What Is Vomiting? Symptoms, Causes, Diagnosis, Treatment, and Prevention

Treatment for nausea and vomiting depends on the underlying cause.

Most episodes of vomiting can be treated at home. Self-care measures you can take to treat vomiting include:

• Drink plenty of liquids to avoid dehydration.
• Adhere to a clear liquid diet to rest the stomach.
• Avoid strong odors, including food and cooking smells, perfume, and smoke, that could possibly trigger vomiting.
• When you begin eating solid food again, stick to bland foods that are easily digestible, like cereal, rice, and crackers.
• Avoid spicy and fatty foods.

If you are planning a trip and have a history of motion sickness, try over-the-counter medications to treat the condition, like dimenhydrinate and meclizine. For longer journeys like cruises, your doctor may prescribe an adhesive patch to treat motion sickness.

Vomiting associated with cancer treatments can often be treated with another type of drug therapy.

There are also prescription and nonprescription drugs that can be used to control vomiting associated with pregnancy. These include vitamin B6 supplements, doxylamine, and a combination drug of doxylamine and pyridoxine.

Consult with a doctor before using any of these treatments.

Severe dehydration caused by vomiting may require treatment with intravenous fluids. (6)

Prevention of Vomiting

A person with nausea has the sensation that vomiting may occur. Other signs that you are about to vomit include gagging, retching, choking, involuntary stomach reflexes, the mouth filling with saliva (to protect the teeth from stomach acid), and the need to move or bend over.

If you feel nauseous, resting either in a sitting position or in a propped lying position can help; activity may worsen nausea and may lead to vomiting.

Pregnant women experiencing morning sickness can eat some crackers before getting out of bed or eat a high protein snack before going to bed (like lean meat or cheese). (6)

Cyclic Vomiting Syndrome – NORD (National Organization for Rare Disorders)

TEXTBOOKS
Rudolph CR, Rudolph AM, Lister GE, First LR and Gershon AA. Rudolph’s Pediatrics. 22nd ed. New York, NY:McGraw Hill; 2011:1372-1375.

Li BUK, Adams K, Howard J. Cyclic Vomiting Syndrome. NORD Guide to Rare Disorders. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:525-526.

JOURNAL ARTICLES
Hejazi RA, McCallum RW. Cyclic vomiting syndrome: treatment options. Exp Brain Res. 2014 Aug;232(8):2549-52. doi: 10.1007/s00221-014-3989-7. Epub 2014 May 28.

Hejazi RA, McCallum RW.Review article: cyclic vomiting syndrome in adults–rediscovering and redefining an old entity. Aliment Pharmacol Ther. 2011 Aug;34(3):263-73. doi: 10.1111/j.1365-2036.2011.04721.x. Epub 2011 Jun 12.

Boles RG (2011): High degree of efficacy in the treatment of cyclic vomiting syndrome with combined co-enzyme Q10, L-carnitine and amitriptyline, a case series. BMC Neurol. 2011;11:102.

Boles RG, Lovett-Barr MR, Preston A, Li BU, Adams K. Treatment of cyclic vomiting syndrome with co-enzyme Q10 and amitriptyline, a retrospective study. BMC Neurol. 2010;10:10.

Hejazi RA, Reddymasu SC, Namin F, Lavenbarg T, Foran P, McCallum RW. Efficacy of tricyclic antidepressant therapy in adults with cyclic vomiting syndrome: a two-year follow-up study. J Clin Gastroenterol. 2010 Jan;44(1):18-21. doi: 10.1097/MCG.0b013e3181ac6489.

Venkatesan T, Tarbell S, Adams K, McKanry J, Barribeau T, Beckmann K, Hogan WJ, Kumar N, Li BUK. A survey of emergency department use in patients with cyclic vomiting syndrome. BMC Emergency Medicine. 2010 Feb 24;10:4.

Abell T, Adams K, Boles RG … Li BUK … Vakil N. Cyclic vomiting syndrome in adults. Neurogastroenterology and Motility 2008;20:269-84.

Li BUK, LeFevre F, Chelimsky GG et al. NASPGHAN Consensus Statement on the Diagnosis and Management of Cyclic Vomiting Syndrome. J Pediatr Gastroenterol Nutr 2008;47:379.

Tarbell S, Li BUK. Psychiatric symptoms in children and adolescents with cyclic vomiting syndrome and their parents. Headache 2008;48:259-66. Epub 2007 Dec 12.

Chelimsky TC, Chelimsky GG. Autonomic abnormalities in cyclic vomiting syndrome. J Pediatr Gastroenterol Nutr. 2007;44:326-30.

Boles RG, Adams K, Li BU. Maternal inheritance in cyclic vomiting syndrome. Am J Med Genet A. 2005;133;71-77.

Sudel B, Li BU. Treatment options for cyclic vomiting syndrome. Curr Treat Options Gastroenterol. 2005;8:387-395.

Fleisher DR, Gornowicz B, Adams K, Burch R, Feldman EJ. Cyclic vomiting syndrome in 41 adults: the illness, the patients, and problems of management. BMC Med. 2005;3:20.

Li BUK, Misiewicz L. Cyclic vomiting syndrome: a brain-gut disorder. Gastroenterol Clin N Am. 2003;32:997-1019.

Boles RG, Adams K, Ito M, Li BU. Maternal inheritance in cyclic vomiting syndrome with neuromuscular disease. Am J Med Genet A. 2003;120:474-482.

INTERNET
Cyclic Vomiting Syndrome. Mayo Clinic Health Information. https://www.mayoclinic.org/diseases-conditions/cyclic-vomiting-syndrome/symptoms-causes/syc-20352161. Accessed May 5, 2021.

Cyclic Vomiting Syndrome. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/cyclic-vomiting-syndrome. Accessed May 5, 2021.

Venkatesan T, Li B UK, Marcus S, Sundaram S, Pandey A. Cyclic Vomiting Syndrome. Medscape. Last Update: Oct 31, 2018. http://emedicine.medscape.com/article/933135-overview. Accessed May 5, 2021.

USC scientists identify the order of COVID-19’s symptoms

USC researchers have found what appears to be the likely order in which COVID-19 symptoms first appear: fever, cough and muscle pain, then nausea and/or vomiting, then diarrhea.

