Akathisia causes. The patient factors include mild severity of akathisia, lack of apparent motor restlessness, no voluntary expression of inner restlessness, no clear communication of inner restlessness, restlessness in body parts other than the The most common cause of akathisia is a side effect of drugs including antipsychotics, antidepressants and antiemetics. The amount of distress that it can cause is often overlooked and clinicians should be active in eliciting this symptom especially when adjusting medication regimes. e. Akathisia is a movement disorder that causes people to experience inner restlessness and constantly feel the need to move. This might include reducing the dosage or switching to lower potency antipsychotics. 5 Poor adherence to treatment, along with other risk factors, such as previous history of depressive disorder Nov 1, 2007 · Chronic akathisia is defined as akathisia persisting more than 3 months after the last antipsychotic dosage change; it does not address acuity of onset . sleepiness. Jul 24, 2023 · Akathisia is a movement disorder that may be associated with the use of antipsychotic medications. Dec 1, 2021 · Carbamazepine can, also, occasionally be a cause of akathisia. Jul 1, 2006 · Droperidol also was more noxious, causing akathisia in 71 percent of patients at the 24-hour follow-up interview compared with 23 percent of patients treated with any of the other medications Akathisia is a medical condition that causes an individual to feel restless along with a constant urge to move. It may coexist with Parkinsonian symptoms, but may be more common, and symptoms can be distressing and cause poor adherence to treatment. Apr 25, 2017 · Akathisia—rare cause of psychomotor agitation inpatients with traumatic brain injury: Case report and review of literature. Learn how to recognize, diagnose, and treat akathisia. In children, this might show up as physical discomfort, agitation, anxiety, or general irritability. ˌā-ka-ˈthizh- (ē-)ə ˌa-. It can occur when drug therapy is initiated (acute akathisia) or after chronic treatment (tardive akathisia). Akathisia is described as a state of restlessness which can Antipsychotics. Aly's FREE "Antidepressants: A Beginner's Guide" ️ https://free. This subreddit is a place for those who suffer from akathisia. [1,2] However, with the emerging evidence, it is now understood that it is not the dopamine mechanism alone which is responsible for akathisia with quetiapine. It is a neuropsychiatric syndrome that is associated with psychomotor restlessness. Aug 13, 2021 · Akathisia is a relatively common adverse effect of antipsychotics although some second-generation antipsychotics are known to have a lower liability for the condition. Many people can manage akathisia with treatment, which includes Akathisia can occur in Parkinson’s disease, traumatic brain injury, and other neurological disorders; however, it is most often a medication side effect or withdrawal syndrome. 8 The instrument is easy to Aug 17, 2023 · Akathisia is a common movement disorder associated with the use of antipsychotic medications. Akathisia is an acute medical crisis in which restlessness and agitation cause intense levels of distress, uncontrolled movement and behavioral dysregulation. Propranolol’s side effects (e. It may appear a few hours after starting the drug or it may take a few days or weeks before it begins to manifest. Mental and physical symptoms shade into one another in akathisia, in. Jan 19, 2022 · 2. Key clinical points about akathisia. 23,24 Although low-dose mirtazapine is often listed as a potential treatment for akathisia, it is included Abstract. The severity and risk factors of this condition vary from person to person, making it crucial to consult with your doctor about any symptoms you experience. When antipsychotic switching is not a viable management strategy, additional strategies include: (1) gradually lowering the antipsychotic dose if clinically In general, quetiapine is considered to have low propensity to cause EPS due to higher 5-HT2a/D2 receptor antagonism or a fast dissociation from D2. -ˈthēzh-. Akathisia occurs as a side effect of first-generation or older antipsychotic medications used for the treatment of mental disorders such Akathisia. Occasionally akathisia is induced as a withdrawal effect of certain drugs. Tardive akathisia has a delayed onset, with symptoms beginning 3 months or more after medication initiation or dosage increase . 