( August 31, 2010 ) - Migraines With Aura May Raise Stroke Risk

By Kathleen Doheny
WebMD Health News

Reviewed By Laura J. Martin, MD

Aug. 24, 2010 — Evidence is accumulating that migraines with aura — a transient visual or sensory disturbance, such as light flashes or zigzag patterns– may increase the risk of heart disease and stroke.

Researchers have also found that migraine with aura seems to boost the risk of earlier death from any cause, including cardiovascular disease, compared to those who don’t have the condition, and that women with migraine with aura may be at increased risk for an additional type of stroke called hemorrhagic stroke.

The two new studies, both published in BMJ, add to the evidence of a suspected migraine-disease link. But both research teams say the findings should not alarm those who suffer migraine with aura because the risk is still low.

“We don’t want to scare people at all,” researcher Tobias Kurth, MD, ScD, director of research at INSERM at the Hospital del la Pitie Salpetriere in Paris, tells WebMD. The vast majority of migraine sufferers, he says, will not get a stroke because of their migraines.

More than 29 million Americans suffer from migraines, according to the National Headache Foundation. About 20% of middle-age women have migraines, the researchers say, and up to a third have the aura.

Migraines and Stroke Risk: The New Studies
In one study, researchers looked at nearly 19,000 men and women born between 1907 and 1935 who were enrolled in the Reykjavik (Iceland) Study, set up to study heart disease.

The researchers followed the men and women for 26 years, looking at death from all causes, including heart disease. They had information on which men and women had migraines, with or without aura, and also non-migraine headaches.

They found those with migraine with aura were about 21% more likely to die during the follow-up than those without the condition, and 27% more likely to die from cardiovascular disease compared to those with no headache.

Women with migraine with aura were 19% more likely to die from non-cardiovascular disease than those without.

The absolute risk, however, is low, says researcher Larus Gudmundsson, a doctoral student at the University of Iceland, Reykjavik. “‘In people with migraine with aura, compared to those without headache, the excess absolute 10-year risk of cardiovascular disease mortality (including heart disease and stroke) at age 50 was low: 1.1% for men and 0.1% for women.

“From that we can calculate that due to migraine with aura, 11 extra men per 10,000 persons per year will die from cardiovascular disease and one extra woman per 10,000 persons per year.”

In Kurth’s study, he looked at the nearly 28,000 women participating in the U.S.-based Women’s Health Study, set up to look at the benefits and risks of low-dose aspirin and vitamin E in preventing cardiovascular disease and cancer among healthy women.

Kurth evaluated the information the women had provided about their history of migraine and followed them to see when hemorrhagic stroke might have occurred. Hemorrhagic strokes involve a ruptured blood vessel, while ischemic strokes, linked in other research with migraines, are due to a clot within the blood vessel.

In his 2005 study of the same study participants, Kurth tells WebMD, “We looked at hemorrhagic stroke and didn’t find a significant association [with migraine with aura]. Now, with longer follow-up, we see the significant association.”

In his study, women with active migraine with aura — but not migraine without aura — had more than a twofold increased risk of hemorrhagic stroke compared with those with no migraine history. To put it in perspective, he says: ‘We are talking four additional events for 10,000 women with migraine with aura per year.”

What is it about the aura? It’s not clear, Kurth says. “There are probably several mechanisms, including genetic susceptibility, plus potential involvement of the arteries throughout the body plus involvement of other cardiovascular risk factors.”

Gudmundsson reports getting a travel grant from the Pharmaceutical Society of Iceland Science Fund, while his co-authors report serving on boards for pharmaceutical companies and receiving travel grants from the American Headache Society. Kurth has received research funds from Merck and the Migraine Research Foundation and honoraria from other drug companies for educational lectures.

Second Opinion
The new research “confirms a suspicion that many of us have had for many years, that migraine with aura is a significant risk factor for stroke,” says Patrick Lyden, MD, chair of the department of neurology and the Carmen and Louis Warschaw Chair in Neurology, Cedars-Sinai Medical Center, Los Angeles, who reviewed the research for WebMD.

The Kurth research, he says, suggests the stroke risk may extend to the hemorrhagic type.

He, too, puts the new research findings in perspective. “This does not mean if you have a migraine you should run into the ER for a heart attack workup or a stroke workup,” Lyden tells WebMD.

