will help chill the air;

• dampening a sheet and hanging it across the window, both to block out light and heat, and to take advantage of cooling evaporation as it dries.

 

Cool the bed

• Use cotton, linen, or bamboo sheets, which provide breathability. Also avoid high-thread-count sheets, which tend to trap body heat. Opt for sheets with thread counts under 400.

• Some pillows—like those stuffed with buckwheat—are specifically made to stay cool. Or you can try putting your pillow inside a plastic bag in the freezer for an hour or so before bedtime. Alternatively, place ice packs inside the pillowcase.

• Remove all extraneous bedding, including blankets and extra pillows, which tends to hold heat.

 

Cool yourself

• Avoid alcohol or heavy meals—especially carb-heavy foods—in the evening. Alcohol dehydrates you as well as making you feel hotter, and large meals produce extra heat in your body during digestion.

• Take a cool bath or shower or a dip in the pool just before bedtime. The evaporation of the moisture on your skin acts to cool you.

• Fill a hot water bottle with water and freeze it, then take it to bed and place it beneath your knees or neck, or on your chest or wrists.

• Be sure to stay hydrated throughout the day, because your body needs water to help keep you cool.

• Remember that warm air rises, so if you have the option, sleep on the lowest floor in the house.

 

What if none of this helps?

If you’re still having trouble getting sufficient shut-eye in the summer, you might try the supplement melatonin. A hormone made by the pineal gland, it has been used successfully by many people for sleep issues. Most people can take it without a problem, but some experience such side effects as dizziness, anxiety, or daytime sleepiness. It is also contraindicated for those taking several medicines (blood thinners, birth control pills, and immunosuppressants, among others). So check with us first.

In extreme cases, let us know. If necessary, we can prescribe sleep medications for a few nights. These will help you sleep but can also induce troublesome side effects. Ideally, they should be used only for short periods of time in conjunction with cognitive behavioral therapy. We can also recommend various types of sleep studies that might help pinpoint more serious issues such as sleep apnea.

temperatures

How To Stay Safe in Scorching Temperatures

We’re not even halfway through summer yet, and we’ve already seen record-high temperatures here in south Florida, which can bring dangerous health impacts. The two most serious are heat exhaustion and heat stroke. Our concierge doctors in Jupiter want to remind you of ways you can keep your family safe as temperatures soar.

 

What to watch for

The Red Cross warns that some people are more at risk of developing a heat-related illness. These include: people aged 65 and older, who are less likely to sense and respond to changes in temperature; people with chronic medical conditions, who may be taking medication that can worsen the impact of extreme heat; infants and young children; and, outdoor workers and athletes, who may be more likely to become dehydrated, particularly in extreme heat.

When keeping an eye on the weather forecast, here’s what the various warning terms mean:

  • Excessive Heat Watch: Conditions are favorable for an excessive heat event to meet or exceed local Excessive Heat Warning criteria in the next 24 to 72 hours.
  • Heat Advisory: Heat Index values are forecasted to meet locally defined advisory criteria for the next one-to-two days
  • Excessive Heat Warning: Heat Index values are forecasted to meet or exceed locally defined warning criteria for at least two days.

 

Consequences of extreme heat exposure

Such excessive heat as we’ve been experiencing recently can lead to life-threating heat exhaustion and heat stroke. Most people have heard these terms, but may not fully understand what they mean. We want to explain the differences between the two, because the treatments for each are different.

Heat exhaustion

The Centers for Disease Control and Prevention (CDC) says muscle cramping might be the first sign of heat-related illness. It lists the warning signs of heat exhaustion as:

  • heavy sweating
  • weakness
  • cold, pale, clammy skin
  • fast, weak pulse
  • nausea or vomiting

If you or someone you’re with experiences these symptoms, you should move to a cooler location, lie down and loosen your clothing, apply cool, wet cloths to as much of your body as possible, and sip water. If you have vomited and it continues, seek medical attention immediately.

 

Heat stroke

The signs of heat stroke are:

  • high body temperature (above 103 degrees)
  • hot, red, dry, or moist skin
  • rapid and strong pulse
  • possible unconsciousness.

 

This is a medical emergency. Call 911 immediately. While waiting for the ambulance, move the person to a cooler environment, and try to reduce the person’s body temperature with cool cloths, or if possible, a cool bath. Do NOT try to give fluids.