Knowing the order of COVID-19’s symptoms may help patients seek care promptly or decide promptly to self-isolate, the scientists say. It also could help doctors rule out other illnesses or plan how to treat patients, according to the study led by doctoral candidate Joseph Larsen and his colleagues with faculty advisers Peter Kuhn and James Hicks at the USC Michelson Center for Convergent Bioscience’s Convergent Science Institute in Cancer.

The scientific findings were published in the journal Frontiers in Public Health.

“This order is especially important to know when we have overlapping cycles of illnesses like the flu that coincide with infections of COVID-19,” said Kuhn, professor of medicine, biomedical engineering, and aerospace and mechanical engineering at the USC Dornsife College of Letters, Arts and Sciences. “Doctors can determine what steps to take to care for the patient, and they may prevent the patient’s condition from worsening.”

“Given that there are now better approaches to treatments for COVID-19, identifying patients earlier could reduce hospitalization time,” said Larsen, the study’s lead author and a USC Dornsife professor.

Determining COVID-19 symptoms can help doctors plan treatments accordingly

Fever and cough are frequently associated with a variety of respiratory illnesses, including Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS). But the timing and symptoms in the upper and lower gastrointestinal tract set COVID-19 apart.

“The upper GI tract (i.e., nausea/vomiting) seems to be affected before the lower GI tract (i.e., diarrhea) in COVID-19, which is the opposite from MERS and SARS,” the scientists wrote.

The authors predicted the order of symptoms this spring from the rates of symptom incidence of more than 55,000 confirmed coronavirus cases in China, all of which were collected from Feb. 16-24 by the World Health Organization. They also studied a dataset of nearly 1,100 cases collected from Dec. 11-Jan. 29 by the China Medical Treatment Expert Group via the National Health Commission of China.

To compare the order of COVID-19 symptoms to influenza, the researchers examined data from 2,470 cases in North America, Europe and the Southern Hemisphere that were reported to health authorities from 1994 to 1998.

“The order of the symptoms matter. Knowing that each illness progresses differently means that doctors can identify sooner whether someone likely has COVID-19, or another illness, which can help them make better treatment decisions,” Larsen said.

In addition to Larsen, Kuhn and Hicks, other study co-authors were Margaret R. Martin of Nexus Development PA LLC and John D. Martin at NanoCarrier Co., Ltd., in Chiba, Japan.

The USC Michelson Center for Convergent Bioscience brings together a diverse network of scientists and engineers from the USC Dornsife College of Letters, Arts and Sciences, the USC Viterbi School of Engineering and the Keck School of Medicine of USC to solve some of the greatest intractable problems of the 21st century — from cancer to neurological disease to cardiovascular disease. Established with a generous $50 million gift from retired orthopedic spinal surgeon Gary K. Michelson and his wife, Alya Michelson, the Michelson Center aims to transform and influence the course of scientific discovery and biomedicine for generations to come.

More stories about: COVID-19, COVID-19 Experts, Dornsife Comm, Research

Nausea, Vomiting, and Diarrhea – Physicians Immediate Care

Nausea, Vomiting, and Diarrhea

Nausea, vomiting, and diarrhea are common and uncomfortable symptoms that can result from many different issues of the stomach and digestive system.

Nausea is an unpleasant sensation of uneasiness and discomfort. It often happens before you vomit, which is emptying the contents of your stomach through your mouth.

Diarrhea is having loose, watery bowel movements three or more times in one day. Signs and symptoms of diarrhea can also include pain or cramps in the abdomen, as well as urgent and/or uncontrollable bowel movements. Diarrhea typically lasts only for a day or two. Visit your medical provider if you have chronic diarrhea that continues or comes and goes for four weeks or more, as this could be a sign of a serious issue.

What causes nausea, vomiting, and diarrhea?

There are many causes of nausea and vomiting, including motion sickness, pregnancy, medication side effects, intense pain, emotions or anxiety, gallbladder disease, food poisoning, infections, overeating, heart attack, concussion or brain injury, brain tumors, ulcers, some forms of cancer, excessive alcohol use or ingestion of toxins, bowel obstruction, gastroparesis and appendicitis.

Diarrhea is commonly caused by bacteria, viruses or parasites in contaminated food or water. Taking certain medications, such as antibiotics, cancer drugs or magnesium, or eating food you’re sensitive to or intolerant of (such as with lactose intolerance), can also be a cause.  Conditions that affect the stomach, small intestine, or colon, such as Crohn’s disease or irritable bowel syndrome (IBS) are also common causes of diarrhea.

If nausea, vomiting, and diarrhea occur together, it could be due to gastroenteritis, which is inflammation of the digestive tract. It is also known as the “stomach flu.” Fever or abdominal cramps may also be present if you have gastroenteritis.

How are nausea, vomiting, and diarrhea treated?

When you’re nauseous or vomiting, it can be helpful to avoid eating solid food. Eating soft, bland food can help with diarrhea. In some cases, medications such as Zofran can be used to control nausea and vomiting.

Vomiting and diarrhea cause your body to lose fluids, which can cause dehydration. This can be serious, so it’s important to keep hydrated. Drink plenty of clear fluids. If you’re vomiting, start out slow and gradually increase the amount that you drink. For children, a rehydrating solution like Pedialyte should be taken if diarrhea and vomiting last for 24 hours or more. In adults, sports drinks, fruit juices, caffeine-free sodas, and salty broths should be drunk in addition to water.

Other treatments may be necessary to address the underlying condition that’s causing your nausea, vomiting, diarrhea, and other symptoms. If you have concerns about your symptoms, visit one of our clinics for an examination to determine the causes and most appropriate treatment plan. Your visit to Physicians Immediate Care will include a comprehensive exam and medical history. Treatment may include medications administered in-clinic or by prescription, hydration by mouth or IV, and stool testing to screen for possible causes of your diarrhea. Prescriptions can be filled at our in-clinic pharmacy for your convenience.

When should I see a medical provider?

