logging in or signing up hypertension ( د/ أشرف الأباصيري) ashrafalabasiry Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 2881 Category: Education License: All Rights Reserved Like it (8) Dislike it (0) Added: September 21, 2008 This Presentation is Public Favorites: 2 Presentation Description No description available. Comments Posting comment... By: alhiedi (11 month(s) ago) nice presentation...thanksss Saving..... Post Reply Close Saving..... Edit Comment Close By: AbsentDream (12 month(s) ago) WooooooooW Great Saving..... Post Reply Close Saving..... Edit Comment Close By: venkkat (16 month(s) ago) pl arrange to mail me this presentation or allow me to download this. Saving..... Post Reply Close Saving..... Edit Comment Close By: drkkin (25 month(s) ago) will u plz allow me to download ur presentation Saving..... Post Reply Close Saving..... Edit Comment Close By: 1234alaa (28 month(s) ago) Dr Ashraf will you please email me your presentation t? My email: alaaelcharbini@yahoo.com thanks Alaa Elcharbini Saving..... Post Reply Close Saving..... Edit Comment Close loading.... See all Premium member Presentation Transcript Slide 1: HYPERTENSION (THE SILENT KILLER) BY Dr. Ashraf Al-Abasiry,MBBCh,MSc Internist Specialist,Primary Care Department Saad Specialist Hospital Email: ashrafalabasiry@yahoo.com Case Study : Case Study 1. A 45-year-old man comes in for a hand rash and is noted to have a blood pressure of 150/98 mmHg. He has no other significant medical history. He is taking no medications. Vital signs are otherwise normal. He appears well and comfortable. Skin examination reveals a mild contact dermatitis. Auscultation of the chest reveals a normal S1 and S2 with no murmur or gallop and clear lung fields bilaterally. There is no pedal edema. Dr.Ashraf Al-Abasiry Slide 3: A. What is the next diagnostic step that should be undertaken? B. What other history and physical findings would be most helpful? C. What tests should be ordered? D. How will you treat this patient? Dr.Ashraf Al-Abasiry Hypertension - Introduction : Hypertension - Introduction Hypertension has been called the “silent killer “ Because it usually causes no symptoms until a late stage of the disease . High blood pressure, termed "hypertension,“. is a condition that afflicts more than 50 million Americans and is a leading cause of morbidity and mortality. Tens of millions of Americans are not even aware of being hypertensive because it is usually asymptomatic until the damaging effects of hypertension (such as stroke, myocardial infarction, renal dysfunction, etc.) are observed. Hypertension is much more than a "cardiovascular disease" because it affects other organ systems of the body such as kidney, brain, and eye. Dr.Ashraf Al-Abasiry Definition of hypertension. : Definition of hypertension. The term "hypertension" can apply to elevations in mean arterial pressure, diastolic pressure, or systolic pressure Hypertension can be defined as :- “Chronic elevation of systolic blood pressure > 140 mmHg and or diastolic blood pressure > 90 mmHg” . Dr.Ashraf Al-Abasiry Slide 6: Figure 63-2 Percentage of hypertensive patients whose blood pressures are both treated and controlled to either less than 140/90 mm Hg or less than 160/95 mm Hg in different countries. (From Laragh J: Laragh's lessons in pathophysiology and clinical pearls for treating hypertension. Am J Hypertens 2001;14:84–86. Redrawn with permission from Mancia G, Grassi G: Rationale for the use of a fixed dose combination in the treatment of hypertension. Eur Heart J 1999;1 [suppl L]:L14–L19.) Dr.Ashraf Al-Abasiry Slide 7: ٭ In 90-95% of patients presenting with hypertension, the cause is unknown. This condition is called primary (or essential) hypertension. ٭ The remaining 5-10% of hypertensive patients have hypertension that results secondarily from renal disease, endocrine disorders, or other identifiable causes. This form of hypertension is called secondary hypertension Dr.Ashraf Al-Abasiry Categorising hypertension. The pathogenesis of essential hypertension remains unclear. . What is known is that cardiac output is raised early in the disease course, with total peripheral resistance (TPR) normal, over time cardiac output drops to normal levels and it is an increased (TPR) that maintains the elevated blood pressure.The resistant