Wednesday, August 13, 2014

Acute Abdominal Compartment Syndrome: What Happened to Our Child?

8 weeks after we came so close to suddenly losing our 6 year old son, Jackson, my family and I are just as confused as the day we sat in the hospital pediatric surgical waiting room, praying to God to protect our dying son. The reality that no doctor or specialist has a definite diagnosis for us scares and frustrates us more and more every day. What can be done that hasn't been done? Will this happen again? Can we guarantee this was a one time ordeal? WHAT HAPPENED TO OUR CHILD?? 

It is our dream to get answers, so I am seeking any advice and/or knowledge from the public. Perhaps this reaches that one specific person who has seen this rare case and can answer our prayers, giving us more insight as to how and why this happened. However, the likelihood of that happening is so slim. As a very paranoid mother, I can only keep the faith that this case will not close undiagnosed.


This past Father's Day was a day I will never forget. June 15, 2014 will forever haunt me and my husband. The days and hours leading up to our emergency may or may not be relevant, but here is the sequence of events:


Thursday, June 12th:  First Grade Field Trip to the Tide Pools at Lincoln Park in West Seattle
  • Kids were chaperoned into small groups with parent chaperones
  • No one directing the children; freedom to roam and touch
  • Based on some parents feedback and Jackson's knowledge, the children saw and touched the following: clams, algae, star fish (dead and alive), sea urchins, sea anemones, crabs (dead and alive)



Friday, June 13th:  Sporadic Stomach Pains Begin
  • Jackson is picked up from school at 2:00pm and occasional complaints of stomach pains begin and continue throughout the day
  • Appetite beginning to slow down



Saturday, June 14th:  Stomach Pain, Nausea, Vomiting, Loss of Appetite
  • Jackson woke up feeling a little off; he did not want breakfast
  • Jackson threw up in the morning after having a cup of orange juice
  • He felt better by swimming lesson time at 10 am
  • During his swim lesson, husband and I noticed bloating in his belly and even made mention of it to each other
  • Throughout his 30 minute lesson, Jackson was not performing up to his ability
  • As soon as it was over, Jackson ran to the bathroom with the sudden urge to vomit: nothing was able to come out and he soon felt a bit better
  • For the remainder of the day, sporadic stomach pains continued, slightly worsening, but overall feeling and acting normally

Sunday, June 15th:  Father's Day, Emergency Surgery Day
  • Jackson woke up, acting well: he ate a good breakfast
  • 11am: We headed to Acme Bowl as a family (30 mins away)
       - Jackson complained that his "belly REALLY hurt" and he chose not to eat with us
       - He wanted to continue bowling, and did so with a big smile on his face


  • 1pm: Headed back home where Jackson started screaming out, crying, that his belly really hurt
  • 2pm: Jackson lays down with his dad for a couple hours to rest
  • 4pm: Jackson goes from bad to worse. I have never seen him in so much pain before. He was screaming out, body completely straight saying he could not sit up or move. He was yelling at us that he needed to throw up and poop, but every time we went to go to help him up, the pain worsened. We took a look at his abdomen: we've never seen it so large and bloated before. We immediately react. This was serious.
  • Dad takes Jackson to the nearest Urgent Care/Emergency Room while I arrange child care for my younger 2.
  • Jackson is seen right away. They immediately call in for an ambulance to transfer him to the nearest children's hospital (30 minutes away). While they waited for transportation, an X-ray was performed.
  • 5:30pm: Ambulance transports Jackson with dad by his side. He is in so much pain, he goes into shock, so morphine was given.     
  • I arrive at Mary Bridge Children's Hospital shortly after Jackson. His pain was unbearable. One minute he would be passed out, the next he would be screaming out in pain, not knowing what to do with himself. 

  • 7:15pm: The ER doctor calls in the pediatric surgeon, Dr. Escobar. At this point, we have no idea what was going on. Jackson was getting a second IV line, tube down his nose to release air, anal exam… all at the same time.

  • 7:30pm: We are told Jackson has Acute Abdominal Compartment Syndrome and the X-rays showed his colon was distended. His skin was mottling, which was a sign his circulatory system was beginning to shut down. The surgeon gave us 2 guarantees: one, Jackson will have an incision from the top of his abdomen all the way below his belly button, and two, that he will need to stay open for at least a few days until the swelling would go down and they could go back in and close him up. By the appearance of his X-ray, the surgeon was not entirely hopeful that he could save his colon; we had to be prepared for him to remove it. Jackson needed surgery right away. There was no time to waste, not even time to perform a CT scan… we were about to lose our son.
  • 8:00pm: Jackson is back in surgery. 