While nausea, vomiting, and diarrhea are usually not harmful on their own, they can become dangerous or can be caused by a more serious health problem. Visit a medical provider if you notice any of the following:

• Signs of dehydration such as increased thirst, dry lips or mouth, sunken eyes, a rapid pulse, or rapid breathing
• Nausea that lasts for more than 3 days
• Vomiting that lasts for more than 1 day
• In children under six years, vomiting that lasts more than a few hours, vomiting and diarrhea occurring together, or lack of urination for 4-6 hours
• In children over six years of age, lack of urination for 6 hours
• Possibility of pregnancy
• Presence of an injury or infection that may be causing the vomiting
• Diarrhea for more than 48 hours in adults, or 24 hours in children
• Intense pain in the abdomen or rectum
• Stools that have blood or pus, or that are black and tarry
• Fever over 101 degrees

If you or your child are experiencing any of these symptoms, it is important to visit a medical provider. Walk-in or Reserve Your Time Online at a Physician’s Immediate Care clinic near you for fast, reliable service from our dedicated health care team. Our 40+ clinics in Indiana, Illinois, and Wisconsin are open extended hours every day of the week, so you can get better faster.

is nausea a symptom of Covid 19?

As doctors learn more about COVID-19, more and more symptoms are being reported. Some people who are ill with the coronavirus may experience a “fizzing” sensation, others could be coughing up blood. Dermatologists have used the term “COVID toes” to describe a phenomenon among some coronavirus patients. The coronavirus symptoms kids are experiencing weeks after a possible infection are alarming.

There is also recent evidence an upset stomach can be a key symptom for people who have a mild form of the disease.

Digestive problems, particularly diarrhea, can be the first clue in a “unique sub-group” of patients who are infected with the new coronavirus, but don’t have the more well-known warning signs, according to a recent study made available before peer review by the American Journal of Gastroenterology.

These people may only later — or never — go on to develop respiratory issues and fever. They’re also diagnosed later than other patients, which means they may unknowingly spread the virus.

Download the TODAY app for the latest coverage on the coronavirus outbreak.

The findings come after previous research found up to half of COVID-19 patients in general may complain of digestive symptoms.

The authors of the new paper wanted to understand more about the 80% of people who have the mild form of the disease, said Dr. Brennan Spiegel, study co-author and director of health services research at the Cedars-Sinai Health System in Los Angeles.

“COVID-19 is not just a cough,” Spiegel told TODAY. “Of course, we’re very focused on the lungs because that’s what can cause people to die. But this virus, if it gets into your saliva and you swallow it, can then enter the intestinal system.”

The virus enters the human body through a particular receptor that’s found in very high levels in the gastrointestinal tract, he noted.

“If you unfurl your intestines, you have almost a tennis court worth of surface area. So you have this huge area where the virus can just start to replicate itself over and over again,” Spiegel said.

“It seems that’s happening in some patients who have the GI version of this disease.”

Is nausea a symptom of COVID-19 as well?

The findings mean that people who suddenly complain of diarrhea, nausea or vomiting after being around someone possibly infected with the new coronavirus should be suspected for the illness, even if they don’t have a cough, shortness of breath, sore throat or fever, the authors wrote.

Related

The study involved 206 patients with mild cases of lab-confirmed COVID-19 in Wuhan, China, where the outbreak began.

They were divided into three groups: 48 patients who only experienced a digestive symptom; 69 who had both digestive and respiratory issues; and 89 who only experienced respiratory symptoms. The authors followed them until they tested negative for the disease.

Of those suffering stomach problems, 57% had diarrhea — with one-fifth of those patients experiencing it as their first COVID-19 symptom.

About 62% of patients with a digestive symptom had a fever at the same time, which left more than one-third of patients who continued to have a normal temperature.

Related

What to know if you have digestive problems now:

Diarrhea is one of the most common symptoms people experience in everyday life. Moreover, stress and anxiety — both of which are at high levels during the coronavirus outbreak — can cause GI symptoms like abdominal pain, bloating, discomfort and diarrhea.

So Spiegel advised people to consider the whole picture.

“I don’t want people to panic and think, ‘Oh my god, I had some loose stools so I have COVID-19.’ Well, probably not,” he said.

“I would say this: If you have new onset diarrhea — you’ve not had it before, and now all of a sudden you have new diarrhea — and you have a fever, that should be something that causes you to contact your doctor anyway, whether we’re in a pandemic or not. ”

Additional symptoms like nausea and vomiting, cough and shortness of breath should be concerning, too.

Can stool transmit the disease?

The study didn’t directly confirm that, but the virus is being found in the stool of patients.

“We don’t yet know 100% that those particles being shed are infectious, but we also don’t have reason to doubt it at this point,” Spiegel said.

That’s more reason to regularly wipe down the toilet handle, seat and bowl, and wash your hands after using the bathroom.

In a concerning finding, some COVID-19 patients were considered recovered because the virus was no longer found in their sputum (mix of saliva and mucus), but still tested positive for the pathogen when their stool was checked, Spiegel noted. Right now, stool is not being routinely tested.

“The most rigorous definition (of viral clearance) would be: It’s not coming out of any of your body parts,” he said.

A. Pawlowski is a TODAY senior contributing editor focusing on health news and features. Previously, she was a writer, producer and editor at CNN.

Vomiting – treatments, self care and causes

On this page

Vomiting is one of the symptoms of COVID-19. Even if your symptoms are mild, get tested for COVID-19 immediately — use the COVID-19 Symptom Checker if you’re not sure what to do.

What is vomiting?

Vomiting can be unpleasant but it is usually not a sign of anything serious. Be careful not to get dehydrated, and see your doctor if it doesn’t go away in a day or 2.

Many different things can cause vomiting. It usually improves within 48 hours (2 days) and may have completely gone within 3 days.

Children tend to vomit more than adults. They usually get over vomiting very quickly.

What symptoms are related to vomiting?

If you are vomiting, you may also have:

Dehydration is a serious risk, especially in children. Symptoms of dehydration include:

• urinating less often (fewer wet nappies in babies)
• dark urine
• sunken eyes
• dry mouth and tongue
• tiredness and lethargy
• headache

CHECK YOUR SYMPTOMS — Use our diarrhoea and vomiting Symptom Checker and find out if you need to seek medical help.

What causes vomiting?

Vomiting may be caused by a viral infection including COVID-19. Food poisoning can also cause vomiting. These often cause diarrhoea as well. Vomiting can also be caused by an illness or pregnancy.

You can find more information about the underlying causes of vomiting here.

When should I see my doctor?

Call an ambulance if you are vomiting and also have:

• chest pain
• severe abdominal pain or cramping
• blurred vision
• confusion
• high fever and stiff neck
• faeces in the vomit
• bleeding from your rectum
• you think you have swallowed something poisonous

Visit your doctor if:

• you have been vomiting for more than 2 days
• you also have a severe headache
• you are dehydrated
• you have not been able to keep down fluids for 12 hours or more
• your vomit is green. In this case you are probably bringing up bile, a fluid the digestive system uses to digest foods
• there is blood in your vomit or what looks like coffee granules
• you have abdominal pain
• you have diabetes, especially if you need to take insulin

How is vomiting treated?