vessels( the small arteries & arterioles)show structure changes in hypertension .there are increase in wall thickness with a reduction in the vessel lumen diameter. : The pathogenesis of essential hypertension remains unclear. . What is known is that cardiac output is raised early in the disease course, with total peripheral resistance (TPR) normal, over time cardiac output drops to normal levels and it is an increased (TPR) that maintains the elevated blood pressure.The resistant vessels( the small arteries & arterioles)show structure changes in hypertension .there are increase in wall thickness with a reduction in the vessel lumen diameter. Essential (primary) hypertension Dr.Ashraf Al-Abasiry Other factors that may be involved in the pathogenesis of essential hypertension are the following : Other factors that may be involved in the pathogenesis of essential hypertension are the following (1)-An overactive renin / angiotension system leads to vasoconstriction and retention of sodium and water. The increase in blood volume leads to hypertension. (2)-An overactive sympathetic nervous system, leading to increased stress responses. (3) Defect in naturesis. Is is also known that hypertension is highly heritable and polygenic (caused by more than one gene) and a few candidate genes have been postulated in the etiology of this condition. Dr.Ashraf Al-Abasiry Renin-Angiotensin-Aldosteron System : Renin-Angiotensin-Aldosteron System Dr.Ashraf Al-Abasiry Secondary Hypertension : Secondary Hypertension Secondary hypertension accounts for approximately 5-10% of all cases of hypertension, with the remaining being primary hypertension. Secondary hypertension has an identifiable cause whereas primary hypertension has no known cause (i.e., idiopathic). Patients with secondary hypertension are best treated by controlling or removing the underlying disease or pathology, although they may still require antihypertensive drugs Dr.Ashraf Al-Abasiry Slide 12: *Renal artery stenosis *Chronic renal disease *Primary hyperaldosteronism *Cushing’s syndrome or steroid *Sleep apnea *Hyper- or hypothyroidism *Pheochromocytoma *Preeclampsia *Aortic coarctation *Drug induced/ related causes for secondary hypertension are : Dr.Ashraf Al-Abasiry Slide 13: Regardless of the origin of hypertension, the actual increase in arterial blood pressure is caused by either an increase in systemic vascular resistance (SVR) or an increase in cardiac output (CO). The former is determined by the vascular tone (i.e., state of constriction) of systemic resistance vessels, whereas the latter is determined by heart rate and stroke volume. Therefore, in order to understand how arterial blood pressure can become elevated, it is necessary to understand the mechanisms that regulate both SVR and CO. Hemodynamic basis of hypertension. Dr.Ashraf Al-Abasiry Slide 14: Dr.Ashraf Al-Abasiry Risk Factors for high blood pressure : Risk Factors for high blood pressure Modifiable (we can change) Smoking Raised cholesterol Diabetes Obesity Stress Lack off exercise Diet-salt alcohol Non-modifiable(we can’t change) Genetic factor Gender-more men than women get high blood pressure Age Racial background Dr.Ashraf Al-Abasiry Long-term effects of high blood pressure : Long-term effects of high blood pressure While elevated blood pressure alone is not an illness, it often requires treatment due to its short- and long-term effects on many organs. The risk is increased for: Cerebrovascular accident (CVAs or strokes) Myocardial infarction (heart attack) Hypertensive cardiomyopathy (heart failure due to chronically high blood pressure) Hypertensive retinopathy - damage to the retina Hypertensive nephropathy - chronic renal failure due to chronically high blood pressure Dr.Ashraf Al-Abasiry Hypertensive Retinopathy : Hypertensive Retinopathy Dr.Ashraf Al-Abasiry approach to the Patient : approach to the Patient Dr.Ashraf Al-Abasiry Medical History : Medical History The history should focus on modifiable lifestyle factors including weight change, dietary intake of sodium and cholesterol, level of exercise, psychosocial stressors, and patterns of alcohol and tobacco use. Determine all medications being used--including herbal supplements, over-the-counter, prescription, and illicit drugs--as many agents may temporarily elevate blood pressure