I cannot describe to you the pain me and my husband, Cameron, felt during all of this. Seeing our first born son, who has been incredibly healthy throughout his entire life, in a hospital bed dying was a complete nightmare. NEVER have we experienced so much shock and heartache in our entire lives. Sitting there, waiting for news, ANY kind of news from any nurse or doctor, was the longest and most horrific hours you can ever imagine. Things could go either way and imagining the worst, imagining what was expected, was unbearable. Jackson is such an amazing child: such a warm hearted soul. I would have traded places with him in a heartbeat. All we could do was wait and pray…

  • 10:30pm: Surgery is complete. Dr. Escobar comes in with a smile, "I closed him." 

Details of the surgery:

  • As soon as Jackson went under, his body released a horrible smelling, toxic gas.
  • When the catheter was inserted, no fluids drained.
  • Because his body voluntary released some gases, the surgeon was able to make the incision smaller than planned. 
  • As soon as they opened him up, his colon literally popped out.
  • Acute Colonic Pseudoobstruction is what they determined with his colon. It was filled with this toxic gas and the only way it was releasing this gas was if the doctors manually compressed it out. 
  • Retention of Urine: his bladder appeared like an "80 year old man's"; stretched out, weak, retaining a large amount of fluid. The only way the bladder would drain was when the doctor, once again, compressed it out.
  • There were no signs of trauma; nothing else appeared wrong. 
  • After his bladder and colon were compressed, it was like a miracle… his abdomen began to flatten and THEY WERE ABLE TO CLOSE HIM!!!



Jackson remained sedated and intubated for the next 2 days. At first, it appeared that his involuntary muscles weren't wanting to perform as expected. We had many doctors on his case and they first wanted to rule out anything neurological. An EMG was performed during the 2nd day of sedation and he passed that, along with all other neurological testing. 

Routine bloodwork and labs continued coming back normal. 

48 hours after surgery, Jackson was extubated. No concerns there. 

Day 3 and 4, Jackson shocked the doctors with his progress. He was up walking, talking, eating. Overall, he was doing amazingly well!! Never in a million years did any of us, especially doctors, think he was supposed to recover like this. But, test after test, evaluation after evaluation, we continued to hear, "I've never seen something quite like this. I'm stumped." As they continued to rule out possible diagnoses, the likelihood of knowing what and why this happened seemed to be slipping away.



Friday, June 20th:  Jackson is Discharged- Possible New Lead



On the 5th day, Jackson was doing so well, he was getting discharged!! From day one we believed we were going to stay anywhere from 2 weeks to maybe even months, so this was an absolute miracle. Just 20 minutes from walking out of that hospital room, a new face came in with some interesting news…

Another pediatric surgeon, Dr. Pohlson, had been graciously working on Jackson's case. Like many of the doctors and specialists, the field trip taken to the tide pools just 24 hours prior to Jackson's first symptoms was constantly in the back of their minds. And, as more time went on, what happened to Jackson appeared to be more of an exposure than a disease or syndrome.

After reporting the details of the events, Dr. Pohlson took the case nationwide and soon there was an urge to isolate Lincoln Park and perform necessary testing. We were now questioning whether or not Jackson could have had some sort of PSP (Paralytic Shellfish Poisoning) or something of the sort. Could this have been a anticholinergic reaction from a toxin in the waters?

Immediately, Dr. Pohlson contacted the emergency line of the Department of Health of Seattle. She spoke directly to the epidemiologist in charge and expressed her concerns. We held onto hope that the department would take our son's case serious and perform testing, not only for us to get some answers, but to possibly save the life of another innocent child. Toxins don't live forever; 2 weeks at max. So, yes, time was of the essence.

As Jackson improved day by day at home, there was no isolation of the beach; no testing was performed. Soon, the 2 weeks were up and the Department of Health continued to neglect the concerns of a professional. We will forever be frustrated with the way things were handled. We thank Dr. Pohlson for putting so much time and effort into urging the DOH to act, but she could only do so much.