The best thing is to have small sips of water or oral rehydration fluid to prevent dehydration. If your child is vomiting, they will also need comforting.

You can buy over the counter medications to stop vomiting, but you shouldn’t give these to children.

You should continue to breastfeed your baby if you have vomited, but you should make sure you drink plenty of fluids to avoid getting dehydrated. Maintain good hygiene and speak to your midwife or doctor for further advice.

Here is some self-help information:

• Eat normally — do not starve yourself. If you are hungry, eat regular meals.
• Rest at home and don’t go to work while you are ill.
• If you have been vomiting, if you are in pain, get advice on medicines you can take.
• Antibiotics are not usually given to treat vomiting.
• Drink plenty of clear fluids (dilute 1 part juice to 4 parts water). Avoid undiluted fruit juice or soft drinks.
• Re-hydration drinks are available over-the-counter from your local pharmacy and from some supermarkets. These drinks provide the correct balance of water, sugar and salt that your body needs. Follow the instructions on the packaging.
• Sports drinks and energy drinks should be avoided as a rehydration fluid option. They have high sugar content that does not assist with rehydration.

Can vomiting be prevented?

The best way to prevent vomiting is to avoid getting sick. To prevent catching a virus or to make sure you don’t pass it on to others:

• Maintain good personal hygiene — you can do this by ensuring that you and your family always wash your hands with soap and warm water before eating or handling food and after using the toilet, cleaning contaminated surfaces or handling garbage.
• Clean surfaces — washing with detergent and water is a very effective way of removing germs from surfaces that you have touched.
• Do not share personal items — use your own personal items, such as towels, toothbrushes, flannels or face cloths.
• Avoid handling or preparing food for others until 48 hours after the vomiting has stopped to avoid spreading germs.
• To prevent the spread of infection, do not go swimming in a public pool for 2 weeks after your last episode of vomiting.
• While you are unwell you should keep away from people who can easily pick up infections, such as newborn babies, pregnant women, older people and those with a lowered immune system.

Are there complications of vomiting?

Vomiting can affect the contraceptive pill (both the combined pill and mini pill). It can make the pill less effective at preventing pregnancy. Extra care must be taken if you wish to avoid pregnancy, such as using condoms. The effectiveness of the pill may not be back to normal for at least one week following vomiting, making it necessary to continue extra precautions.

Diarrhea and Vomiting | University Health Service

If you experience diarrhea and/or vomiting, you may wish to get Nurse Advice by Phone. 

On this page:

Causes:

• Bacteria, parasites, viruses (including norovirus) 
• Food poisoning e. g. from food that has been improperly stored
• Consumption of irritating food, drink or medication
• Pregnancy
• Overeating or overdrinking (especially alcohol)
• Stress and anxiety
• Taking antibiotics recently

Symptoms:

Symptoms may include abdominal pain, nausea, vomiting, diarrhea, and fever. People may feel very sick and vomit many times a day. Most people improve within three days. However, sometimes people become dehydrated and need medical treatment. Dehydration is the most serious complication. See also When to Call for Medical Advice.

Transmission:

Norovirus, a common cause of infectious outbreaks, can easily spread from person to person. People are contagious from the moment they begin to feel ill until at least three days after recovery. Good hygiene is critical to break the chain of transmission (see Prevention).  

Specific means of transmission are:

• Having close contact with another person who is infected, for example by providing health care or sharing food or utensils
• Touching contaminated objects then touching your mouth
• Consuming contaminated food or drinks

Self-care for adults:

For vomiting, follow these instructions in order:

1. Do not eat or drink anything for several hours after vomiting.
2. Sip small amounts of water or suck ice chips every 15 minutes for 3-4 hours.
3. Next, sip clear liquids every 15 minutes for 3-4 hours. Examples include water, sports drinks, flat soda, clear broth, gelatin, flavored ice, popsicles or apple juice. Do not drink citrus juices or milk. Increase fluids as tolerated.
4. When you can tolerate clear liquids for several hours without vomiting and if you’re hungry, try eating small amounts of bland foods. Try foods such as bananas, rice, applesauce, dry toast, soda crackers (these foods are called BRAT diet). For 24-48 hours after the last episode of vomiting, avoid foods that can irritate or may be difficult to digest such alcohol, caffeine, fats/oils, spicy food, milk or cheese.
5. When you can tolerate bland food, you can resume your normal diet.

Retake medications if vomiting occurs within 30 minutes of taking usual medication. If you vomited after taking oral contraceptive pills, use a back-up contraception method for the rest of the month.

If diarrhea is the only symptom, try Imodium, a non-prescription (over-the-counter) medication available at the UHS Pharmacy according to package directions. Follow a bland diet (see 4 above). After the passage of a soft, formed stool, you can resume a normal diet. Call for medical advice if you have no improvement within 48 hours after starting Imodium. 

If you are sick in a Residence Hall:

You can ask a friend to make arrangements to bring you food from the dining room. See information about Feel Better Meals. 

If you have questions or concerns about your food intake, you may call the Dining Services dietician at 734-647-2614 or send email to [email protected].

Notify your Housing director and let your parent/s know if you are ill. If you need assistance, contact the staff at your Community Center. 

If you are sick and work in food service, you should contact your supervisor.