5% of people who take antipsychotics, but can vary between 3. : a condition characterized by uncontrollable motor restlessness. Nov 22, 2018 · Gabapentin and its prodrug are candidate therapeutic agents for akathisia. For the disabling akathisia, the patient was continued on propranolol 20 mg/day and clonazepam 1 mg/day was added, while trihexyphenidyl 3 mg/day (2 mg tablet as 1-1/2) was added to treat the DIP. It is now believed that akathisia The most common cause of akathisia is iatrogenic. Fidgeting. Jan 20, 2023 · Dystonia is an involuntary movement that can occur as part pf a movement disorder or due to brain damage. aka· thi· sia. Propranolol, a non-selective beta-adrenergic receptor antagonist, is currently considered a first-line treatment for antipsychotic-induced akathisia (AIA). (1-3 months after starting treatment), it is known as tardive akathisia. Akathisia may also rarely occur with antidepressant agents. Feelings of discomfort and inner restlessness can begin within one month of starting antipsychotic medication. 3 Drug-induced akathisia is usually caused by antidopaminergic antipsychotics, particularly the conventional or non-atypical antipsychotics. 32 Akathisia should resolve after drug discontinuation, but could temporarily worsen or persist in withdrawal or tardive forms. Akathisia has been misdiagnosed for many decades (Lohr, et al. This is a place to discuss akathisia, and support Feb 14, 2024 · Tardive akathisia: Restlessness or the compulsion to move that typically affects the legs or trunk of the body. g Oct 17, 2018 · People with akathisia complain of inner restlessness and the inability to remain still. Parkinson's disease slowly gets worse over time. Akathisia is a medical condition where the sufferer experiences a painful inner restlessness and discomfort that often causes them to stay in motion all of the time, such as pacing, or leg shaking. Jun 6, 2002 · Akathisia has been well documented as a common and distressing side effect of antipsychotic drugs and an important cause of poor drug compliance. Older antipsychotic drugs are the biggest cause of akathisia symptoms. Oct 19, 2017 · Akathisia is a side effect of certain drugs that causes an uncontrollable urge to move the legs. May 21, 2013 · Akathisia is an under-recognised side effect of antipsychotic neuroleptic agents that can lead to fatal outcomes when missed. There is no definitely accepted definition of akathisia or agreement on the diagnostic features. The leading cause of akathisia is the initiation or rapid increase of traditional antipsychotics (i. 8 The instrument is easy to Recognizing akathisia is critical because it can be very distressful to patients and may cause suicidal ideations. Akathisia has been linked to an increased likelihood of developing sui­cidal ideation and behavior. I’d rather go through natural childbirth, daily. 5 Chronic akathisia persists beyond 6 months and is generally associated with less severe feelings of restlessness than during the acute phase. However, even in psychiatric settings, it is not recognised readily. be ceased, giving oral benztropine 2mg will settle the matter - whereas. 1 It can present as a diagnostic and treatment challenge affecting the Mar 1, 2010 · Extrapyramidal Symptoms. Aug 27, 2020 · Akathisia is a psychomotor syndrome involving subjective feelings of agitation and dysphoria, accompanied by repetitive and/or purposeless movement and symptoms of cognitive dysfunction such as selective attention deficit, perceptual disorder, and impaired coping responses. Learn about the types, risk factors, diagnosis, and treatment options for this condition. Can be observed as fidgety movements of the legs, rocking from foot-to-foot, pacing, and inability to sit or stand still. increased saliva (drool) production. People with akathisia suffer from repetitive movements such as pacing, rocking and swaying, fidgeting, crossing and uncrossing the legs and a general inability However, the causes are multifaceted and can include a range of factors, from medical conditions to medication side effects. The first thing the doctor will do is to change the medications you're taking that are causing the akathisia. Akathisia does cause some ‘restlessness’ and that can be ‘ uncomfortable …’ but akathisia is a motor dysfunction characterized by… and it does not ‘cause’ suicidal feelings…” The pain of akathisia is worse than anything I’ve ever experienced in my life. Dec 4, 2017 · People with choreoathetosis experience sudden, involuntary movements of the face, limbs, or trunk. noun. Jan 9, 2024 · Akathisia is an emotional state caused by over 100 different drugs, primarily antidepressants and antipsychotics, but also antibiotics, anti-hypertensives and others. Aug 25, 2022 · Akathisia is most often a side effect of medications, especially antipsychotic drugs. Objective symptoms are expressed in fussiness, restlessness, trampling on the spot, aimless movement. May 22, 2017 · Akathisia is a side effect of antipsychotic drugs that causes restlessness and an urge to move. Akathisia is a movement disorder characterized by the compulsion to be in constant motion, restlessness, and severe discomfort (primarily in the legs). Akathisia is a constant internal urge to move, pathological restlessness. Akathisia can be a quite common and very troubling side effect of psychotropic treatment. To confirm the diagnosis, if the putatively offending drug can't. Akathisia is usually grouped with extrapyramidal movement disorders (ie, movement Dr. Some patients, such as the patient presented in the clinical Akathisia. Work with your doctor to adjust your current medications. 