We continued taking care of our son and continued with routine testing.

2 weeks after Jackson was discharged, he had an Upper GI and a Lower Contrast Study performed. We got the results almost immediately; Jackson looked PERFECT!! No one could believe it. His colon was performing amazingly well and there was not a single sign that something was off. For his body to go through so much trauma just 2 weeks prior, it is just a miracle how good he looked after the GI tests. And, because of that, the planned colonoscopy and colon biopsy were cancelled! What a relief.

As of today, we are being followed clinically by his surgeon, Dr. Escobar, and his gastroenterologist, Dr. Pickens. 8 weeks later, Dr. Pickens believes this is one of two things: Ogilvie's Syndrome (which is appearing less and less likely as the weeks pass and Jackson shows no problems) or a toxin ingested from the tide pools. Dr. Escobar can't diagnose him 100% without the actual proof, but he believes they have exhausted all other explanations, so it is very safe to assume it is a toxin.

Frustrated. Scared.

That is exactly how Cameron and I feel. Every day that passes we hold on to the hope that one day someone will tell us exactly why this happened. I cannot accept the fact that we may end up "assuming" the cause. How are we supposed to live our lives normally, believing that this could very well happen again? We are so scarred from this traumatic experience and having a clear cut solution would ease so much pain.

If at all you have any insight please do not hesitate to comment or email. And, please, consider passing this along to anyone that may be able to help. Thank you in advance… this kid of ours deserves the world and more!!




And, finally, we have to thank this man. Dr. Escobar, without you, we very well could have lost our son. You found a way into our hearts from the moment we met you and we will always be thankful for God putting you into Jackson's care. There is not a day that goes by where I don't wish I could give you a big hug and just thank you over and over again for saving Jackson. I know you were just doing your job, but to our family, you are our hero.  


5 comments:

  1. The doctor really is a special find, he seemed to really know his profession. Thank you to him you have your son back. He is smiling so nicely in the picture, must have been such a relief to have things go back to the way they were. Thank you for writing about it and sharing it with us, thanks again.

    Edwin @ U.S. HealthWorks Bradenton

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  2. Hello Ashley,

    I'm a Brazilian girl that just finished reading your whole blog journey this last week.
    And wow! So many overwhelming emotions and inspirations in these documented years! You could seriously write a book lol
    I don't know you, but I hope you and your family are alright. It'd be lovely to have an update on you guys and on the surro girls too (:

    I've seen your photography blog and gosh, you are so talented! Anyways, wishing you the best ❤

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  3. OCHO, PLEASE, ALLA SATA-N-AZIST-A-SSASSINA CINZIA LONGERI NATA A LODI IL 31.1.1970. GIA' DI MAFIASET, NDRANGASET, NAZISTSET, MEDIASET! https://www.facebook.com/cinzia.longeri SEMPRE AD ARCORE-HARDCORE A SBOCCHINARE E PRENDERE...... CAZZI DI VECCHI.... BAVOSI.... BERLUSCO-N-AZISTI E PADA-N-AZISTI! E SUO MARITO..IL NOTO ASSASSINO TERRORISTA DI ESTREMA DESTRA, CLAUDIO CREMONESI DI IMQ E PAULLO VIA MASCHERPA 29 ( SE ANCORA ABITANTE LI, SE NON SCAPPATO DA LI, COME IMMAGINO, AVENDO LA COSCIENZA LERCISSIMA)