When to call for medical advice:

Call for medical care if you:

• Can’t keep down liquids or food for more than 24 hours
• Have fever (101º F or 38.3º C or higher) with abdominal pain (may include diarrhea, vomiting, nausea)
• Have diarrhea for more than 3 days or without gradual improvement over 5 days
• Have signs of dehydration, for example, lightheadedness, decreased urination (no urination at least every 8 hours) or severe fatigue
• Took antibiotics recently
• Have bloody diarrhea
• Have abdominal pain that is not relieved by vomiting and/or diarrhea (that is, abdominal pain is unrelated to episodes of vomiting or diarrhea)
• Have insulin-dependent diabetes and experience vomiting, diarrhea or nausea
• Are unable to take medications that you usually take
• Recently traveled to a country that poses a health risk

Prevention:

• Wash hands frequently with soap and water and wash for at least 15 seconds, especially after toilet visits and before eating. Hand-washing is more effective than hand sanitizer against norovirus, but do use alcohol-based sanitizer when hand-washing is not possible (see also Wolverines Wash).
• Don’t share eating utensils, drinking glasses or bottles, toothbrushes or other personal items.  
• Sharing keyboards and other items? Be sure to wash your hands and clean surfaces. Using wipes with bleach helps.  
• Immediately after an episode of illness, flush vomit and feces in the toilet and make sure that the surrounding area is clean.
• Before cleaning, put on disposable gloves if possible. 
• Place contaminated waste in a plastic bag, tie the bag and put it in a trash receptacle.
• Thoroughly clean and disinfect contaminated surfaces including doorknobs and faucets. Clean first, then spray the area with a disinfectant cleaner (e.g. Lysol) or clean with a wipe that has bleach (see Video for instructions). You can buy cleaning products at a pharmacy, grocery store and at U-M retail stores. Be mindful that bleach can harm fabrics. Dispose of used cleaning items in the trash. 
• Keep soiled clothing separate from other clothing, and wash soiled clothing or linens in hot water. Also, use pre-wash cycle if it’s available. 
• Avoid touching your eyes, nose or mouth.
• Stay home when you are sick and for 48 hours after the last episode.
• Avoid close contact with people who are sick, if possible.

More information:

90,000 Is cat vomiting a cause for concern? •

Vomiting occurs when any irritant is exposed to the body. It is important to identify the cause in order to know how to proceed.
If the irritating factor is not dangerous, then the malaise will go away on its own or with the help of home treatment. If vomiting is repeated and accompanied by other symptoms, then self-medication is not worth it, it is better to consult a specialist.

Non-dangerous causes

Vomiting in a cat is not a rare phenomenon, in this case it is necessary to pay attention to the pet’s well-being, as well as examine the vomit. They should not be cloudy or colored, they may contain various inclusions: wool, threads, blades of grass.

Pregnancy
As in humans, in cats, pregnancy can occur with toxicosis arising from hormonal disruption. Vomiting appears at 2 weeks of gestation, lasts no more than 14 days. At a later date, the cause may be fruits that put pressure on the internal organs.
Veterinarian assistance is required if vomit contains bile, blood, or mucus.

Removal of fur from the stomach
Cats are surprisingly clean animals, they constantly lick their fur for no apparent reason. Gradually, hairballs accumulate in the stomach, which the pet removes using the gag reflex.
Long-haired cat breeds most often suffer from this problem. Special pastes that dissolve formations will help to cope with tricheobesoars (hairballs).

Overeating
Some cats do not feel full, and eat all the food without residue.In this case, the body empties the overflowing stomach by vomiting.
Animal feed should be dosed to avoid vomiting and other health problems caused by overeating.

Hunger
Long breaks between feeds can also lead to vomiting. It occurs due to irritation of the gastric mucosa by digestive juices, which are secreted even in the absence of food.

Vaccination
Sometimes an allergic reaction occurs to the vaccine, which is accompanied by nausea, diarrhea, fever, lethargy, and lack of appetite may also occur.All symptoms go away on their own within 3-4 days.

Stress
Prolonged stress, trauma or shock often cause nausea in cats. The reasons may be different: moving, the appearance of a new pet in the house, repairs.

Dangerous causes

Repeated and prolonged bouts of vomiting, which are accompanied by other symptoms such as diarrhea, lack of appetite, lethargy, apathy, should alert the owner and cause a visit to the veterinary clinic.

Poisoning
Poisoning is often caused by expired food or cheap animal feed. Cats should not be allowed near household chemicals or medicines, they should be kept out of the reach of pets.

Foreign object
Small toys, threads, twigs or stones can get stuck in the esophagus, irritating its mucous membrane and causing the gag reflex. The animal can independently get rid of the foreign object, unless it is stuck too deep and does not have sharp edges.

Infectious diseases
Vomiting is one of the symptoms of various diseases: rabies, calcivirosis, panleukopenia, enteritis and others. In this case, blood or mucus can be found in the vomit.

Helminthic infestation
Intestinal parasites develop in the pet’s body, poisoning it with the products of its vital activity. In this case, a veterinarian should prescribe anthelmintic drugs. Mass death of parasites can aggravate the condition of the animal.

Diseases of internal organs
Oncological and inflammatory diseases of the gastrointestinal tract can cause frothy vomiting mixed with blood. A similar condition causes liver and kidney problems.

Types of vomiting

Having studied the color and consistency of the vomit, a preliminary diagnosis can be made. It is advisable to photograph them to show the veterinarian, this will help establish the cause.

Varieties of vomiting:

1. Foamy – most common, odorless. It appears due to irritation of the gastric mucosa with digestive juices. The reason may be long breaks between feedings, overeating, changing feed. If the attacks are frequent, accompanied by a decrease in appetite, then it is worth checking the cat for gastritis.

2. Yellow – speaks of problems with the liver or bile ducts. It occurs with helminthic invasions, pancreatitis, unbalanced diet (with excess fat).

3. With an admixture of blood – a symptom of a serious disorder of internal organs. Brown vomiting indicates bleeding in the gastrointestinal tract, scarlet vomiting indicates problems with the oral cavity or esophagus.

4. With undigested food – speaks of overeating.

5. Gray mass – typical for partially digested food, for example, with toxicosis, overeating.

When vomiting occurs in a pet, the owners need to calmly assess the situation. Usually, the cause is harmless and can be easily eliminated at home.But if additional alarming symptoms appear, do not postpone a visit to the veterinarian.

The material was prepared by specialists of the veterinary clinic of Daria Sukhova.

If you notice a change in the state of your pet, call +7 (3452) 66-21-29 or come to our veterinary clinic immediately. The sooner the veterinarian makes a diagnosis, the faster the pet will recover.

90,000 Early toxicosis of pregnant women – causes and treatment

Most women, having barely learned about the onset of pregnancy, expect poor health, bouts of nausea and even vomiting.Indeed, early toxicosis often becomes a constant companion of many expectant mothers in early pregnancy. Is there any way to relieve these unpleasant symptoms?

Toxicosis (and doctors call this condition gestosis) is a syndrome that is defined as a violation of a woman’s adaptation to pregnancy. By the time of occurrence, early gestosis is distinguished, which will be discussed in this article, and late gestosis, which appears in the last 2-3 months of pregnancy and is manifested by edema, increased blood pressure and the appearance of protein in the urine.