 

Staying safe in the heat

Here are steps you can take to avoid experiencing either of these serious conditions.

  • Limit outdoor activity. The sun is hottest from 11 a.m. (D.S.T.) to 3 p.m., so try to stay indoors, or at least in shaded areas, during those times. If you must be outdoors, take frequent breaks, preferably in air-conditioned environments, and, if possible, take cool showers or baths to cool down.
  • Dress appropriately. Wear loose, lightweight, light-colored clothing. Wear a hat with a wide brim.
  • Drink water frequently, from two to four cups of water every hour. Don’t wait until you’re thirsty to drink, because by then you’re already started to dehydrate. Monitor urine color: If your urine is dark, you’re not drinking enough water. Urine should be light yellow or clear. And avoid alcoholic drinks, which can not only impair judgment regarding time spent in the heat but also dehydrate you.
  • Never leave children or pets in cars for any amount of time. Also check on animals frequently, ensuring they have access to shade and plenty of cool water.
  • Check on family, friends, and neighbors who do not have air conditioning, who spend much of their time alone, or who are more likely to be affected by the heat.

 

Keep these safety tips in mind as you enjoy the outdoor fun in summer, and check with us if you feel more bothered than usual by the heat. This could be a sign of a medical condition that warrants investigation.

primary care jupiter fl

The Danger In Ultra-Processed Foods

Sausages. Mayonnaise. Pizza. Potato chips. Bacon. Even whiskey, gin, and rum. All these foods and many more share two common traits: All were “processed” into their familiar form by humans, and all have been implicated in an increased risk for early death.

Our concierge primary doctors in Jupiter want to make you aware of the latest studies on the dangers of consuming these foods as the primary part of your diet.

The difference in these studies is that they don’t just address so-called “junk” foods like cookies and fast foods, but many of the items that all of us have in our kitchens and rely on as staples of our diet.

 

The studies

Published last month in the journal BMJ, one study followed more than 100,000 adults in France for five years. They found that those who ate the most processed foods were 23 percent more likely to experience a heart condition or stroke than those who consumed the lowest amounts.

The second study, also published in BMJ, tracked 20,000 Spanish adults over 20 years. Those who ate the most processed foods were 62 percent more likely to die during the study period than those who ate the lowest.

“High consumption” was defined as four or more servings of ultra-processed foods daily, with health risks rising 18 percent for each additional daily serving.

While researchers cautioned that correlation doesn’t prove causation, both studies controlled for such other possible risk factors as lifestyle, demographics, physical activity, weight, and overall health in drawing their conclusions. They also noted that their findings correspond to other earlier studies showing an association between highly processed foods and higher risks of obesity, high blood pressure, high cholesterol, and some cancers.

 

The cause

Researchers classified foods into roughly three categories:

  • “unprocessed or minimally processed” foods included fruits, vegetables, milk, eggs, legumes, meats, poultry, fish and seafood, yogurt, white rice and pasta, and natural juices;
  • “processed” foods included cheeses, breads, beer, wine, ham, and bacon;
  • “ultra-processed” foods included potato chips, pizza, cookies, chorizo, sausages, mayonnaise, chocolates and candies, artificially sweetened beverages, and whisky, gin, and rum.

 

They also created a separate category called “processed ingredients,” which included salt, sugar, honey, olive oil, butter, and lard.

The problem seems to stem from the processing, which changes foods from their natural state into something that will last longer on our shelves. These tend to be high in poor-quality fats, additional sugar, salt, and preservative chemicals, and low in vitamins and fiber. The common factor can be summed up in the phrase “convenience foods”; that is, foods that are quick and easy to prepare at home.

Dr. Andrew Freeman, a cardiologist who was not involved in the study, told CBS News, “I like to say: The longer the shelf life, the shorter your life.” Freeman directs cardiovascular prevention and wellness at National Jewish Health in Denver.

 

The solution

The takeaway in both these studies, as well as preceding ones is, the closer to a food’s natural state that you can eat, the better the effect on your overall health.

Freeman told CBS News that the most heart-healthy diet is one rich in whole foods, particularly plant-based foods like fruits and vegetables, legumes, whole grains, and nuts. He added that, for affordability and convenience, fresh-frozen vegetables were perfectly acceptable.