5% and 57% depending on the medication prescribed. Psychiatric conditions: Akathisia can occur in patients with psychiatric conditions such as schizophrenia, bipolar disorder, and major depressive disorder. The causes are considered to be related to both the patient's symptoms and the clinician's attitude toward akathisia. This restlessness frequently occurs in the legs. Unlike other movement disorders, akathisia can be diagnosed solely on the basis of the patient’s subjective symptoms in the absence of any objective signs. Acute akathisia is eliminated on withdrawal of the medication. Iatrogenic chorea can be caused by anticonvulsants, among which in particular phenytoin, gabapentin, carbamazepine, and valproate. biperiden, trihexyphenidyl, benzatropine) may be considered. It is a frequent complication of drugs that block dopamine receptors, such as antipsychotic drugs. The first three usually begin Dec 3, 2021 · However, the timely recognition of akathisia is paramount as is it may cause considerable patient distress and may have an impact on treatment outcomes, leading, for example, to non-concordance and subsequent exacerbation of psychosis. It is a common side effect of drugs, such as antipsychotics and serotonin selective reuptake inhibitors (SSRIs), but it also occurs Other causes of akathisia include anxiety disorders, drug withdrawal or discontinuation states, early serotonin syndrome, restless legs syndrome, iron-deficiency anaemia and endocrinopathies. Akathisia is primarily caused by prescribed medications. variants also acathisia. Drugs like Risperidone, Amisulpride have been reported to cause extrapyramidal symptoms in the withdrawal phase, but akathisia by risperidone withdrawal have been reportedly rarely in the literature. The subjective component of the phenomenon is a painful desire to move, uncomfortable sensations, a feeling of increasing anxiety in the absence of movement. Apr 12, 2024 · Drug-induced akathisia is one of the many possible side effects that some prescription drugs, notably antipsychotics, may cause. Subacute akathisia is a dose Jan 2, 2021 · Akathisia is a symptom defined by inner restlessness and an overwhelming need to move irresistibly and incessantly. It may also occur when the dose of the drug being taken is changed or if the medication has stopped [1, 6]. Akathisia is a common, but often under-recognised, drug-induced movement disorder that can occur as an acute, subacute or tardive reaction. Withdrawal akathisia occurs while switching or stoppage of Jan 18, 2022 · A diagnosis of drug-induced parkinsonism (DIP) and akathisia was made. The most common trigger for akathisia is the use of neuroleptic drugs, also known as antipsychotics. While akathisia occurs more frequently with the use of high-potency first-generation antipsychotics (such as haloperidol and fluphenazine) (Sachdev & Loneragan, 1991; Sachdev, 1995; Ossowska, 2002), the prevalence of akathisia with intermediate (e. Less common subjective symptoms include rage Jul 24, 2023 · Akathisia is defined as an inability to remain still. They may begin as fine movements called tremors, or even as tics, and then develop into the common symptoms characteristic of dyskinesia like: Body swaying. Clinicians have become steadily more aware of this disorder, owing to original descriptions of restless movement disorder dating back to the first half of this century. May be caused by medications across a number of categories, including antipsychotics, antidepressants and Aug 27, 2020 · Acute akathisia has a relatively rapid onset and short duration, and is associated with intense dysphoria. This results in a compulsion to move. , neuroleptics), although it can also manifest as a side effect of withdrawal from Some symptoms may be mistaken for anxiety or agitation. Akathisia is a feeling of restlessness that makes it hard to sit down or hold still. Medication-Induced Akathisia. Jan 1, 2012 · Definition and classification. Dystonia can be distressing, and there are several types of treatment for it that can be effective. orthostatic May 17, 2021 · weight gain. An open-label pilot study was conducted to investigate the therapeutic potential of gabapentin enacarbil (GE) for akathisia. The Hillside Akathisia Scale is often helpful (see Physical Examination). Head bobbing. Jul 19, 2018 · Quetiapine is often an agent of choice in this setting , but other agents that have a lower propensity to cause DIP (as well as akathisia) include iloperidone and