When early toxicosis begins during pregnancy

Early toxicosis usually occurs in the first half of pregnancy. As a rule, after the end of the formation of the placenta, that is, at 12-13 weeks of pregnancy, the symptoms of toxicosis stop. During normal pregnancy, adaptive changes in the function of almost all organs and systems occur in a woman’s body, which are regulated by the nervous system with the participation of the endocrine glands. Toxicosis occurs due to the impossibility of the adaptive mechanisms of the organism of the expectant mother to adequately meet the needs of the developing fetus.

Manifestation of early toxicosis

The most common manifestation of toxicosis is vomiting. Other forms of early toxicosis are very rare:

• dermatoses of pregnant women is a group of skin diseases that occur during pregnancy and disappear after it. When it occurs in the early stages of pregnancy, dermatosis is caused by immune disorders in the body of a pregnant woman, and also most often occurs in patients with diseases of the digestive and endocrine systems.The most common form of prenatal dermatoses is prenatal itching, which can be on a small area of ​​the skin or spread throughout the body, including the feet and palms.
• tetany (chorea) of pregnant women . This condition occurs when the function of the parathyroid glands decreases, as a result of which the exchange of calcium in the body is disturbed. Clinically, the disease is manifested by muscle cramps, more often cramps are in the fingers, sometimes in the muscles of the face.
• drooling – increased salivation, which leads to a large loss of fluid (up to 1 liter per day).Drooling can be an independent manifestation of toxicosis or accompany vomiting of pregnant women. In the development of salivation, not only changes in the central nervous system are important, but also local disturbances in the salivary glands and their ducts under the influence of hormonal changes.
• bronchial asthma of pregnant women is an extremely rare form of preeclampsia.
• osteomalacia of pregnant women – softening of bones due to impaired metabolism of calcium and phosphorus, while the bones of the pelvis and spine are more often affected
• neuropathy and psychopathy of pregnancy .

Causes of toxicosis in the early stages

There are many theories trying to explain the causes and mechanisms of development of early toxicosis: the most recognized are the so-called neuro-reflex and immunological.

According to neuro-reflex concept , vomiting occurs due to a violation of the relationship between the cerebral cortex and subcortical structures. During pregnancy, the subcortical centers of the brain begin to work more intensively than usual, which are responsible for most of the protective reflexes, including breathing and cardiac activity.In the same areas of the subcortical structures, the emetic and salivary centers, the nuclei of the olfactory system of the brain are located. Excitation processes capture them too. Therefore, nausea and vomiting may be preceded by such phenomena as deepening breathing, increased heart rate, increased amount of saliva, pallor due to vasospasm, change in smell.

A certain role in the development of gestosis is played by immunological disorders . The timing of vomiting usually coincides with the formation of blood circulation in the placenta, increased multiplication of white blood cells – lymphocytes, which are involved in immune reactions. The fetus is foreign to the mother’s body, and her immune system reacts to it in this way. After full maturation of the placenta, which accumulates all these immune cells, toxicosis usually goes away.

Human chorionic gonadotropin (hCG) plays a certain role in the development of vomiting in pregnant women. This hormone is produced by the placenta during pregnancy. Its high concentration can provoke vomiting.

Severity of toxicosis during pregnancy

The main symptom of early pregnancy toxicosis is vomiting.Depending on the frequency of its occurrence, as well as the degree of metabolic disorders in the body of the expectant mother, doctors distinguish three degrees of severity of vomiting in pregnant women.

How to cope with toxicosis and relieve symptoms

Treatment of mild toxicosis is usually carried out at home. But, nevertheless, a pregnant woman should be under the supervision of doctors, take all the tests recommended by the doctor, and follow the appointment. This will allow the doctor to monitor the state of the body of the expectant mother and prevent possible complications in time.A woman needs to organize a normal mode of sleep and rest, showing walks in the fresh air, a calm atmosphere in the family.

Proper nutrition

You need to eat in small portions, fractionally, every 2-3 hours. Food should be easily digestible, as high-calorie as possible and fortified. In connection with a decrease in appetite, they recommend a varied and pleasant food for the expectant mother, that is, the products are selected taking into account the wishes of the pregnant woman, with the exception of spicy dishes, smoked meats.It is important to remember that very hot or very cold food often induces vomiting, so the food should be warm. Shown is the intake of alkaline mineral waters in small volumes 5-6 times a day.

If nausea and vomiting occur in the morning, immediately after waking up, it is recommended to have breakfast while lying in bed without getting up. For breakfast, you can eat dry crackers, crackers, drink tea or water with lemon, light yogurt is allowed. It is better to put all this next to the bed in advance or ask someone to bring breakfast.

Every woman chooses for herself a remedy that helps fight nausea. Someone is helped by a slice of orange, lemon or apple, some expectant mothers carry croutons or mint candies to relieve symptoms of toxicosis. Pumpkin juice has a good antiemetic effect. Ginger tea helps a lot of pregnant women. It is very simple to prepare:

finely chopped or coarsely grated ginger root is poured with boiling water and infused for 15-20 minutes.Tea can be drunk warm or chilled with lemon, mint or honey.

Fats and proteins of animal origin are recommended to be consumed in the morning, when pancreatic enzymes are more active. Dairy products are best eaten after lunch or before bed.

It is not recommended to use food with preservatives, meat of broiler chickens, instant food, fast food.

To maintain metabolic processes in the body, it is advisable to drink 2-2.5 liters of liquid per day.With an increase in vomiting, it is not recommended to eat solid and liquid foods at the same time. Liquids should not be drunk 30 minutes before and within 1.5 hours after meals, as this provokes vomiting by stretching the walls of the stomach and affecting receptors.

Decoctions and infusions

Oat broth
Oat broth is recommended as a coating agent, that is, a substance that forms a mucous film and prevents irritation of receptors on the walls of the stomach and intestines.It is prepared as follows: 2-3 tbsp. spoons of oat grains are washed, pour 500-700 ml of water, simmer under a lid for 30 minutes. The broth is drained, the grains are crushed and poured with new water and boiled until fully cooked. The resulting mass is crushed with a blender. You need to consume the broth on an empty stomach and in the evening before bedtime, but not earlier than 2 hours after dinner, as well as in small portions throughout the day.
It has a particularly good effect in combination with rosehip infusion.