    NAZIRAZZISTA PUTTANONA MONICA CINZIA LONGERI (VIA MASCHERPA 29 PAULLO)! NATA A LODI IL 31.1.1970. GIA' A SBOCCHINARE E PRENDERE CAZZI MOSCI DI BAVOSI VECCHI FASCIO-MAFIOSI IN COSANOSTRASET, CAMORRASET, NDRANGASET, NAZISTSET, MEDIASET ( https://www.facebook.com/cinzia.longeri ). INOLTRE, SEMPRE AD ARCORE-HARDCORE, A FARE SESSO ANALE CON CAVALLI, SI, CON CAVALLI... INNAFFIANDOSI POI DI LITRI E LITRI DI SBORRA EQUINA... E PARLO DEI NOTI CAVALLI DI COSA NOSTRA, QUELLI DI VITTORIUZZO BEDDU MANGANO, SILVIO BERLUSCONI E MARCELLO "O GALEOTTO" DELL'UTRI.... AAAAA ( http://www.repubblica.it/2009/09/sezioni/cronaca/processo-dell-utri/processo-dell-utri/processo-dell-utri.html
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    1
    COME DICEVO, TRATTASI DI PROSTITUTA BERLUSCO-N-AZISTA E PADA-NAZISTA: MONICA CINZIA LONGERI DI PAULLO VIA MASCHERPA 29. PROSTITUTA BERLUSCO-N-AZISTA E PADA-NAZISTA SEMPRE A FARSI SFONDARE IL DI DIETRO AD ARCORE-HARDCORE. ANCHE DA CAVALLI, SI, I CAVALLI MAFIOSI DI VITTORIO MAGANO, SILVIO BERLUSCONI E GALEOTTO MARCELLO DELL'UTRI! SCHIFOSISSIMA CRIMINALE CINZIA MONICA LONGERI DI PAULLO VIA MASCHERPA 29. NOTA NINFOMANE NEONAZISTA NATA A LODI IL 31.1.1970. COME DICEVAMO, SEMPRE A FAR INFINITO SESSO ANALE ( A VOLTE ANCHE CON CAVALLI, SI, SI, I FAMOSI "CAVALLI MAFIOSI" DI VITTORIO MANGANO, IL RAS DI COSA NOSTRA)! PRESSO IL PEDOFILO, FASCIOMAFIOSO, STRAGISTA SPAPPOLA MAGISTRATI SILVIO BERLUSCONI! TRATTASI DI ZOCCOLA HITLERIANA, RAZZISTA, KUKLUKLANISTA! ODIA I MERIDIONALI CHE CHIAMA SEMPRE "TERUN DE MERDA", AGGIUNGENDO POI: " SPERIAMO CHE IL VESUVIO E L'ETNA LI LAVINO CON LA LAVA". ODIA CHI DI COLORE, CHE CHIAMA SEMPRE "NEGHER DE MERDA". TRUFFATRICE, LAVA SOLDI MAFIOSI, LADRA. SPOSATA CON L'ESTREMISSIMO CRIMINALE DI CUI SCRIVO ORA QUI A SEGUITO...
    SPOSATA CON PERICOLOSISSIMO TERRORISTA E PEDERASTA NAZIFASCISTA CLAUDIO CREMONESI DI PAULLO E DI IMQ MILANO ( VICINISSIMO A NOTO MASSONE OMICIDA GENNARO MOKBEL E AD ACCLARATI ASSASSINI GIOVANNI BATTISTA CENITI ED ALEXANDER BOETTCHER, CHE PRIMA DI UCCIDERE GENTE PER BENE VIA ACUDO MURIATICO, ERA AMANTE OMOSESSUALE DI GIULIO TREMONTI, COME, D'ALTRONDE, QUESTO TWITTER ACCOUNT FA STRA CAPIRE https://twitter.com/alexanboettcher E NOI NE ABBIAMO PROVE, FRA L'ALTRO). A SUA VOLTA VICINO AD ALTRO KILLER DI ESTREMISSIMA DESTRA, ANCHE LUI NOTO PEDOFILO, MAURIZIO BARBERO DI TECHNOSKY MONTE SETTEPANI E MERCATOLIBERONEWS.BLOGSPOT.COM. COME AD ALTRE 2 TERRORISTE NAZISTE E RAZZISTE, DEL KU KLUK KLAN AMERICANO E PADANO, NONCHE' NOTE PUTTANE SEMPRE AD ARCORE-HARDCORE A FARE SESSO ANALE: ELISA COGNO E PIERA CLERICO DELLA FRUIMEX DI CUNEO!
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  4. 2
    STO PEDERASTA OMICIDA DI CLAUDIO CREMONESI, COME DETTO, OPERA PRESSO CRIMINALISSIMA IMQ DI VIA QUINTILIANO 43 MILANO. SOCIETA' CHE PREPARA E COMMISSIONA ANCHE STRAGI. DI PROPRIETA' DI COSIDETTI " SERVIZI SEGRETI DEVIATI" DI ESTREMISSIMA DESTRA ( GIRI KILLER DI LEGA LADRONA E FORZA ITALIA "MAFIOSA).
    DIFFAMA ANCHE, STO FIGLIO DI PUTTANA DI CLAUDIO CREMONESI, GENTE PER BENE, VIA INTERNET! PREPARA UCCISIONI MIRATE DI CHI NON FASCIO E FILO NDRANGHETISTA COME LORO! IL SANGUINARIO OMICIDA CLAUDIO CREMONESI DI IMQ E PAULLO VIA MASCHERPA 29 (NATO A LANDRIANO IL 31.1.1966) PREPARA ATTENTATI SPEZZA VITE PER LE OVRA E GESTAPO, SIA PUBBLICHE CHE PRIVATE, DI SILVIO BERLUSCONI, PAOLO BERLUSCONI E VERMINOSA BAGASCIA DANIELA SANTANCHE’ O VERMINOSA BAGASCIA DANIELA GARNERO SANTANCHE' CHE SIA ( GIRI SIMILI A QUELLI DALLA POLIZIA SEGRETA ED ASSASSINA DEI NOTI TOPI DI FOGNA GAETANO SAYA E RICCARDO SINDOCA:
    http://www.corriere.it/Primo_Piano/Cronache/2005/07_Luglio/01/polizia.shtml O VEDI COPPIA DI MASSONI NEOPIDUISTI, MEGA FIGLI DI PUTTANA UBALDO LIVOLSI E GIULIO OCCHIONERO , CHE INTENDEVANO SGOZZARE LA DEMOCRAZIA, FINO A SOLO POCHE SETTIMANE FA). COME DEI, VI ASSICURO, FREQUENTI MANDANTI DI OMICIDI TANTO QUANTO, UMBERTO BOSSI, ROBERTO MARONI, MATTEO SALVINI E ROBERTO COTA (CHE SI COMPRAVA LE MUTANDE PEDERASTA, MUTANDE VERDE-ROSA, A BOSTON, COI SOLDI DEL POPOLO CIUCCIONE
    http://www.identitainsorgenti.com/lega-ladrona-anche-le-mutande-verdi-di-cota-tra-i-rimborsi-spese-della-regione-piemonte/ )!
    COME DICEVAMO, LO SCHIFOSO ESCREMENTO NAZIRAZZISTA CLAUDIO CREMONESI DI PAULLO VIA MASCHERPA 29 E DI IMQ, ORGANIZZA UCCISIONI, ED ANCHE "EVENTUALI NEOPIDUISTE STRAGI", PRESSO CRIMINALISSIMA IMQ DI VIA PRIVATA MARCO FABIO QUINTILIANO 43 MILANO. ALIAS, QUALCOSA DI GEMELLO ALLE MEGA AMMAZZANTI MILIONI DI PERSONE, DINA DI AUGUSTO PINOCHET, GHESTAPO DI ADOLF HITLER E OVRA DE ER PUZZONE PORCO BENITO MUSSOLINI! IL BASTARDO ASSASSINO CLAUDIO CREMONESI PREPARA UCCISIONI DI CHIUNQUE NON SIA MERDACCIA PREZZOLATA COME LUI, DA NOTO PEDOFILO SPAPPOLA MAGISTRATI SILVIO BERLUSCONI ( PER NON DIRE DEL SILVIO BERLUSCONI STRAGISTA, MEGA MANDANTE DI CENTINAIA E CENTINAIA DI OMICIDI MASCHERATI DA FINTI MALORI, SUICIDI, INCIDENTI.... ED ANCORA... SILVIO BERLUSCONI VERMINOSO DITTATORE, MAFIOSO, CAMORRISTA, NDRANGHETISTA, MEGA RICICLA SOLDI MAFIOSI, CAMORRISTI, NDRANGHETISTI…AND AGAIN AND AGAIN AND AGAIN... SILVIO BERLUSCONI PEDOFILO, IMMENSO LADRO, TRUFFATORE, PAGLIACCIO, FALSO, POR-CORRUTTORE E TANTO DI TERRIFICANTE ALTRO). AGGIUNGIAMO ORA, QUALCOSA, PURE, A PROPOSITO DEGLI ALTRI DELINQUENTI DI ULTERIORE RIFERIMENTO DELLA DIARRE-A-SSASSINA CLAUDIO CREMONESI DI IMQ E PAULLO VIA MASCHERPA 29. OSSIA I PRIMA CITATI RAZZISTI, PREZZOLATI, FALSI, VISCIDI, NAZIRAZZISTI E LADRONI ROBERTO MARONI, MATTEO SALVINI, UMBERTO BOSSI, LUCA ZAIA E ROBERTO COTA ( QUELLO DELLE MUTANDE PEDERASTA, MUTANDE VERDE ROSA, COMPRATE A BOSTON COI SOLDI DEL POPOLO CIUCCIO). TIPO IL MEGA LAVA EURO MAFIOSI O FRUTTO DI MEGA MAZZETTE O MEGA FURTI RIGUARDANTI LL LEGA LADRONA ED EX PDL POPOLO DI LADRONI, IL GIA’ 3 VOLTE IN CARCERE, BASTARDO ASSASSINO TANTO QUANTO, PAOLO BARRAI NATO A MILANO IL 28.6.1965. DI CRIMINALISSIMA WMO SA PANAMA, CRIMINALISSIMA WORLD MAN OPPORTUINITIES LUGANO, CRIMINALISSIMA BLOCKCHAIN INVEST, CRIMINALISSIMA BIGBIT, CRIMINALISSIMA BSI ITALIA SRL DI VIA SOCRATE 26 A MILANO ( QUEST'ULTIMA PURE CONTROLLATA DA SERVIZI SEGRETI KILLER DI ESTREMISSIMA DESTRA). E CRIMINALISSIMO, MEGA ARCI TRUFFATORE BLOG MERCATO LIBERO NOTO A TUTTO IL MONDO COME “MERDATO” LIBERO. CANNANTE SEMPRE IN BORSA. CHE TI LADRA E AZZERA TUTTI I RISPARMI, SEMPRE. ESSENDO “BERLUSCONES CLASSIC E NON CERTO SPECIAL”, VI SONO SEMPRE PIU' WHISTLEBLOWINGS, CHE IL PURE PEDOFILO CLAUDIO CREMONESI DI IMQ, PROPRIO COSI', IL PURE PEDOFILO CLAUDIO CREMONESI DI IMQ E DI PAULLO VIA MASCHERPA 29, INCULI DA SEMPRE IL FIGLIO ( ORMAI OMOSESSUALE PERSO PURE LUI) FILIPPO CREMONESI (NATO A LODI IL 26.1.1992)!!!