clozapine [35, 36]. Akathisia is not always related to an underlying condition. Particular care must be taken to distinguish akathisia from psychotic agitation and restless legs. Higher the strength of the medication and greater is the chance of acquiring this condition. * To learn more about this side effect, see the “Side effects Jan 19, 2002 · Akathisia (restlessness and characteristic movements of the legs) is one of the most disagreeable extrapyramidal side effects and often causes non-compliance. trouble moving or slow movements. Olanzapine was serially withdrawn at the rate of 5 mg every two days and was Feb 26, 2024 · Akathisia — Akathisia or motor restlessness is a form of levodopa withdrawal, which may resemble restless legs syndrome and usually occurs at night, several hours after the last dose of levodopa. dr Introduction: Akathisia is a medication-induced movement disorder often described by patients as restlessness or an inability to stay still. It also can cause symptoms not related to movement. Jun 23, 2023 · Causes of Akathisia: Medications: Akathisia is a common side effect of certain medications such as antipsychotics, antidepressants, and antiemetics. It is most commonly associated with antipsychotics, antidepressants, antibiotics, and anti-nausea medications; however, the list of medications and supplements that can cause it is very long. It is a sense of internal restlessness, irritability and tension without necessarily manifesting with physical signs, unlike restless legs syndrome which is typically more severe and worse at night. Left untreated, akathisia can lead to extreme anxiety and depression, as well as suicidal or violent behaviors. Feb 2, 2019 · Many antipsychotic drugs can produce drug withdrawal associated symptoms. Certain second-generation antipsychotics, such as lurasidone and the partial D2-agonist aripiprazole, are more likely to cause akathisia compared to other second-generation antipsychotics. The Diagnostic and Statistical Manual of Mental Disorders, 5 th edition (DSM-5) describes medication-induced akathisia as: Abstract. Apr 1, 2019 · Akathisia. There are two aspects of akathisia the first is the sensory Akathisia. Akathisia may also appear to be a worsening of a disorder. Symptoms include tension, anxiety, and general unease and dissatisfaction. It can result in an inability to stand, sit, or lie still, and an intense urge to move around. use of a benzodiazepine would only confuse it. Nov 18, 2018 · “Sure. Antiemetic dopamine receptor blockers (ie, metoclopramide and promethazine) can also cause akathisia (02). Antipsychotic-induced akathisia has been described as acute or tardive: the former occurs within 6 weeks of starting antipsychotics, whereas the later occurs after 3 months [Sachdev, 1995]. nausea and vomiting. Antipsychotics are thought to be the most common cause of akathisia in clinical settings. It is often interpreted as anxiety and insomnia. In evaluating patients, keep in mind that the inner restlessness that characterizes akathisia can affect the trunk, hands, and arms, as well as the legs, and can cause dys­phoria and anxiety. It may be caused by: Antipsychotic drugs (side effect) Sedatives or anti- nausea drugs (side effect) Apr 1, 2018 · The word akathisia (pronounced ak-uh – thizh – uh) has Greek origins and translates to “not to sit” or “inability to sit. It is often a side effect of antipsychotic medications, but it can also be caused by other drugs and conditions. Akathisia also can be seen in Parkinson-related conditions and untreated schizophrenia. Antipsychotics Jul 1, 2012 · Venlafaxine-induced akathisia, although rare, has been reported in the medical literature. These blockades can lead to increased cholinergic activity, resulting in acute dystonia, acute akathisia, antipsychotic-induced parkinsonism, tardive dyskinesia (TD), tardive dystonia, and tardive Feb 26, 2024 · Common signs of EPS include: Repeated muscle contractions ( dystonia) Urge to move around (akathisia) Slow movement or inability to bend (parkinsonism) Tardive dyskinesia. Antidepressants and antiemetics can also cause akathisia. ” This condition is most commonly a side effect of taking certain neuroleptic, psychotic and psychotropic drugs, although a number of other drugs can cause akathisia too. In its typical form there are two components, which are subjective and objective. Rarely, you may not be May 25, 2024 · Symptoms can vary from person to person and might appear differently depending on the type of dyskinesia diagnosed. The most frequent offenders are antipsychotics, antidepressants, anti-nausea medications, and antibiotics, but it can be caused by many other medications as well. The primary movement disorders from antipsychotic agents are akathisia, acute dystonia, pseudoparkinsonism, and tardive dyskinesia. People using these drugs have around 50-80% chances