It does mean those with migraine should be aware of the potential increased risk, he says. “If you have migraine, you need to talk to your doctor and control your [other] risk factors [for stroke],” Lyden says. That includes controlling high cholesterol and high blood pressure.

Lyden suggests asking your doctor to review your medications for migraine, to be sure they are the best for you.

SOURCES: Patrick D. Lyden, MD, chair of neurology; Carmen and Louis Warschaw Chair in Neurology, Cedars-Sinai Medical Center, Los Angeles.

Larus Gudmundsson, doctoral student, pharmacology and toxicology, University of Iceland, Reykjavik, Iceland.

Tobias Kurth, MD, ScD, director of research, INSERM, Paris; adjunct associate professor of epidemiology, Brigham and Women’s Hospital, Boston.

Gudmundsson, L. BMJ online, Aug. 25, 2010.

Kurth, T. BMJ online, Aug. 25, 2010.

Berger, K. BMJ online, Aug. 25, 2010.

©2010 WebMD, LLC. All Rights Reserved.

Article URL - http://bit.ly/a75CMR

( August 31, 2010 ) - Medicare Expands Coverage To Help Smokers Quit

By RICARDO ALONSO-ZALDIVAR
The Associated Press
Saturday, August 28, 2010; 4:07 PM

WASHINGTON — They’ve lived with the health warnings about smoking for much of their lives and doubtless seen the ill effects on friends, relatives and even themselves, yet about 4.5 million older people in the U.S. keep on lighting up. Medicare is finally catching up to most private insurers by providing counseling for anyone on the program who’s trying to kick the habit.

Dr. Barry Straube, Medicare’s chief medical officer, says it’s never too late to quit, even for lifelong smokers.

“The elderly can respond to smoking cessation counseling even if they have been smoking for 30 years or more,” says Straube. “We do know we can see a reduction in the death rate and complications from smoking-related illnesses.” Not only cancer, heart disease and lung problems, which can kill, but also gastric reflux, osteoporosis and other ailments that undermine quality of life.

Smoking-related illnesses cost Medicare tens of billions a year. Straube cites a two-decade estimate of $800 billion, from 1995 through 2015.

Medicare already covers drugs used to help smokers quit, as well as counseling for those who have developed a smoking-related illness. But starting immediately, the program will expand the benefit to cover up to eight counseling sessions a year for people who want to quit.

Next year, such counseling will be free, under a provision in President Barack Obama’s health care law that eliminates co-payments for preventive services.

Older smokers often don’t get as much attention from doctors as do younger ones. “They just figure, ‘Well, it’s too late,’” said Straube, that the damage is already done. That may start to change now.

About one in 10 seniors smoke, compared with one in five people among the U.S. population as a whole. It turns out that smokers age 65 and older present a medical paradox.

Many started when it was fashionable to light up. They are more likely than younger smokers to be seriously hooked on nicotine and less likely to attempt quitting. But research shows that their odds of success are greater if they do try to give up the habit.

Older smokers who receive counseling are significantly more likely to quit than those who only get standard medical care. One study of elderly heart attack patients found that those who got counseling to help quit smoking were more likely to be alive five years later.

It’s unclear why older people who try to quit have better luck than younger smokers.

Some experts think it’s because older smokers are more motivated, perhaps from having seen a loved one die of cancer or heart disease, or by recognizing how the cigarette habit has left its mark in their own bodies, anything from wrinklier skin to shortness of breath.

Straube has his own theory: “They’re under less stress,” he said. “They are not working anymore, and they have more time.”

Medicare’s new smoking cessation benefit will also be available to younger people who are covered by the program because of a disability. About 1 million of them are smokers.

Article URL - http://bit.ly/dvnOSP

( August 30, 2010 ) - Type 2 Diabetes May Have Link to Alzheimer’s

( August 30, 2010 ) - Study Shows Insulin Resistance May Raise Risk of Brain Plaques Associated With Alzheimer’s

By Denise Mann
WebMD Health News

Reviewed By Laura J. Martin, MD

Aug. 25, 2010 — People with insulin resistance or type 2 diabetes may be at increased risk for developing telltale brain plaques that are closely linked to Alzheimer’s disease, a study shows.

The new findings, which appear in the Aug. 25 issue of Neurology, may give more evidence of the connection between diabetes and Alzheimer’s disease.

