Stress: Enough Already

Perceptions, Implications, and Adaptations

Presented by:Heather Baker, BSN, RN

April 2014

What is Stress?• By Definition, stress is any uncomfortable “emotional

experience accompanied by predictable biochemical, physiological, and behavioral changes”

• In other words, it is not the demand or the event that causes us stress, but rather our reaction or emotional response that determines how we are going to handle what we consider a perceived threat.

• unavoidable and in small doses it is beneficial• motivates us to achieve our goals.

• Baum, A (1990). “Stress, Intrusive Imagery, and Chronic Distress, “ Health Psychology, Vol.6.pp. 653-675.

What is stress? (cont)

• fight or flight response • In moderation, it produces a boost • provides us with energy and drive to get

through situations.

Types of stress• Acute stress

– often situational– Cause is known – (examples include: looming deadlines, test taking, running late for an

appointment, getting into an argument with a loved one)– Resolution occurs when perceived stress is gone– No long term effects

** You have heard the saying “Everything in moderation” It is this level of stress that helps us work efficiently, motivates us to complete tasks, prepares us for new experiences, so what this means is a little bit of stress keeps us on track and allows us to perform at an optimal level.

Allostasis• A regulatory process • a stress mechanism that protects and promotes short

term adaptation to a perceived physical or behavioral demand.

• maintains equilibrium during the exposure period and allows for return to normal functioning once the demand is gone.

• The ability of the body to have time to recover from stress is crucial to maintaining one’s overall health.

McEwen, B and Gianaros, P (2010). “Central role of the brain in stress and adaptation: Links to socioeconomic status, health, and disease,” Ann NY Acad Sci., February: 1186. pp. 190-222.

Racial and Ethnic Disparities

in Birth Outcomes:

The Life Course Perspective

Presented by

Alisa Jones, MPH

September 2012

Racial and Ethnic Disparities

in Birth Outcomes:

The Life Course Perspective

Presented by

Alisa Jones, MPH

September 2012

Ongoing Acute Stress

• Ongoing acute stress– Situation that is causing you to feel the stress does not

end.– examples: the pile of paperwork that sits on your desk,

always being in a hurry but not ever managing to get anywhere on time, inability to say “no” to people and then getting upset that you didn’t say “no”

• No resolution• can have an effect on you physically and emotionally.• causes a shift in equilibrium.

Chronic Stress• Chronic Stress

– ongoing acute stress– much larger scale and over a much longer period of time.– becomes part of your everyday life.– examples: poverty, an unhappy marriage, and chronic illness– “fight or flight “ response meant to be utilized in emergency

situations never fully shuts off causing your body to stay in stress mode longer than it should.

• causes wear and tear on your body• Potential for long term physical and emotional health

problems.

Allostatic Load• “This wear and tear on the body and brain promotes ill

health, involving not only the consequences of the stressful experiences themselves, but also the alterations in lifestyle that result from a state of chronic stress”

• Equilibrium cannot be maintained • The body’s inability to shut off its physiological responses

and ineffective coping mechanisms can invoke illness and chronic diseases.

McEwen, B and Gianaros, P (2010). “Central role of the brain in stress and adaptation: Links tosocioeconomic status, health, and disease,” Ann NY Acad Sci., February: 1186. pp. 190-222.

See-Saw Effect

The lower image is an image of Allostasis- maintaining little stress over the life course. The upper image is one of allostatic load- if you put too much chronic stress, the see saw will inevitably break.

McEwen, B. and Lasley, E. The endOf stress: As we know it. WashingtonDC: John Henry Press. 2002.

Causes of perceived stress

• This can be broken down into 3 categories:– Home– Work– Everything else

Sources of stress at home

• Death of a loved one• Divorce, separation, relationship problems• Chronic illness or major life altering injury• Money problems due to loss of job, high debt, home

foreclosure, just not having enough money to meet your everyday needs or wants

• Marriage• Pregnancy or birth of a new baby• Your children

– Davis, M. (2000) The Relaxation and Stress Reduction Workbook, New Harbinger, Inc.

Sources of stress at work• Losing your job, a demotion or change in work duties• A new job• Your relationship with your coworkers or boss• The workplace environment• The amount of pressure you are under• Number of hours you work (too many, not enough, work

schedule)• Feeling unappreciated or not valued• Being passed over for a promotion or pay raise

Davis, M (2000) The Relaxation and Stress Reduction Workbook. New Harbinger, Inc.

Sources of stress everywhere else

• Poverty• Environment (where you work, play, live)• Racism• Gender• Emotional Health (how you feel about yourself, relationships, your

purpose)• Fears about Safety• Education• Lack of a support system• Negative feelings about oneself• Drug and Alcohol abuse

– Davis, M (2000) The Relaxation and Stress Reduction Workbook. New Harbinger, Inc.

Socioeconomic Status and Stress

• “There is evidence to support that disparities in income, education, occupation, health care accessibility, housing, and many other variables account for appreciable variance in cause and disease specific morbidity and mortality rates as well as the prevalence of risk factors for chronic medical conditions, psychopathologies of mood and substance abuse.

McEwen, B and Gianaros, P (2010). “Central role of the brain in stress and adaptation: Links tosocioeconomic status, health, and disease,” Ann NY Acad Sci., February: 1186. pp. 190-222.

Environment and Racism• Chronic stressors of neighborhood environment and racial

discrimination have shown to be associated with preterm birth especially among the African American population which may contribute to the disparity in preterm births and infant mortality rates.

• The feelings of physical isolation, living in unsafe and violent neighborhoods, lack of social support, and racism contribute to the stress that is felt among these women.