of acquiring these symptoms. This sensorimotor disorder is localized primarily in the lower limbs. Akathisia is a disorder, induced as a side effect of medications (including SSRI's and antipsychotics), which can cause a person to experience such intense inner restlessness that the sufferer is driven to violence and/or suicide. In one study of movement disorders induced by neuroleptics, akathisia was diagnosed in only 26% of patients who had it. The evidence base for the treatment of akathisia is growing, but generally the first line is to attempt to reduce or remove the Akathisia is a medical condition where the sufferer experiences a painful inner restlessness and discomfort that often causes them to stay in motion all of the time, such as pacing, or leg shaking. If the symptoms are severe enough, the agitation that it causes may be treated with neuroleptic medication that can worsen the condition if it hasn't been Jan 1, 2013 · To the Editor: Akathisia is an extrapyramidal symptom (EPS) that is characterized by an objective inability to sit or stand still and by a subjective feeling of inner restlessness. Oct 8, 2021 · The term akathisia refers to feeling restless and unable to keep your legs still. The individual with akathisia will generally experience an intense sensation of unease or an inner restlessness that usually involves the lower extremities. The akathisia syndrome is classified into several subcategories, that are most applicable to the drug-induced forms of the disorder. Dec 16, 1994 · Although it is suggested that atypical antipsychotics have a lower propensity to cause akathisia than typical agents, it is known that both have the potential to cause it depending on dose and potency (62). Nov 29, 2022 · Akathisia is a movement disorder that causes restlessness and the inability to sit still. For example, if akathisia is caused by medication, the prognosis may be improved with a change in medication. Understanding these causes is pivotal in preventing and managing this challenging condition. It is therefore important to find the underlying cause by identifying drug precipitants and associated psychopathology and excluding general medical causes. Antidepressants medications too can cause this condition. These types of medications are the oldest and include drugs such as chlorpromazine, haloperidol, and Loxitane ®. These symptoms include a reduced sense of smell, constipation, acting out dreams and a decline in thinking skills. Akathisia may be accompanied by mood disorders such as depression and anxiety. Antipsychotic medications cause four main extrapyramidal symptoms: pseudoparkinsonism, akathisia, acute dystonia, and tardive dyskinesia. Journal of Rehabilitation Research &Development, 49 (9), 1349-1354 Feb 9, 2022 · Akathisia can be reversed by decreasing the dose or stopping the medication causing the restlessness. Tardive dystonia: Constant or recurring muscle contractions in the face, neck, trunk May 8, 2020 · Akathisia is one of the most prevalent and distressing adverse effects associated with antipsychotic drug treatment. Research suggests that this side effect occurs in roughly 19. The subjective aspect consists of feelings of inner tension and restlessness, with a desire to move. Dec 20, 2021 · What causes akathisia? Antipsychotic drugs. , perphenazine) and low-potency (e. These subcategories refer to the timing and conditions at the onset of the symptoms, with the exception of psuedoakathisia. Akathisia is more prevalent in people taking first-generation antipsychotic medications. May 23, 2017 · Akathisia Causes The manifestation of akathisia is associated with the intake of neurological medications. Use of multiple akathisia-inducing drugs, recent increases in SSRI dose, previous development of akathisia, baseline psychiatric disorders, and brain trauma are among predisposing factors for akathisia. Delineation of acute akathisia from other movement disorders, such as tardive Apr 10, 2024 · Akathisia . The prognosis for Akathisia may be affected by the underlying cause. Unfortunately, this is the way of Western medicine. Non-specific anxiolytic and sedative effects of benzodiazepines alone or in combination with propranolol may be beneficial in some patients. The term akathisia is derived from the Greek word akathemi, which would mean "to never sit down". Oct 29, 2011 · Akathisia is often mistaken for anxiety, and can even present as. Sep 4, 2023 · Extrapyramidal Symptoms (EPS) are drug-induced movement disorders that occur due to antipsychotic blockade of the nigrostriatal dopamine tracts. Discontinuing the offending medication is generally considered the first treatment option, but it must be done slowly, often at a snail’s pace, to prevent further Akathisia. Akathisia is a common side effect experienced from certain antipsychotic medications. Apr 23, 2018 · The most widely used rating scale for the measurement of akathisia symptoms is the Barnes Akathisia Rating Scale, which measures objective signs and subjective (awareness and distress) symptoms of akathisia, and includes a global assessment item, on which a score of 2 or more indicates the presence of akathisia. 