In insulin resistance, the hormone insulin, produced by the pancreas, becomes less effective in lowering blood sugar. People with insulin resistance are at risk for developing type 2 diabetes.

“Type 2 diabetes and Alzheimer’s disease are two epidemics growing at alarming levels around the world,” says study researcher Kensuke Sasaki, MD, PhD, with Kyushu University in Fukuoka, Japan, in a news release. “With the rising obesity rates and the fact that obesity is related to the rise in type 2 diabetes, these results are very concerning.”

Checking for Signs of Alzheimer’s
In the new study, 135 Japanese men and women underwent diabetes screening tests in 1988 and were followed for up to 15 years for signs of Alzheimer’s disease. Overall, 16% showed signs of clinical Alzheimer’s disease before they died; 65% of people in the study also showed evidence of plaques in their autopsied brains after death.

People who had abnormal results on their blood sugar tests were more likely to have plaques in their brain, the study shows. This relationship was more pronounced among people who also had a form of the ApoE gene that’s been linked to a higher risk of developing Alzheimer’s disease.

There was no link between insulin resistance and type 2 diabetes and risk for developing brain tangles, another brain abnormality seen with Alzheimer’s disease, the study shows.

“Further studies are needed to determine if insulin resistance is a cause of the development of these plaques,” Sasaki says. If it is,”it’s possible that by controlling or preventing diabetes, we might also be helping to prevent Alzheimer’s disease.”

The new study “supports the hypothesis that insulin resistance and type 2 diabetes is causally related to a higher risk of dementia including Alzheimer’s disease,” writes Jose A. Luchsinger, MD, MPH, in an accompanying editorial.

More studies are needed to figure out precisely how the conditions are connected, he writes.

“This is urgent considering that over half of the U.S. population in the age group most at risk for cognitive impairment has prediabetes or type 2 diabetes,” he writes.

Some current trials are looking at how available insulin-sensitizing drugs affect cognitive impairment.

SOURCES: Matsuzaki, T. Neurology, Aug. 31, 2010; vol 75: pp 764-770.

Luchsinger, J.A. Neurology, Aug. 31, 2010; vol 75: pp 758-759.

News release, American Academy of Neurology.

©2010 WebMD, LLC. All Rights Reserved.

Article URL - http://www.medicinenet.com/script/main/art.asp?articlekey=119203

( August 30, 2010 ) - Accessible Home Health Care Of South Miami Dade Is Certified As A Provider By The Center For Medicare And Medicaid Services

Coral Springs, FL (August 25, 2010) - Accessible Home Health Care, a division of Valiant Healthcare Inc. (VHCI), announced today the Medicare and Medicaid certification of its South Miami Dade County Florida location by the federal Department of Health and Human Services (CMS).“

Mirella Salem, President of Accessible, said, “It is a tremendous accomplishment achieving our total franchise business model. South Miami-Dade is now a full service, medical/non-medical, private pay, insurance, long-term insurance, and Medicare/Medicaid home health care provider. It is our corporate objective to be on the cutting edge of meeting the needs in all sectors of the growing home health care industry.” Ms. Salem further stated, “If you are going to be in the home health care business, you should be in a position to maximize all revenue sources and take care of all of the needs of the patients.”

About the company: Accessible Home Health Care provides high quality care to all age groups, from newborns to seniors, in the comfort of their own homes. We provide medical and non-medical services through our staff of screened, highly qualified, and compassionate caregivers which includes aides, nurses, and therapists. Being a full service provider allows us to provide levels of service properly matching the changing needs and desires of our patients and loved ones. For more information about our company and our franchise opportunities, please visit us at www.accessiblehhc.com or call John Rowsell at 954-341-5600.

( August 26, 2010 ) - Slowed Reflexes in Aging Could Be Due to Brain Changes

TUESDAY, Aug. 24 (HealthDay News) — Breakdowns in brain connections may be the reason why your physical response times slow as you age, a new study has found.

The decline occurs in an area of the brain called the corpus callosum, which helps regulate “cross-talk” between the two sides of the brain, said lead author Rachael Seidler, an associate professor in the School of Kinesiology and psychology department at the University of Michigan.

Normally, one side of the brain controls movement on the opposite side of the body. For example, the left side of the brain controls movement on the right side of the body.