and/or adversely affect blood pressure control. A family history of hypertension, cardiovascular disease, cerebrovascular disease, diabetes mellitus, and dyslipidemia should be documented The patient with mild hypertension is usually asymptomatic Dr.Ashraf Al-Abasiry Cont, : Cont, Higher levels of blood pressure may be associated with headaches ,epistaxis or nocturia. Malignant hypertension may present with severe headaches, visual disturbances, fits, transient loss of consciousness or symptoms of heart failure. Attacks of sweating, headaches, and palpitations may point towards the diagnosis of pheochromocytoma. Breathlessness may be present owing to left ventricular hypertrophy or cardiac failure . Dr.Ashraf Al-Abasiry Physical examination : Physical examination 2 or more BP measurements separated by 2 minutes with patient seating & after standing for at least 2 minutes. Verification on contra lateral arm ( if values are different, the higher value should be used ) Measurement of height ,weight, waist circumference. Fundoscopic examination for hypertensive retinopathy. Examination of the neck for carotid bruits, distended veins, or and enlarged thyroid gland The initial physical examination should include the followings Dr.Ashraf Al-Abasiry Physical examination ( cont) : Physical examination ( cont) Examination of the heart for abnormalities of rate rhythm,increased size,third or fourth heart sounds Examination of the lung for rales or bronchospasm. Examination of the abdomen for bruits,enlarged kidney,masses.abdominal abdominal pulsation. Examination of extremeties for diminished pulsation,or peripheral pulsation,or oedema. Neurological examination, Dr.Ashraf Al-Abasiry Investigations commonly performed in newly diagnosed hypertension : Investigations commonly performed in newly diagnosed hypertension Tests are undertaken to identify possible causes of secondary hypertension, and seek evidence for end-organ damage to the heart itself or the eyes (retina) and kidneys. Diabetes and raised cholesterol levels being additional risk factors for the development of cardiovascular disease are also tested for as they will also require management Blood tests commonly performed include: Creatinine (renal function) - to identify both underlying renal disease as a cause of hypertension and conversely hypertension causing onset of kidney damage. Also a baseline for later monitoring the possible side-effects of certain antihypertensive drugs Electrolytes (sodium, potassium) Glucose - to identify diabetes mellitus Lipid panel ,CBC,Serum uric acid Dr.Ashraf Al-Abasiry Additional tests often include: : Additional tests often include: Testing of urine samples for proteinuria - again to pick up underlying kidney disease or evidence of hypertensive renal damage. Electrocardiogram (EKG/ECG) - for evidence of the heart being under strain from working against a high blood pressure. Also may show resulting thickening of the heart muscle (left ventricular hypertrophy) or of the occurrence of previous silent cardiac disease (either subtle electrical conduction disruption or even a myocardial infarction). Chest X-ray - again for signs of cardiac enlargement or evidence of cardiac failure. Dr.Ashraf Al-Abasiry Slide 25: Dr.Ashraf Al-Abasiry Classification of Blood Pressure ( BP)( JNC7) : Classification of Blood Pressure ( BP)( JNC7) Dr.Ashraf Al-Abasiry Slide 27: Dr.Ashraf Al-Abasiry Slide 28: Dr.Ashraf Al-Abasiry Slide 29: Dr.Ashraf Al-Abasiry Slide 30: Dr.Ashraf Al-Abasiry Slide 31: 2003 European Societyof Hypertension-European Society of cardiology Guiedlines for the management off arterial hypertension –guidelines Committee Dr.Ashraf Al-Abasiry Slide 32: Dr.Ashraf Al-Abasiry Slide 33: Risk factors for cardiovascular diseases used for stratification *Levels of systolic and diastolic BP *Men >55 years / Woman >65 years *Smoking * Dyslipidemia ( total ch > 6.5 mmole/l or LDL > 4 mmole/l or HDL < 1 w < 1.2 mmole/l *Family history of premature cardiovascular disease ( at age < 55 years for M or < 65 years for W *Abdominal obesity ( abdominal circumference M ≥ 102 cm .W ≥ 88cm *C-reactive protein ≥ 1 mg/dl Dr.Ashraf Al-Abasiry Slide 34: Dr.Ashraf Al-Abasiry Slide 35: Dr.Ashraf Al-Abasiry Slide 36: Dr.Ashraf Al-Abasiry Slide 37: Dr.Ashraf Al-Abasiry You do not have the permission to view this presentation. 