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  5. 3
    ED INCULI DA SEMPRE, ANCHE L'ALTRO FIGLIO, DIVENUTO PEDERASTA TANTO QUANTO, MATTIA CREMONESI (NATO A SEGRATE IL 4.9.1998)! DAVANTI AGLI OCCHI DELLA CRIMINALISSIMA MOGLIE, CITATA SCHIFOSA PROSTITUTA BERLUSCO-N-AZISTA E PADA-N-AZISTA MONICA CINZIA LONGERI (NATA A LODI IL 31.1.1970). SEMPRE DI PAULLO, VIA MASCHERPA 29. PER TANTI ANNI ( E, FATEMELO DIRE, PLS: TANTI A-N-I) AD (H)AR(D)CORE, A FARE DEPRAVATO SESSO ANALE CON SCHIFOSI, PERVERTITI, BAVOSI, OMICIDA, MAFIOSI, FASCISTI BERLUSCONICCHI ( COME PURE CON CAVALLI, SI, I FAMOSI CAVALLI MAFIOSI DI VITTORIO MANGANO E SILVIO BERLUSCONI, IAMM E STRA IAMM BEEE)! I GIRI BASTARDI DI LEGA LADRONA E FORZA ITALIA MAFIOSA ODIANO CHE LA VERITA' VENGA A GALLA. USANO SEMPRE MEGA CENSURA STILE LORO IDOLI ADOLPH HITER ED AL CAPONE. DI CERTO CERCHERANNO E STRA CERCHERANNO DI FARE CANCELLARE QUESTE ASSOLUTE VERITA', IN QUANTO TANTISSIMO, LI IMBARAZZANO. MA PER OGNI COMMENTO CANCELLATO, NE RIAPPAIONO CENTOTTANTASETTE E MEZZO! ANZI.. CENTOTTANTASETTE E TRE QUARTI!! ANZI.. CENTOTTANTASETTE E CINQUE SESTI!!! SOON BACK!!!!!!
    PS
    HASTA LA VICTORIA SIEMPRE, WAGLIO'!!!!!!!!!

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