But when regulation of cross-talk between the two sides of the brain starts to break down with age, both sides of the brain talk simultaneously while one side of the body tries to move, resulting in slower response times, the researchers explained.

Seidler and colleagues studied the response times and brain activity of adults aged 65 to 75 as they used computer joysticks, and compared them to a group of 20-25 year olds.

They also used a functional MRI to image the blood-oxygen levels in different parts of the brain, as a measurement of brain activity in the older group.

“The more they recruited the other side of the brain, the slower they responded,” Seidler said in a University of Michigan news release.

The study was published online recently in the journal Frontiers in Systems Neuroscience.

– Robert Preidt

Article URL: http://www.medicinenet.com/script/main/art.asp?articlekey=119150

( August 20, 2010 ) - Deaths From Heart Attack Rise With Delays in Care

TUESDAY, Aug. 17 (HealthDay News) — Deaths from a severe type of heart attack rise by about 10% for every hour of delay between the time the patient calls for an ambulance and the time that patient is treated in the hospital, a new European study finds.

Researchers in Denmark analyzed data from Danish medical registries on 6,209 patients taken by ambulance to three major hospitals for an ST-segment elevation myocardial infarction (STEMI), a particularly serious type of heart attack caused by a blocked artery, between January 2002 and December 2008.

In patients with such heart attacks, the longer the artery is blocked, the more heart muscle that is damaged and the greater the chances of death, explained study author Dr. Christian Juhl Terkelsen, a cardiologist at Aarhus University Hospital in Denmark.

During a median follow-up period of 3.5 years, about 15.4% of patients died in the group that waited less than an hour from the time they called for an ambulance to the time they were being treated at the hospital, compared to 23.3% of those treated in up to two hours; 28.1% of those treated within just over two to three hours; and 30.8% of those treated within three to four hours.

Previous research has focused on delays in such care (called door-to-balloon delay, since the preferred treatment is known informally as balloon angioplasty), the researchers noted. But this study is the first to document that delays from the moment the patient calls for an ambulance increases the risk of death, Terkelsen said.

“Our message is we should focus on all health-care system delays, which often starts with the call for the ambulance,” Terkelsen said.

The study is published in the Aug. 18 issue of the Journal of the American Medical Association.

The three hospitals included in the study were high-volume centers that offer primary percutaneous coronary intervention (PCI), also known as balloon angioplasty, in which a catheter is threaded into the artery and a balloon at the end is inflated to help widen it. Usually, when the tube is removed, a stent, or wire mesh structure, is left behind to prevent the artery from narrowing again.

All the patients were treated within 12 hours by PCI, and 2% of them were pretreated with clot-busting drugs to restore blood flow.

In Denmark, PCI became the recommended treatment for STEMI heart attacks in 2003, according to the study. Research shows that PCI is more effective than older treatments, such as clot-dissolving medications, Terkelsen said.

But in the United States, not every hospital is equipped to do PCI, said Dr. Christopher Granger, director of the cardiac care unit at Duke University Medical Center.

Even hospitals that do offer PCI don’t necessarily have the medical staff on hand 24-7 to get it done quickly, Granger said.

That makes it critical to get to the right sort of hospital — one that has a “catheterization lab” in which staff can be activated quickly when a STEMI patient is on route, Granger said.

A key step in activating the “cath lab” is making sure that paramedics can diagnosis the heart attack en route, Granger said. To do this, ambulances need to be equipped with 12-lead electrocardiogram (ECG) machines, which can diagnosis the telltale signs of STEMI.

While all ambulances in Denmark have 12-lead electrocardiogram, the same can’t be said of all U.S. ambulances, Granger said.

Even when STEMI is diagnosed by first responders, it is not ideal to rush a patient to a hospital that doesn’t offer PCI.

“The time from the 911 call until the artery is opened is a very powerful, independent predictor of long-term survival,” Granger said. “The faster you get to a hospital that has the ability to PCI, the better your chances of living.”

About 400,000 people in the United States have a STEMI heart attack annually, according to the American Heart Association, which is working with hospitals and emergency medical services to develop more coordinated, regional systems of care for heart attacks. Called Mission:Lifeline, the program calls for a new approach to improve outcomes, including training first responders to use 12-lead electrocardiograms and protocols that instruct responders to consider bypassing hospitals that don’t offer PCI for those able to perform PCI quickly, even if the hospital is further away.