Rosehip infusion
This infusion is a good source of vitamins and minerals – it contains vitamins C, K, P and PP, potassium, manganese, iron, helps to normalize the function of the gallbladder. To cook it, you need 1 tbsp. pour 250 ml of boiling water over a spoonful of chopped rose hips and leave in a thermos for about 2 hours.
The following infusions and decoctions contribute to reducing nausea and improving the condition of the expectant mother.

Fitonastoy
Take equally: valerian root, common anise fruits, fireweed leaves, linden flowers, calendula flowers, blueberry shoots, blood-red hawthorn fruits.1 tbsp. pour a spoonful of the mixture crushed in a coffee grinder with 500 ml of boiling water and insist in a thermos for 2 hours, then strain. Take the infusion as needed, up to 6 times a day, heated, 1/3 cup.

Benedict’s Collection
To prepare this collection, you will need: yarrow (10 g), peppermint herb (20 g), shepherd’s purse herb (20 g), valerian rhizomes (10 g), calendula inflorescences (20 g) and chamomile inflorescences (20 G). Pour 10 g of the mixture with 400 ml of water, stand in a water bath for 30 minutes, strain. Take 50 ml 6 times a day for 25 days, three courses with 15-day breaks.

Viburnum with honey
Grind 2 tbsp. tablespoons of fresh viburnum berries, pour 250 ml of boiling water over them, heat for 10 minutes in a water bath, strain, add a little honey. Take 1/3 cup of warm infusion before meals 3-4 times a day.

Cranberries with mint, honey and lemon
Squeeze the juice from 250 g of cranberries, cool it, boil the cake in 1 liter of water, add 1 tbsp.a spoonful of mint leaves and leave for 15 minutes under the lid. Strain, dissolve in a hot broth 2-3 tbsp. tablespoons of honey, let cool to room temperature, add chilled cranberry juice and a slice of lemon. Consume 0.5 cups after meals or if nausea occurs.

Rosehip with apples
Crushed rose hips (about 1 tbsp. Spoon) pour 250 ml of boiling water, add 0. 5 tbsp. tablespoons of dried apples, heat in a water bath for 15-20 minutes.This drink can be consumed in place of tea throughout the day.

Rosehip with garden berries
To prepare a drink you will need: 1 tbsp. spoon of rose hips, 1 tbsp. spoonful of raspberries, 1 tbsp. spoon of black currant leaves, 1 tbsp. spoon of lingonberry leaves. 2 tbsp. spoon the mixture pour 500 ml of boiling water, boil for 5 minutes, leave for 1 hour, drain. Take 100 ml of broth 3 times a day.

Physiotherapy exercises

Among non-drug means, physiotherapy exercises have a good effect.The set of exercises includes walking, deep breathing with stretching of the muscles of the trunk and limbs. It is necessary to exclude inclinations, they can increase nausea. The complex includes dynamic exercises for training the muscles of the arms, legs, relaxation exercises. Remedial gymnastics also includes training in breathing techniques. As a result, the body is saturated with oxygen, the excitability of the vomiting center decreases – toxicosis is alleviated.

Physiotherapy procedures

Electrosleep, acupuncture, laser therapy are used among physiotherapeutic procedures for the treatment of early toxicosis.Electric sleep is a technique that uses low frequency currents to induce sleep. The duration of the procedure is from 60 to 90 minutes, the course of treatment is 6-8 sessions.

Laser therapy

In the complex therapy of early toxicosis, blood is irradiated with a helium-neon laser through a light guide passed through a needle placed in the ulnar vein. The procedure takes 15-20 minutes. The therapeutic effect is achieved due to the effect of the laser on blood cells, changes in its properties, the accumulation of biologically active substances in the blood.As a result, the metabolism in cells changes, the resistance of tissues and the body to unfavorable conditions increases, and vitality increases.

Acupuncture, acupuncture

These are methods of treatment based on irritation of biologically active points and zones on the body and face. With early toxicosis, such an effect changes the tone of the nervous system of a pregnant woman. An acupuncture session is performed 1-2 times a week and lasts 15-30 minutes.

For morning sickness and vomiting of pregnant women, the method of acupressure is effective.To do this, you need to press your finger on a point that is located on the inner side of the wrist, in the middle, 3 transverse fingers above the palm.

Aromatherapy

The use of plant aromas – has a positive effect on the expectant mother and baby. Inhaling pleasant aromas, you can achieve a good psychological effect, create a good mood, and reduce the symptoms of toxicosis. During pregnancy, aroma lamps, aroma medallions, pads – sachets are mainly used.To relieve nausea and vomiting, oils of laurel, lemon, lavender, real cardamom, dill, lemon balm, peppermint, anise, eucalyptus, ginger are suitable. To flavor the air, you can use the following mixture 0 3 drops of lavender oil, 1 drop of peppermint oil, 1 drop of eucalyptus oil.

Principles of early toxicosis treatment

Even with a mild course of early toxicosis of pregnant women, the attending physician will necessarily prescribe a number of tests – a general blood test, a general urine test, a biochemical blood test, a hemostasiogram.This is necessary to monitor the condition of a pregnant woman and for the timely prescription of medications to correct the changes occurring in the body.

If non-drug drugs are ineffective, the doctor prescribes drugs that help fight toxicosis. First of all, these are herbal sedatives, homeopathic medicines for nausea, vitamin B6 preparations, antiemetic medicines.

If, despite all the therapy, vomiting increases, the doctor detects changes in blood and urine tests, and body weight continues to progressively decrease, hospitalization is indicated.

In a hospital, intravenous infusion of drugs is carried out that restore fluid, microelements and proteins lost by the body. The pregnant woman receives at least 2-2. 5 liters of fluid intravenously per day.

To improve blood flow through the placenta and improve oxygen supply to the fetus, oxygen therapy can be prescribed – inhalation of an oxygen-air mixture for 20-30 minutes twice a day.

Most often, the symptoms of toxicosis gradually decrease by 12-13 weeks of pregnancy.