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hypertension ( د/ أشرف الأباصيري) ashrafalabasiry Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 2881 Category: Education License: All Rights Reserved Like it (8) Dislike it (0) Added: September 21, 2008 This Presentation is Public Favorites: 2 Presentation Description No description available. Comments Posting comment... By: alhiedi (11 month(s) ago) nice presentation...thanksss Saving..... Post Reply Close Saving..... Edit Comment Close By: AbsentDream (12 month(s) ago) WooooooooW Great Saving..... Post Reply Close Saving..... Edit Comment Close By: venkkat (16 month(s) ago) pl arrange to mail me this presentation or allow me to download this. Saving..... Post Reply Close Saving..... Edit Comment Close By: drkkin (25 month(s) ago) will u plz allow me to download ur presentation Saving..... Post Reply Close Saving..... Edit Comment Close By: 1234alaa (28 month(s) ago) Dr Ashraf will you please email me your presentation t? My email: alaaelcharbini@yahoo.com thanks Alaa Elcharbini Saving..... Post Reply Close Saving..... Edit Comment Close loading.... See all Premium member Presentation Transcript Slide 1: HYPERTENSION (THE SILENT KILLER) BY Dr. Ashraf Al-Abasiry,MBBCh,MSc Internist Specialist,Primary Care Department Saad Specialist Hospital Email: ashrafalabasiry@yahoo.com Case Study : Case Study 1. A 45-year-old man comes in for a hand rash and is noted to have a blood pressure of 150/98 mmHg. He has no other significant medical history. He is taking no medications. Vital signs are otherwise normal. He appears well and comfortable. Skin examination reveals a mild contact dermatitis. Auscultation of the chest reveals a normal S1 and S2 with no murmur or gallop and clear lung fields bilaterally. There is no pedal edema. Dr.Ashraf Al-Abasiry Slide 3: A. What is the next diagnostic step that should be undertaken? B. What other history and physical findings would be most helpful? C. What tests should be ordered? D. How will you treat this patient? Dr.Ashraf Al-Abasiry Hypertension - Introduction : Hypertension - Introduction Hypertension has been called the “silent killer “ Because it usually causes no symptoms until a late stage of the disease . High blood pressure, termed "hypertension,“. is a condition that afflicts more than 50 million Americans and is a leading cause of morbidity and mortality. Tens of millions of Americans are not even aware of being hypertensive because it is usually asymptomatic until the damaging effects of hypertension (such as stroke, myocardial infarction, renal dysfunction, etc.) are observed. Hypertension is much more than a "cardiovascular disease" because it affects other organ systems of the body such as kidney, brain, and eye. Dr.Ashraf Al-Abasiry Definition of hypertension. : Definition of hypertension. The term "hypertension" can apply to elevations in mean arterial pressure, diastolic pressure, or systolic pressure Hypertension can be defined as :- “Chronic elevation of systolic blood pressure > 140 mmHg and or diastolic blood pressure > 90 mmHg” . Dr.Ashraf Al-Abasiry Slide 6: Figure 63-2 Percentage of hypertensive patients whose blood pressures are both treated and controlled to either less than 140/90 mm Hg or less than 160/95 mm Hg in different countries. (From Laragh J: Laragh's lessons in pathophysiology and clinical pearls for treating hypertension. Am J Hypertens 2001;14:84–86. Redrawn with permission from Mancia G, Grassi G: Rationale for the use of a fixed dose combination in the treatment of hypertension. Eur Heart J 1999;1 [suppl L]:L14–L19.) Dr.Ashraf Al-Abasiry Slide 7: ٭ In 90-95% of patients presenting with hypertension, the cause is unknown. This condition is called primary (or essential) hypertension. ٭ The remaining 5-10% of hypertensive patients have hypertension that results secondarily from renal disease, endocrine disorders, or other identifiable causes. This form of hypertension is called secondary hypertension Dr.Ashraf Al-Abasiry Categorising hypertension. The pathogenesis of essential hypertension remains unclear. . What is known is that cardiac output is raised early in the disease course, with total peripheral resistance (TPR) normal, over time cardiac output drops to normal levels and it is an increased (TPR) that maintains