“What’s clear is you should do pre-hospital diagnosis. You should reroute patients to hospitals that can provide PCI quickly, within 30 minutes,” Juhl said. “And when patients arrive, they should not go to emergency room, the intensive care unit or the coronary care area. They should go directly to the cath lab.”

Patients also need to be aware they should call 911 if they are experiencing the signs of a heart attack, which can include squeezing chest pain, shortness of breath and fatigue, Granger said.

Article URL - http://www.medicinenet.com/script/main/art.asp?articlekey=118981

( August 19, 2009 ) - Palliative Care Improves Lung Cancer Patients’ Quality Of Life And Helps Them Live Longer

THURSDAY, Aug 19. (www.medicalnewstoday.com) - Patients with advanced lung cancer who received integrated palliative care early on during treatment had a better quality of life and survived for two months longer compared to patients receiving standard care only, according to a study published in the August 19th issue of NEJM (New England Journal of Medicine).

Investigators from Massachusetts General Hospital (MGH) explained that metastatic non-small-cell lung cancer (NSCLC) is hard to treat - patients are not generally expected to survive for more than 12 months.

Lead author, Jennifer Temel, MD, of the MGH Cancer Center,said:

“For me as an oncologist, results like this are incredibly exciting. We showed that adding the services of a care team focused on quality of life and not altering patients’ cancer treatments could both enhance and extend life in patients with an incurable cancer diagnosis. These findings are very promising, and we are already taking steps to examine the impact of early palliative care in other situations.”

Vicki Jackson, MD, MPH, acting chief of the MGH Palliative Care Service and a co-author of the study, said:

“One of the most common misconceptions about palliative care is that it indicates treatment has failed — that it means giving up. In this study the addition of palliative care early in the course of illness extended the survival of patients with incurable lung cancer. These patients not only lived longer, they also experienced improved quality of life and were better able to enjoy the time they had remaining.”

Palliative care consists of a team of specially trained personnel, including doctors, nurses, social workers and chaplains - their aim is to help patients cope with the psychological and spiritual aspects of their disease. Palliative care also focuses on managing pain, nausea, shortness of breath and other symptoms.

Traditionally, palliative care kicks in later on, when the disease is well advanced and the patient is hospitalized and symptoms have become debilitating.

In a study in 2007, an MGH team found that it was feasible to combine palliative care with the treatment of patients newly diagnosed with metastatic NSCLC, America’s leading cause of death. This latest study aimed to evaluate the impact on patients’ lives by integrating palliative care early on.

All the study participants had metastatic NSCLC. They were randomly selected to either receive standard oncology care or early palliative care combined with standard care (palliative care group). There were 151 patients - 77 assigned to the palliative care group, and 74 to standard care. The study lasted three years.

Patients in the palliative care group met members of the palliative care team within three weeks of study enrollment, and then at least once a month throughout the course of their illness. Extra sessions could be arranged when needed.

Article source - http://www.medicalnewstoday.com/articles/198249.php

( August 19, 2010 ) - Early Care Urged for Patients With Trouble Swallowing

TUESDAY, Aug. 17 (HealthDay News) — Difficulty swallowing (also called dysphagia) is associated with poor outcomes in hospital patients, researchers warn.

“The consequences of dysphagia can be profound. Although it is appreciated that nutrition, hydration, quality-of-life issues and social isolation may arise, aspiration (especially if not immediately recognized) may be the pivotal factor that precipitates a significant decline in a patient’s outcome,” wrote Dr. Kenneth W. Altman, of the Mount Sinai School of Medicine in New York City, and colleagues. An example of aspiration is when food gets into the airway.

In their study, the researchers analyzed data from nearly 272,000 dysphagia-related hospital admissions that were recorded in the 2005-2006 National Hospital Discharge Survey.

“Dysphagia was most commonly associated with fluid or electrolyte disorder, esophageal disease, stroke, aspiration pneumonia, urinary tract infection and congestive heart failure,” the researchers wrote.

The investigators also found that being over 75 years of age was linked to a doubled risk of dysphagia.

The median number of days spent in the hospital was 40% longer for patients with dysphagia than for other patients — 4.04 days versus 2.4 days. Among patients undergoing rehabilitation, the risk of death was 13 times higher for those with dysphagia, which also increased the risk of death among patients with intervertebral disk disorders and heart disease.

