DIABETES AND CARDIOVASCULAR DISEASE - THE CONTINUUMPraveen Nagula
DIABETES IS ONE OF THE MOST COMMON NONCOMMUNICABLE DISEASES WORLD WIDE.
EVERY 6 SECONDS ONE PERSON IS AFFECTED BY DIABETES..
THEME FOR 2014-2016
LETS UNITE FOR DIABETES
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
DIABETES AND CARDIOVASCULAR DISEASE - THE CONTINUUMPraveen Nagula
DIABETES IS ONE OF THE MOST COMMON NONCOMMUNICABLE DISEASES WORLD WIDE.
EVERY 6 SECONDS ONE PERSON IS AFFECTED BY DIABETES..
THEME FOR 2014-2016
LETS UNITE FOR DIABETES
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
1. A Case report of Heart Failure
2. Discussion on Heart Failure
3. Role of Peptides in Heart Failure
4. Importance of 30 days in heart failure
5. Role of ENTRESTO in Stable Heart Failure patient (PARADIGM-HF study)(HFrEF)
6. Biomarkers in Heart Failure
7. Role of ARNI in Hospitalized Heart Failure patient (PIONEER-HF study)
8. Role of ARNI in HFpEF (PARAMOUNT Trial)
9. Safety and usefulness of ACEI/ARB/ARNI
10. Role of SGPL2 inhibitors in HF with/without DM
Diabetes mellitus (DM) refers to a group of common metabolic disorders that share the phenotype of hyperglycemia.
Several distinct types of DM are caused by a complex interaction of genetics and environmental factors.
Depending on the etiology of the DM, factors contributing to hyperglycemia include reduced insulin secretion, decreased glucose utilization, and increased glucose production.
The metabolic dysregulation associated with DM causes secondary pathophysiologic changes in multiple organ systems that impose a tremendous burden on the individual with diabetes and on the health care system.
1. A Case report of Heart Failure
2. Discussion on Heart Failure
3. Role of Peptides in Heart Failure
4. Importance of 30 days in heart failure
5. Role of ENTRESTO in Stable Heart Failure patient (PARADIGM-HF study)(HFrEF)
6. Biomarkers in Heart Failure
7. Role of ARNI in Hospitalized Heart Failure patient (PIONEER-HF study)
8. Role of ARNI in HFpEF (PARAMOUNT Trial)
9. Safety and usefulness of ACEI/ARB/ARNI
10. Role of SGPL2 inhibitors in HF with/without DM
Diabetes mellitus (DM) refers to a group of common metabolic disorders that share the phenotype of hyperglycemia.
Several distinct types of DM are caused by a complex interaction of genetics and environmental factors.
Depending on the etiology of the DM, factors contributing to hyperglycemia include reduced insulin secretion, decreased glucose utilization, and increased glucose production.
The metabolic dysregulation associated with DM causes secondary pathophysiologic changes in multiple organ systems that impose a tremendous burden on the individual with diabetes and on the health care system.
Prof. DR. Dr. Rochmad Romdoni, SpJP(K), FINASIM, FIHA, FAsCC. 3rd Pekanbaru Cardiology Update, August 24th 2013. Pangeran Hotel Pekanbaru. Learn more at PerkiPekanbaru.com
Secondary Prevention after ACS: Focused on Anticoagulant TherapyPERKI Pekanbaru
Dr. Nathania Marliani Kristanti, SpJP, FIHA. 3rd Pekanbaru Cardiology Update, August 25th 2013. Pangeran Hotel Pekanbaru. Learn more at PerkiPekanbaru.com
Strategy to Go for Goal in Dyslipidemia with Acute Coronary Syndrome PatientsPERKI Pekanbaru
Dr. A. Fauzi Yahya, SpJP (K), FIHA, FAsCC. 3rd Pekanbaru Cardiology Update, August 24th 2013. Pangeran Hotel Pekanbaru. Learn more at PerkiPekanbaru.com
Antiplatelet therapy there is a gap between guidelines and implementationA.Salam Sharif
platelets play an important role in cardiovascular diseases, the final event leading to ACS is a spontaneous atherosclerotic plaques which initiates a platelet response with platelet adhesion to vascular wall with activation and agregation and finally clot formation with clinical sequences od CV deaths, MI and myocardial ischemia and arrhythmias, so atiplatelet therapy is crucial in treatment of ACS, in the topic I review the traditional agents and new agents , focusing on guidelines and real world of their cinical uses .