Simply switching from sodas to water is another good choice, as well as substituting fresh fruit for sweets. Options for quick snack foods include such treats as homemade sweet potato chips, and oven-“fried” vegetables like cauliflower and broccoli, as well as celery and carrot sticks cut up and stored in water.

If you have any questions about a healthy eating plan, please let us know. We can help you substitute a healthy diet for foods likely to negatively impact your health.

heat summer

Beware the Danger of High Temperatures

May 30th is Heat Safety Awareness Day, so our concierge family doctors at MD 2.0 in Jupiter want to take this opportunity to acquaint you with this important health concern. The fact is, heat is a killer, and we here in south Florida need to pay particular attention to the danger high temperatures can present.

Heat exhaustion, heat stroke, and dehydration are some of the leading weather-related killers. For example:

  • A 1980 heat wave killed more than 1,250 people.
  • In 1995, a heat wave in Chicago took more than 700 people (the deadliest weather event in Chicago history).
  • In August 2003, a record heat wave in Europe claimed an estimated 50,000 lives.

 

Some people are more susceptible to negative effects from the heat. These include:

  • people 65 and older, who are less likely to sense and respond to changes in temperature;
  • people with chronic medical conditions, who may be taking medication that can worsen the impact of extreme heat;
  • infants and young children; and,
  • outdoor workers and athletes, who may be more likely to become dehydrated, particularly in extreme heat.

It’s vital to know the difference between heat exhaustion and heat stroke, the warning signs for each, and what to do in the event you or someone else experiences them. You should also know how to avoid these serious conditions.

 

Heat exhaustion

The Centers for Disease Control and Prevention (CDC) says muscle cramping might be the first sign of heat-related illness. It lists the warning signs of heat exhaustion as:

  • heavy sweating
  • weakness
  • cold, pale, clammy skin
  • fast, weak pulse
  • nausea or vomiting

If you or someone you’re with experiences these symptoms, you should move to a cooler location, lie down and loosen your clothing, apply cool, wet cloths to as much of your body as possible, and sip water. If you have vomited and it continues, seek medical attention immediately.

 

Heat stroke

The signs of heat stroke are:

  • high body temperature (above 103 degrees)
  • hot, red, dry, or moist skin
  • rapid and strong pulse
  • possible unconsciousness.

This is a medical emergency. Call 911 immediately. While waiting for the ambulance, move the person to a cooler environment, and try to reduce the person’s body temperature with cool cloths, or if possible, a cool bath. Do NOT try to give fluids.

 

Stay safe in the heat

Following are steps you can take to avoid experiencing either of these potentially deadly conditions.

Limit outdoor activity. The sun is hottest from 11 a.m. (D.S.T.) to 3 p.m., so try to stay indoors, or at least in shaded areas, during those times. If you must be outdoors, take frequent breaks, preferably in air-conditioned environments, and, if possible, take cool showers or baths to cool down.

Dress appropriately. Wear loose, lightweight, light-colored clothing. Wear a hat with wide brim.

Stay hydrated. Drink water frequently, from two to four cups of water every hour. Don’t wait until you’re thirsty to drink, because by then you’ve already started to dehydrate. Monitor urine color: If your urine is dark, you’re not drinking enough water. Urine should be light yellow or clear. And avoid alcoholic drinks, which can not only impair judgment regarding time spent in the heat but also dehydrate you.

Check the car. Despite all the awareness and warnings in the last few years, more children—51—died in hot cars in 2018 than any year on record. It happens to the most conscientious parents who simply have too many things on their minds. When transporting children, place something necessary—a purse or briefcase—next to the child. Keep car doors locked and never allow children to play in a car. And countless numbers of pets die when owners leave them alone in a hot car “just for a couple minutes.” Never leave pets alone in a closed car, even for a few minutes.

 

Check with us to see whether any medical conditions might make you more susceptible to heat.

asthma doctor

5 Myths About Asthma

If you don’t have asthma, chances are you know someone who does. That’s because an estimated 26 million Americans, or 8.3 percent of the population, have this sometimes deadly disease. Because May is Asthma and Allergy Awareness Month, our concierge primary care doctors at MD 2.0 in Jupiter want to take a closer look at asthma and the common misunderstandings surrounding it.