“While dysphagia occurs in only a small portion of hospitalized patients, the impact on hospital resources is substantial,” the researchers concluded. “We recommend early identification of dysphagia in hospitalized patients, particularly in those with high-risk [coexisting] conditions such as older age, stroke, dehydration, malnutrition, neurodegenerative disease, pneumonia, cardiac disease and the need for rehabilitation. The plan of care in these patients should include proper assessment, early intervention using appropriate therapy and aspiration precautions, and consideration of [alternate] feeding or supplementation options in the high-risk populations.”

The study findings are published in the August issue of the journal Archives of Otolaryngology — Head & Neck Surgery.

( August 18, 2010 ) - Home Care After Hip Surgery May Aid Survival, Study Says

MONDAY, Aug. 16 (HealthDay News) — Providing home care to elderly people after they’ve had hip surgery improves their chances of survival, finds a new study.

Canadian researchers looked at 11,326 men and women age 65 and older in Quebec who had partial hip surgery between 1997 and 2004. Those who received home care after leaving the hospital were 43% less likely to die within three months after their surgery than those who didn’t receive home care.

But the study, published Aug. 16 in the Canadian Medical Association Journal, found that home care was given to less than 16% of the elderly patients who were discharged home after partial hip surgery.

Patients who received home care were younger; more likely to have been treated in teaching hospitals or lower volume hospitals; and more likely to have stayed more than seven days in the hospital. They were also more likely to have acute kidney failure and a heart rhythm condition called atrial fibrillation

The study also found that men were more likely than women to die, and patients hospitalized longer had higher survival rates.

With the exception of atrial fibrillation and acute kidney failure, co-existing health conditions didn’t seem to influence the chances of receiving home care, the researchers said in a news release from the publisher.

“This indicates perhaps that receiving this care may depend on availability, rather than need of the service,” wrote Dr. Elham Rahme, a researcher in epidemiology at the Research Institute of the McGill University Health Center in Montreal, and colleagues in the release.

The finding has significant public health implications and requires further investigation, the authors said.

– Robert Preidt

Article URL: http://www.medicinenet.com/script/main/art.asp?articlekey=118936

( August 18, 2010 ) - Stress In Middle Age Could Contribute To Late Life Dementia

Tuesday, Aug. 17 (www.medicalnewstoday.com) - Psychological stress in middle age could lead to the development of dementia later in life, especially Alzheimer’s disease, reveals research from the University of Gothenburg, Sweden. Based on data from a study which followed women for 35 years, this is the first research in Sweden to indicate a link between stress and dementia.

The research, published in prestigious scientific journal Brain, is based on a major population study of women from Gothenburg. A representative sample of women were examined for the first time in 1968 when aged between 38 and 60, and then re-examined in 1974, 1980, 1992 and 2000.

A question about psychological stress was included in the 1968, 1974 and 1980 surveys and was answered by 1,415 women.

“Stress was defined as a sense of irritation, tension, nervousness, anxiety, fear or sleeping problems lasting a month or more due to work, health, family or other problems,” explains Lena Johansson, a researcher from the Neuropsychiatric Epidemiology Unit at the Sahlgrenska Academy’s Department of Psychiatry and Neurochemistry at the University of Gothenburg.

During the 35 years of the study, 161 of the participants developed dementia, mainly in the form of Alzheimer’s disease. The risk of dementia was about 65% higher in women who reported repeated periods of stress in middle age than in those who did not. In women who reported stress in all three surveys, the risk more than doubled.

“This is the first study to show that stress in middle age can lead to dementia in old age, and confirms similar findings from studies of animals. Stress has previously been shown to increase the risk of cardiovascular diseases such as stroke, heart attack and hypertension,” says Johansson, who also refers to earlier research at the Sahlgrenska Academy showing that cardiovascular disease can lead to Alzheimer’s.

“This study could result in a better understanding of the risk factors for dementia, but our results need to be confirmed by other studies, and further research is needed in the area. Most of those who said that they were stressed did not develop dementia, so it’s not currently possible to advise people to be less stressed or warn about the dangers of high stress levels due to an increased risk of developing dementia.”

Source: University of Gothenburg

Article URL: http://www.medicalnewstoday.com/articles/197877.php

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