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
2. Power of Prevention
“An ounce of prevention is worth a pound of cure”
Benjamin Franklin, 1736
3. 3
Burden of Atherosclerotic Vascular
Disease: CAD, CVD, PVD
• Prevalence– 25 million in United States
• Annual rates
Myocardial infarction–1.2 million
Strokes-795,000
CVD Mortality–814,000 (every 30 seconds a death)
Cardiac catheterization–1.1 million
Percutaneous revascularization–622,00
Surgical revascularization–232,000
• Annual direct cost–>$280 billion
American Heart Association. 2011 Heart and Stroke Statistical Update. At: http://www.americanheart.org.
4. 4
Centers for Disease Control and Prevention. Available at:
http://www.cdc.gov/nchs/ppt/hus/HUS2004Chartbk.ppt#280,25,Slide25. Accessed July 11, 2005.
Stroke
Cancer
Heart disease
Unintentional injuries
Chronic lower
respiratory disease
1000
100
10
1950 1960 1970 1980 1985 1990 1995 2002
Death Rates for Leading Causes of Death for All Ages (US, 1950-2002)
Year
Deathsper100,000Population(logscale)
Cardiovascular Disease Remains the
Leading Killer of Men and Women
6. 6
Nitrates
Calcium Channel Blockers
Beta Blockers
Diet
Exercise
Vitamin E
Vitamin C
Beta Carotene
Iron Chelation
Calcium Chelation
Alcohol
Red Wine
Folate
Vitamin B12
Biofeedback
Meditation
Blood Pressure Control
Glucose Control
Estrogen
Oat Bran
Walnuts
Garlic
ACE Inhibitors
Aspirin Coumadin
Gene Therapy
Olive Oil
Weight Loss
Fish Oils
Vegetables
L-Arginine
Stents
Niacin
Statins
Fibrates
Resins
Anti-Oxidants
Lasers
Acupuncture
Platelet antagonists
Phlebotomy
Fiber
Thyroid Hormones
Soy Beans
?
Potential Therapies for Atherosclerosis
7. 7
Secondary Prevention Guidelines
• Since the 2006 update of the AHA/ACC consensus
statement on secondary prevention, important evidence
from clinical trials has emerged that further supports and
broadens the merits of aggressive risk reduction therapies
• This growing body of evidence confirms that aggressive
comprehensive risk factor management improves survival,
reduces recurrent events and the need for interventional
procedures, and improves the quality of life
• The secondary prevention patient population includes
those with established coronary and other atherosclerotic
vascular disease, including peripheral arterial disease,
atherosclerotic aortic disease and carotid artery disease.
8. 8
Secondary Prevention Definition
• Therapy to reduce recurrent cardiovascular events and
decrease cardiovascular mortality in patients with
established atherosclerotic vascular disease
• Patients covered include those with established
coronary and other atherosclerotic vascular disease,
including peripheral arterial disease, atherosclerotic aortic
disease and carotid artery disease
• Individuals with sub-clinical atherosclerosis and patients
whose only manifestation is diabetes are covered in other
guidelines
9. 9
• Aspirin
• Clopidogrel
• β-blockers
• ACE inhibitors/ARBs
• Aldosterone blockade (Low EF)
• Lipids
- Fasting lipid panel within 24 h
of hospitalization
– Statins before discharge
– Goal LDL-C <100 mg/dL
– LDL <70 mg/dL is reasonable
• BP <140/90 mm Hg (<130/80
mm Hg with diabetes or CKD)
• Smoking cessation/no
environmental smoke
exposure
• Physical activity (30 min,
7 d/wk; min 5 d/wk)
• Weight management
• Diabetes management: HbA1c
<7%
• Annual influenza
immunization
Medications Goals
King SB 3rd, et al. J Am Coll Cardiol. 2008;51:172-209.
Anderson JL, et al. J Am Coll Cardiol. 2007;50:652-726.