• At mild vomiting on an empty stomach or after eating is observed from 3 to 5 times a day. Despite vomiting, part of the food is still retained and significant weight loss is not observed in such pregnant women. The general condition does not significantly suffer, there are no changes in the blood and urine tests. Such vomiting is easily treatable with various non-drug means, and often goes away on its own after the normalization of the diet and rest.
• Moderate vomiting (or vomiting of moderate severity ) is expressed in an increase in vomiting up to 10 times a day, regardless of food intake. Persistent nausea is characteristic. The body becomes dehydrated, the body weight decreases by 3 – 5 kg (6% of the initial weight). The general condition of pregnant women worsens. Expectant mothers complain of weakness, apathy, tearfulness, sometimes depression. The skin is pale, dry, the tongue is coated with a white coating, and yellowness of the skin may be noted.
• Severe (excessive vomiting of pregnant women) is rare. The frequency of vomiting is up to 20 times a day or more. Excessive vomiting is characterized by severe dehydration and intoxication.This condition can occur as a continuation of vomiting in pregnant women of moderate severity or initially become severe. With excessive vomiting, the body weight quickly decreases, on average by 2-3 kg per week, the skin becomes dry and flabby, the subcutaneous fat quickly disappears, the tongue and lips are dry, the smell of acetone is noted from the mouth, and the body temperature can rise up to 38 degrees.
  Moderate to severe vomiting is treated in a hospital.

Doctors named the main symptoms of coronavirus in children :: Society :: RBC

Photo: John Moore / Getty Images

The main symptoms of COVID-19 in children are fever, diarrhea and vomiting. This is stated in a study by a group of pediatricians conducted in four hospitals in western China. His results are published in Plos Medicine.

According to a study, fever or fever occurs in 76% of children infected with coronavirus. 62% of infected children also had a severe cough, and another 12% had diarrhea and vomiting. Lung problems in minors appear at later stages of the disease, it follows from the analysis.

In the course of the study, pediatricians examined 34 children aged from one month to 12 years.The analysis was carried out in the period from January 27 to February 23 of the current year. All patients in the current study had mild (18%) or moderate (82%) COVID-19.

Petersburg bypassed Moscow. The most relevant about the pandemic on August 10

Earlier, in April, Rospotrebnadzor reported that children carry coronavirus infection more easily than adults. At the same time, they remain active carriers of the virus longer, the department warned. Children six to seven years old are the most vulnerable to COVID-19 among minors, the ministry said.

First aid for food poisoning

Eating spoiled foods or improperly stored dishes can provoke poisoning. The greatest danger is posed by products of animal origin infected with microorganisms.How to alleviate the patient’s condition and in what cases do you need to see a doctor?

How to identify the problem: symptoms of poisoning

Unpleasant symptoms of poisoning appear a couple of hours after the patient has eaten or drunk a poor-quality product. Among them:

• weakness,
• nausea and vomiting, repeated repeatedly,
• urge to the toilet and loose stools,
• blood pressure surges,
• fever or chills,
• dizziness and fainting.

These are the most obvious signs when the patient needs rest and first aid at home.

What food poisoning is there?

• Poisoning by substances that should not be eaten;
• Poisoning by spoiled food, including mushrooms.

Often people expose the body to harmful effects for a number of reasons: eating dirty fruits and vegetables, drinking raw water, stale dairy products.Failure to follow the rules of personal hygiene is one of the causes of the problem, especially in young children.

Help with poisoning

For food poisoning, home treatment is sometimes sufficient. Seek medical help in case of poisoning only in severe forms of damage to the digestive system, for example, in case of poisoning with mushrooms or low-quality alcohol.

First aid directly depends on when the symptoms appeared and how much time has passed since the moment of poisoning:

• If no more than two hours have passed since the poisoning, you need to drink two liters of a two percent solution of baking soda and induce vomiting (1. 5 liters of water + 1 tablespoon of soda), wash the stomach, and then take activated charcoal;
• If three to four hours have passed, then it is necessary to use sorbents that cleanse the intestines, they are taken every three hours.

To restore lost strength and water-salt balance, it is recommended to drink plenty of saline solution (up to 2-3 liters per day).

When to call a doctor?

It is necessary to call a local doctor or an ambulance when the following symptoms appear in a patient:

• not relieving abdominal pain,
• consistently high body temperature,
• persistent vomiting,
• prolonged diarrhea,
• Yellowed whites of the eyes.

If the patient does not come out of a fainting state, the stomach is swollen, and the body temperature does not drop, there are rashes on the skin and breathing is impaired, an ambulance should be called immediately. There is no need to take risks if a small child or an elderly person is poisoned, weak immunity may not be able to cope with the pathogenic microflora, therefore, in this case, a rational solution would be to turn to specialists.

What medicines to use?

After poisoning, it is recommended to use sorbents, but they need to be consumed no more than a day.In the subsequent period, they lose their effectiveness. When treating food poisoning yourself, remember:

• Do not take anti-diarrhea and vomiting drugs, they prevent the elimination of toxins from the body;
• There is no need to buy antibiotics, most often they are pointless, because intestinal poisoning is of a viral nature.

The patient is advised to rest and drink plenty of fluids, after a day or two, the condition should improve, otherwise it is recommended to consult a doctor.

What can you eat?

In case of food poisoning, it is important not to provoke additional problems, therefore, the choice of food must be taken very carefully. In the first hours, the patient, as a rule, does not want to eat at all. When vomiting has passed, you should wait a few hours and only then eat. It is recommended to introduce food products gradually, in small doses, starting with light foods: crackers, crackers, black bread or boiled rice. It is strictly forbidden to consume alcohol, dairy products, spicy and fatty foods.

How to avoid re-poisoning?

In order to prevent poisoning from becoming a frequent guest in the body, adhere to the following rules:

• Wash your hands thoroughly before preparing food, after handling food, before sitting down to the table;
• Defrost meat and fish in the refrigerator or microwave, fry thoroughly when cooking;
• Do not use dubious expired products, do not use canned food from damaged or swollen cans;
• Do not store household items for more than one year;
• Be careful when choosing food in public catering;
• Store opened cans for no more than two days, transfer the contents to dishes that do not oxidize;
• Be very careful with mushroom dishes.

Conclusion

Food poisoning is a common occurrence in the life of every person. However, it is enough to follow simple rules, and it will not be a frequent guest of your body. A healthy person with high immunity copes with poisoning on their own without additional medical assistance. But if a small child or an elderly person is poisoned, it is necessary to call a doctor or show the patient to a specialist. To make an appointment with a therapist or gastroenterologist, choose a day convenient for you and fill out the form on the website.You can also call our clinic by phone +7 (3412) 330-770. We care about your health!

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