1 Apr 17, 2019 · Akathisia With akathisia , you may feel very restless or tense and have a constant desire to move. g. Journal of Rehabilitation Research &Development, 49 (9), 1349-1354 . What you can do For most people, insomnia is a temporary side effect of Abilify, lasting a few days to weeks. There is evidence to suggest differences in the clinical manifestation and response to treatment in acute and tardive akathisia. In many cases, drug side effects end up being worse than the original symptoms one sought relief for. Abstract. It often begins soon after a person starts on a new medication. In antipsychotic-induced akathisia associated with Parkinsonism, anticholinergic agents (e. Learn more about this disorder, its causes and symptoms. Oct 3, 2016 · Akathisia may begin within several days after treatment but usually increases with duration of treatment, occurring in up to 50% of cases within one month and 90% of cases within three months. Akathisia is one of the most vexing problems in neuropsychiatry. Treatment options for akathisia are limited. Apr 3, 2019 · Advertisement. Consumers may then be diagnosed incorrectly and wrongly treated by increasing their current dose, which could lead to a worsening of the akathisia. tremors. 1 It was first described by Haskovec, who linked symptoms of akathisia to dopamine receptor blockade in nigrostriatal regions of the brain. Oct 10, 2022 · The causes and risk factors for akathisia. The objective component is manifest May 22, 2024 · Noncompliant patients should be thoroughly assessed and asked about side effects to determine if akathisia is a potential cause. , 2015) 1: 5 days ago · Parkinson's disease causes tremors, muscle stiffness, slow or decreased movement, or loss of balance. Cause and symptoms. Presents as a very distressing subjective feeling of restlessness and dysphoria. Antiepileptics such as Lamotrigine, Carbamazepine, and Oxcarbazine have been reported to cause tics (129, 162–165). The most common cause of akathisia is iatrogenic. 2–4 Akathisia may develop at different time points during treatment with DRBAs. The core feature of akathisia is mental unease characterized by a sense of agitation, usually accompanied by motor restlessness, which can cause patients to pace up and down and This is a crucial distinction because diagnosing akathisia as a mental illness instead and treating the patient with an antipsychotic, antidepressant, or any dopamine-depleting agent would likely cause severe exacerbation of the patient’s condition. If akathisia occurs, switching to an antipsychotic with a lower risk of akathisia may improve symptoms. This side effect may cause a patient to want to stop taking their medication. The cause of akathisia must first be identified and initial treatment must be Common causes. 5 This discussion will focus on acute and chronic akathisia as opposed to tardive akathisia Akathisia can be generalized or focal; the latter often produces a sensation of burning or pain, again relieved by moving that body part. Akathisia consists of motor restlessness accompanied by subjective feelings of inner tension and discomfort, mainly in the limbs. Surprisingly, the evidence for its anti-akathisia effect is modest. The exact underlying pathology of drug-induced akathisia is far from clear, but an association with an altered The medications that most commonly cause or exacerbate akathisia are listed below, including all antipsychotics and antiemetics that deplete dopamine as well as most classes of antidepressants as they can indirectly do this as well. In an open-labeled investigator-initiated clinical trial, Nov 28, 2019 · Akathisia is a serious condition that can be temporary or permanent, depending on the cause and treatment. Dopamine blocking agents such as antipsychotics and antiemetics, may induce akathisia. Common sites for focal akathisia are the mouth and vagina. Akathisia is a movement disorder characterized by an inner sense of unease, unrest, and dysphoria. Although it is one of the most common side effects of antipsychotic medications, it is often difficult to describe by patients, and is difficult to diagnose and treat by practitioners. Akathisia is also common Jun 6, 2021 · Akathisia has a number of causes, though drug-induced akathisia is the most common. 9. If the underlying cause is a neurological disorder, however, the prognosis may be less predictable and may depend on the severity of the condition. insomnia. 2. Rob discusses akathisia and its causes, symptoms, treatment, and MORE! ***Link to Dr. al tz sh it lo em yc pp tr ha