Secondary Prevention:
10. 10
Class I
Benefit >>> Risk
Procedure or
treatment SHOULD
be performed or
administered
Class IIa
Benefit >> Risk
Additional studies with
focused objectives
needed
IT IS REASONABLE to
perform procedure or
administer treatment
Class IIb
Benefit ≥ Risk
Additional studies with
broad objectives
needed; Additional
registry data would be
helpful
Procedure or treatment
MAY BE CONSIDERED
Class III
Risk ≥ Benefit
No additional studies
needed
Procedure or treatment
should NOT be
performed or
administered SINCE IT
IS NOT HELPFUL AND
MAY BE HARMFUL
Applying Classification of Recommendations
and Level of Evidence
A: Multiple randomized controlled trials
B: Single trial, non-randomized studies
C: Expert opinion
Level of
Evidence
12. 12
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
Beta-blocker therapy should be used in all patients with
left ventricular systolic dysfunction (ejection fraction
40%) with heart failure or prior myocardial infarction,
unless contraindicated. (Use should be limited to
carvedilol, metoprolol succinate, or bisoprolol, which
have been shown to reduce mortality.)
Beta-blocker therapy should be started and continued for
3 years in all patients with normal left ventricular
function who have had myocardial infarction or ACS
Consider chronic therapy for all other patients with
coronary or other vascular disease or diabetes unless
contraindicated.
MI=Myocardial infarction, HF=Heart Failure
ββββ-blocker Recommendations
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
13. 13
Phase of
Treatment
Acute
treatment
Secondary
prevention
Overall
Total #
Patients
28,970
24,298
53,268
0.5 1.0 2.0
RR of death
β-blocker
better
RR (95% CI)
Placebo
better
0.87 (0.77-0.98)
0.77 (0.70-0.84)
0.81 (0.75-0.87)
ββββ-blocker Evidence
Antman E, Braunwald E. Acute Myocardial Infarction. In: Braunwald E, Zipes DP, Libby P, eds. Heart
Disease: A textbook of Cardiovascular Medicine, 6th ed., Philadelphia, PA: W.B. Sanders, 2001, 1168.
Summary of Secondary Prevention Trials of β-blocker Therapy
CI=Confidence interval, RR=Relative risk
14. 14
6,644 patients with LVEF <0.40 after a MI with or without HF randomized to
carvedilol or placebo for 24 months
The CAPRICORN Investigators. Lancet. 2001;357:1385–1390.
RR 0.77 P=.03
0.7
0.75
0.8
0.85
0.9
0.95
1
0 0.5 1 1.5 2 2.5
Carvedilol
Placebo
Years
ProportionEvent-free
n=975
n=984
ββββ-blocker Evidence: Post MI with
Left Ventricular Dysfunction
Carvedilol Post-Infarct Survival Control in LV Dysfunction
(CAPRICORN)
16. 16
Study Drug
HF
Severity
Patients
(n)
Follow-up
(years)
Mean
Dosage
Effects on Outcomes
CIBIS Bisoprolol* Moderate-
Severe
641 1.9 3.8
mg/day
All cause mortality
↓↓↓↓22% (p=NS)
CIBIS-II Bisoprolol* Moderate-
Severe
2,647 1.3 7.5
mg/day
All cause mortality
↓↓↓↓34% (P<0.0001)
BEST Bucindolol* Moderate-
Severe
2,708 2.0 152
mg/day
All cause mortality
↓↓↓↓10% (p=NS)
MERIT-HF Metoprolol
succinate#
Mild-
Moderate
3,991 1.0 159
mg/day
All cause mortality
↓↓↓↓34% (P=0.0062)
MDC Metprolol
tartrate*
Mild-
Moderate
383 1.0 108
mg/day
Death or Need for Tx
↓↓↓↓30% (P=NS)
CAPRICORN Carvedilol Mild 1,989 1.3 40
mg/day
All cause mortality
↓↓↓↓23% (P =0.03)
US Carvedilol Carvedilol Mild-
Moderate
1,094 0.5 45
mg/day
All-cause mortality†
↓↓↓↓65% (P=.0001)
COPERNICUS Carvedilol Severe 2,289 0.9 37
mg/day
All-cause mortality
↓↓↓↓35% (P =0.0014)
ββββ-blocker Evidence: Benefit in HF and LVSD
*Not an approved indication
†Not a planned end point.