the elevated blood pressure.The resistant vessels( the small arteries & arterioles)show structure changes in hypertension .there are increase in wall thickness with a reduction in the vessel lumen diameter. : The pathogenesis of essential hypertension remains unclear. . What is known is that cardiac output is raised early in the disease course, with total peripheral resistance (TPR) normal, over time cardiac output drops to normal levels and it is an increased (TPR) that maintains the elevated blood pressure.The resistant vessels( the small arteries & arterioles)show structure changes in hypertension .there are increase in wall thickness with a reduction in the vessel lumen diameter. Essential (primary) hypertension Dr.Ashraf Al-Abasiry Other factors that may be involved in the pathogenesis of essential hypertension are the following : Other factors that may be involved in the pathogenesis of essential hypertension are the following (1)-An overactive renin / angiotension system leads to vasoconstriction and retention of sodium and water. The increase in blood volume leads to hypertension. (2)-An overactive sympathetic nervous system, leading to increased stress responses. (3) Defect in naturesis. Is is also known that hypertension is highly heritable and polygenic (caused by more than one gene) and a few candidate genes have been postulated in the etiology of this condition. Dr.Ashraf Al-Abasiry Renin-Angiotensin-Aldosteron System : Renin-Angiotensin-Aldosteron System Dr.Ashraf Al-Abasiry Secondary Hypertension : Secondary Hypertension Secondary hypertension accounts for approximately 5-10% of all cases of hypertension, with the remaining being primary hypertension. Secondary hypertension has an identifiable cause whereas primary hypertension has no known cause (i.e., idiopathic). Patients with secondary hypertension are best treated by controlling or removing the underlying disease or pathology, although they may still require antihypertensive drugs Dr.Ashraf Al-Abasiry Slide 12: *Renal artery stenosis *Chronic renal disease *Primary hyperaldosteronism *Cushing’s syndrome or steroid *Sleep apnea *Hyper- or hypothyroidism *Pheochromocytoma *Preeclampsia *Aortic coarctation *Drug induced/ related causes for secondary hypertension are : Dr.Ashraf Al-Abasiry Slide 13: Regardless of the origin of hypertension, the actual increase in arterial blood pressure is caused by either an increase in systemic vascular resistance (SVR) or an increase in cardiac output (CO). The former is determined by the vascular tone (i.e., state of constriction) of systemic resistance vessels, whereas the latter is determined by heart rate and stroke volume. Therefore, in order to understand how arterial blood pressure can become elevated, it is necessary to understand the mechanisms that regulate both SVR and CO. Hemodynamic basis of hypertension. Dr.Ashraf Al-Abasiry Slide 14: Dr.Ashraf Al-Abasiry Risk Factors for high blood pressure : Risk Factors for high blood pressure Modifiable (we can change) Smoking Raised cholesterol Diabetes Obesity Stress Lack off exercise Diet-salt alcohol Non-modifiable(we can’t change) Genetic factor Gender-more men than women get high blood pressure Age Racial background Dr.Ashraf Al-Abasiry Long-term effects of high blood pressure : Long-term effects of high blood pressure While elevated blood pressure alone is not an illness, it often requires treatment due to its short- and long-term effects on many organs. The risk is increased for: Cerebrovascular accident (CVAs or strokes) Myocardial infarction (heart attack) Hypertensive cardiomyopathy (heart failure due to chronically high blood pressure) Hypertensive retinopathy - damage to the retina Hypertensive nephropathy - chronic renal failure due to chronically high blood pressure Dr.Ashraf Al-Abasiry Hypertensive Retinopathy : Hypertensive Retinopathy Dr.Ashraf Al-Abasiry approach to the Patient : approach to the Patient Dr.Ashraf Al-Abasiry Medical History : Medical History The history should focus on modifiable lifestyle factors including weight change, dietary intake of sodium and cholesterol, level of exercise, psychosocial stressors, and patterns of alcohol and tobacco use. Determine all medications being used--including herbal supplements, over-the-counter, prescription, and illicit drugs--as many