Read more

Take Sleep Seriously – World Sleep Day

Our concierge family practice doctors at MD 2.0 in Jupiter know that sleep is often the best medicine for any illness or injury. Conversely, lack of adequate sleep can not only interfere with recovery, but it can also trigger a host of diseases.

This Friday, March 15th, is World Sleep Day, designed to highlight the critical role sleep plays in maintaining health. World Sleep Day is hosted by the non-profit World Sleep Society (WSS) and was created because “Time and time again, sleep medicine professionals and researchers came up against the belief that sleep was not important enough in personal health and well-being to be a priority,” the WSS explains. It added that “society’s 24/7 flow” exacerbates what some medical professionals and researchers have called a national health crisis.

Several causes

The health issues associated with lack of sufficient sleep are myriad: obesity, type 2 diabetes, cancer, cardiovascular disease, dementia, depression . . . even a shorter lifespan overall.

How does poor sleep impact health? In short, the time we spend sleeping is time the body uses to repair itself, which it can’t do when we’re eating, working, playing, active, or stressed. From a medical standpoint, during sleep the immune system releases cytokines, which are a type of protein the body needs not only to sleep, but to fight the effects of stress, illness, or injury.

Research has shown that lack of sleep also reduces the number of certain antibodies used to fight infections. In addition, Japanese researchers found that losing six hours of sleep over a single night resulted in significantly elevated blood glucose and triglyceride levels, warning signs for increased risk of heart disease and diabetes.

Effects of poor sleep

According to the National Institutes of Health (NIH), here are some of the effects of insufficient sleep on adults, as well as children and teens.

Brain and emotions

Sleep helps form new pathways to enhance learning, memory, problem-solving, decision-making, and creativity. Sleep deficiency has been linked to anxiety, depression, suicide, risky behavior, and inability to cope with change. The loss of even a single night of sleep has been shown to increase formation of the proteins associated with Alzheimer’s disease. In addition, children who are sleep deficient may feel angry and impulsive, have difficulty paying attention, and get lower grades.

Physical health

Ongoing sleep deficiency is linked to an increased risk of heart disease, kidney disease, high blood pressure, diabetes, and stroke in adults. It also increases the risk of obesity in all age groups. In addition, insufficient sleep hinders the body’s ability to repair itself, including hampering the immune system. Sleep also supports healthy growth and development in children and teens, helping to boost muscle mass.

Performance and Safety

A loss of even one to two hours of sleep a night over several nights has the same effect as if you haven’t slept at all for a day or two. Sleep deficiency not only interferes with the ability to drive a car, it can affect people in all lines of work, including health care workers, pilots, students, lawyers, mechanics, and assembly-line workers. So insufficient sleep is not only affecting those who experience it, but can impact others, as well. The NIH estimates that driver sleepiness is a factor in approximately 100,000 auto accidents each year, resulting in about 1,500 deaths.

What Is Healthy Sleep?

The Centers for Disease Control and Prevention (CDC) estimates that up to a third of Americans do not get the recommended seven hours of sleep a night. If you’re sleeping well, you:

  • will fall asleep within 15 to 20 minutes of going to bed;
  • will sleep between seven and nine hours per night (longer than that is also unhealthy);
  • will remain asleep for the entire night;
  • will awaken feeling refreshed, and will remain alert and productive during the day; and,
  • will not snore, gasp for breath, or feel restless while you’re trying to sleep.

If you typically skimp on sleep during the week and try to catch up by sleeping in on the weekends, a new study published last month in the journal Current Biology has some bad news for you. Researchers found that so-called “recovery sleep” has no benefit to the body in the long term. As reported in The Washington Post, participants in a sleep laboratory who we limited to five hours of sleep on weekdays then allowed to “binge sleep” on weekends still gained nearly three pounds over two weeks and also experienced metabolic disruption that would increase the risk of diabetes later in life.

To help you obtain the proper amount of sleep, you should:

  • go to bed at the same time every night
  • don’t try to sleep on a full stomach
  • refrain from using caffeine or alcohol after dinner
  • turn off “blue-light” devices (TVs, computers, smartphones) at least an hour before bedtime; and,
  • restrict activity in the bed to sex and sleep (i.e., no working, reading, TV, etc.)

Because healthy sleep is so crucial to your health, please let us know if you have any difficulty falling asleep or staying asleep so we can help uncover the cause and provide solutions.

1 2 3 8