#Not approved for severe HF or mortality reduction alone
17. Which beta-blocker?
No good evidence that one beta-blocker is more
effective in than another in managing stable angina.9
Select according to contraindications, co-morbidities,
patient preference and cost.8
Avoid beta-blockers if history of asthma or
bronchospasm. Contraindicated in decompensated
heart failure or critical peripheral vascular disease.9
Do not combine a beta blocker with verapamil and use
caution with diltiazem.9
Sudden withdrawal may cause exacerbation of
angina9
17
18. History of beta-blockers and IHD
• 1956-58 James Black (later to receive the Nobel Prize for
Medicine and a knighthood) proposed that inhibition of the
stress hormones adrenaline and noradrenaline would prevent
angina and heart attacks
• First beta-blocker, propranolol, came to market in 1964
• Propranolol, and other BBs, benefitted angina cases
• Oral propranolol, decreased death rate in post MI cases
• IV/oral BBs (atenolol and metoprolol) reduced death rate in
acute MI cases
• Atenolol and bisoprolol reduced ischaemia and hard end-points
in patients with chronic angina
• All the above benefits stem from beta-1 blockade and are
diminished by ISA
• 1964 – Propranolol was noted to reduce blood pressure (B.
Prichard)
19. Beta Receptors
Beta 1 - on cardiac scarcolemma
- coupled by G protein system
- cAMP activation
- opening of calcium channels
Positive - inotropic, chronotropic, lusitropic
effect, dromotropic effect
20. Beta 2 – on bronchial and vascular smooth
muscle - relaxation
Increased in heart failure
Beta 3 – mediate vasodilatation by release of
nitric oxide
22. Anti-ischaemic Effects of
betablockade
Negative inotropic, chronotropic and
dromotropic effect
Decreases myocardial oxygen demand
Decrease in heart rate – long diastolic
myocardial perfusion
23. PROPERTIES OF ββββ-BLOCKERS
Name ββββ-1
Selective
αααα-
blockade
Lipophilic Increases
ISA
Other ancillary
properties
Atenolol Yes No No No No
Acebutolol Disputed No No yes No
Bisoprolol Yes No Weak No No
Bucindolol No No Yes Disputed Vasodilator action
Carvedilol No Yes Yes No Antioxidant, effects
on endothelial
function
Celiprolol Yes No No ββββ-2 only No
Metoprolol Yes No Yes No No
Nebivolol Yes No ? No Vasodilation through
nitric oxide
Propranolol No No Yes No Membrane stabilizing
Effect
Timolol No No Weak No Anti-platelet effects
28. Conclusions
• ACS is a manifestation of diffuse
atherothrombosis
– Multiple plaques, inflammation +
thrombosis
• Long-term medical Rx to prevent events: 5
drugs
“Athero + thrombosis”
Statins (high-dose) ASA (low-dose)
ACE Inhibitor Clopidogrel
Beta-blocker
29. Secondary Prevention
Class I Indications
Aspirin
Beta-blockers: (all pts, slow titration with moderate to
severe failure
ACE-Inhibitors: CHF, EF<40%, HTN, DM
(All pts-Class IIa) ARB when intolerant to ACE.
(Class IIa as alternative to ACEI)
Aldosterone blockade: An ACEI, CHF with either
EF<40% or DM and if CrCl>30 ml/min and K<5.0
mEq/L
Statins
Standard Risk Factor Management
30. 30
Conclusions
• Comprehensive application of secondary
prevention therapies is highly effective in
reducing the risk of cardiovascular events
• Despite the clinical trial evidence and national
guidelines, large number of eligible patients are
not receiving one or more of these
recommended therapies
• As such, large number of patients are having CV
events that could be avoided if there was better
implementation
• Every effort should be made to bridge the
cardiovascular risk reduction gap
31. THANK YOUTHANK YOUTHANK YOUTHANK YOU
.....to a man with a hammer,
everything looks like a nail....