agents may temporarily elevate blood pressure and/or adversely affect blood pressure control. A family history of hypertension, cardiovascular disease, cerebrovascular disease, diabetes mellitus, and dyslipidemia should be documented The patient with mild hypertension is usually asymptomatic Dr.Ashraf Al-Abasiry Cont, : Cont, Higher levels of blood pressure may be associated with headaches ,epistaxis or nocturia. Malignant hypertension may present with severe headaches, visual disturbances, fits, transient loss of consciousness or symptoms of heart failure. Attacks of sweating, headaches, and palpitations may point towards the diagnosis of pheochromocytoma. Breathlessness may be present owing to left ventricular hypertrophy or cardiac failure . Dr.Ashraf Al-Abasiry Physical examination : Physical examination 2 or more BP measurements separated by 2 minutes with patient seating & after standing for at least 2 minutes. Verification on contra lateral arm ( if values are different, the higher value should be used ) Measurement of height ,weight, waist circumference. Fundoscopic examination for hypertensive retinopathy. Examination of the neck for carotid bruits, distended veins, or and enlarged thyroid gland The initial physical examination should include the followings Dr.Ashraf Al-Abasiry Physical examination ( cont) : Physical examination ( cont) Examination of the heart for abnormalities of rate rhythm,increased size,third or fourth heart sounds Examination of the lung for rales or bronchospasm. Examination of the abdomen for bruits,enlarged kidney,masses.abdominal abdominal pulsation. Examination of extremeties for diminished pulsation,or peripheral pulsation,or oedema. Neurological examination, Dr.Ashraf Al-Abasiry Investigations commonly performed in newly diagnosed hypertension : Investigations commonly performed in newly diagnosed hypertension Tests are undertaken to identify possible causes of secondary hypertension, and seek evidence for end-organ damage to the heart itself or the eyes (retina) and kidneys. Diabetes and raised cholesterol levels being additional risk factors for the development of cardiovascular disease are also tested for as they will also require management Blood tests commonly performed include: Creatinine (renal function) - to identify both underlying renal disease as a cause of hypertension and conversely hypertension causing onset of kidney damage. Also a baseline for later monitoring the possible side-effects of certain antihypertensive drugs Electrolytes (sodium, potassium) Glucose - to identify diabetes mellitus Lipid panel ,CBC,Serum uric acid Dr.Ashraf Al-Abasiry Additional tests often include: : Additional tests often include: Testing of urine samples for proteinuria - again to pick up underlying kidney disease or evidence of hypertensive renal damage. Electrocardiogram (EKG/ECG) - for evidence of the heart being under strain from working against a high blood pressure. Also may show resulting thickening of the heart muscle (left ventricular hypertrophy) or of the occurrence of previous silent cardiac disease (either subtle electrical conduction disruption or even a myocardial infarction). Chest X-ray - again for signs of cardiac enlargement or evidence of cardiac failure. Dr.Ashraf Al-Abasiry Slide 25: Dr.Ashraf Al-Abasiry Classification of Blood Pressure ( BP)( JNC7) : Classification of Blood Pressure ( BP)( JNC7) Dr.Ashraf Al-Abasiry Slide 27: Dr.Ashraf Al-Abasiry Slide 28: Dr.Ashraf Al-Abasiry Slide 29: Dr.Ashraf Al-Abasiry Slide 30: Dr.Ashraf Al-Abasiry Slide 31: 2003 European Societyof Hypertension-European Society of cardiology Guiedlines for the management off arterial hypertension –guidelines Committee Dr.Ashraf Al-Abasiry Slide 32: Dr.Ashraf Al-Abasiry Slide 33: Risk factors for cardiovascular diseases used for stratification *Levels of systolic and diastolic BP *Men >55 years / Woman >65 years *Smoking * Dyslipidemia ( total ch > 6.5 mmole/l or LDL > 4 mmole/l or HDL < 1 w < 1.2 mmole/l *Family history of premature cardiovascular disease ( at age < 55 years for M or < 65 years for W *Abdominal obesity ( abdominal circumference M ≥ 102 cm .W ≥ 88cm *C-reactive protein ≥ 1 mg/dl Dr.Ashraf Al-Abasiry Slide 34: Dr.Ashraf Al-Abasiry Slide 35: Dr.Ashraf Al-Abasiry Slide 36: Dr.Ashraf Al-Abasiry Slide 37: Dr.Ashraf Al-Abasiry