• “Racism is seen as a significant health risk because of the psychosocial or affective responses it produces (stress, anxiety, anger, depression, etc), this leads to a physiological response that is associated with chronic illness.”

Giurgescu, C., Banks, A., Dancy, B., Norr, K ( July/August2013). “African American Women’s Views of Factors Impacting Preterm Birth,” MCN, Volume 38. Number 4. pp. 229-234.Jackson, F., Race, Stress, and Social Support: Addressing the Crisis in Black Infant Mortality,” Joint Center for Political and Economic Studies Health Policy Institute.

Delaware Stats• Black infants experienced significantly higher mortality rates than white

infants for the time period of 2006-2010

• For this time period, black IMRs were anywhere from 2.2 to 2.8 times that of white IMRs.

• Significant disparities existed between black non-Hispanics and each of the two other groups, white non-Hispanics and Hispanics.

• Black non-Hispanics had the highest IMRs of 14.1 in 2006-2010 was more than double the white non-Hispanic rate of 5.4 and nearly twice the Hispanic rate of 7.4 infant deaths per 1,000 live births.

Delaware Vital Statistics Report 2010

Gender Stress

• just being a woman invokes a level of stress due to role of expectations placed upon a woman– Sandwich Generation– Balancing multiple roles– the decision makers and organizers– Jackson, F. “Race, Stress, and Social Support: Addressing the Crisis in Black Infant Mortality,” Joint Center for Political and

Economic Studies Health Policy Institute.

Socioeconomic Status and Stress (Individual Level)

• low socioeconomic status can invoke feelings of:– insecurity, low self worth, low self esteem, social

exclusion and an overall feeling of just not being good enough.

• has a direct impact on emotional and physiological reactivity and recovery from life stressors thus impacting the risk of ill health.

McEwen, B and Gianaros, P (2010). “Central role of the brain in stress and adaptation: Links tosocioeconomic status, health, and disease,” Ann NY Acad Sci., February: 1186. pp. 190-222.

Snowball EffectHow does it happen?

• A person who develops, matures, and ages in a low socioeconomic position is more vulnerable to impairments in the function of the regulatory process that is meant to maintain equilibrium which puts them at greater risk for disease and maladaptive coping behaviors.

• Take that a step farther, now their children are being raised in a low socioeconomic environment in which they are being exposed to toxic substances, excessive noise, unfavorable housing conditions, the possibility of unhealthy family dynamics, as well as other forms of early life stress which very likely will alter their abilities to lead a healthy life.

McEwen, B and Gianaros, P (2010). “Central role of the brain in stress and adaptation: Links tosocioeconomic status, health, and disease,” Ann NY Acad Sci., February: 1186. pp. 190-222.

What does stress look like?

What does it feel like?

• the initial feeling is the “fight or flight response”: – Your heart beats faster– Your breathing increases– You feel an adrenaline rush– Your muscles tighten up– Your pupils dilate– Blood moves from the center of your body to your

limbs

Physical Symptoms

• Chest pain or tightness• Weight gain or weight loss• Muscle tension, aches and pains• Skin breakouts• Excessive sweating• Increase in blood pressure• Loss of interest in sex• Hair loss• Headaches• Stomach upset/nausea• Shortness of breath• Sleep issues- too much or too little• Gritting or grinding teeth• Hives• Trembling of lips and hands

• Karren KJ, et al. Mind-Body Health: The Effects of Attitudes, Emotions and Relationships. 4th ed. San Francisco, Calif.: Pearson Education; 2010:28.• Seaward BL. Essentials of Managing Stress. 3rd ed. Sudbury, Mass.: Jones & Bartlett Publishers; 2014.• Charlesworth EA, et al. Stress Management: A Comprehensive Guide to Wellness. New York, N.Y.: Ballantine Books; 2004:24.• Stress: Coping with everyday problems. National Mental Health Association. http://www.nmha.org/go/information/get-info/stress/stress-coping-with-everyday-problems.

Accessed April 5, 2013.

Emotional Symptoms

– Mood swings– Anxiety– Depression– Frustration– Nervousness– Feelings of guilt, shame, helplessness, loss of control– Poor self esteem and lack of confidence– Feelings of failure

– ***Long term effects have been linked to eating disorders, depression and anxiety disorders, panic attacks and suicide***

• Karren KJ, et al. Mind-Body Health: The Effects of Attitudes, Emotions and Relationships. 4th ed. San Francisco, Calif.: Pearson Education; 2010:28.• Seaward BL. Essentials of Managing Stress. 3rd ed. Sudbury, Mass.: Jones & Bartlett Publishers; 2014.• Charlesworth EA, et al. Stress Management: A Comprehensive Guide to Wellness. New York, N.Y.: Ballantine Books; 2004:24.• Stress: Coping with everyday problems. National Mental Health Association. http://www.nmha.org/go/information/get-info/stress/stress-coping-

with-everyday-problems. Accessed April 5, 2013.

Behavioral Symptoms– Irritability or anger outbursts– Maladaptive behaviors such as drinking too much, smoking, poor eating habits– Inability to concentrate– Memory lapses, forgetfulness or short term memory loss– Relationship problems– Poor work performance– Poor time management– Overreacting to minor irritants

• Karren KJ, et al. Mind-Body Health: The Effects of Attitudes, Emotions and Relationships. 4th ed. San Francisco, Calif.: Pearson Education; 2010:28.

• Seaward BL. Essentials of Managing Stress. 3rd ed. Sudbury, Mass.: Jones & Bartlett Publishers; 2014.• Charlesworth EA, et al. Stress Management: A Comprehensive Guide to Wellness. New York, N.Y.: Ballantine Books;

2004:24.• Stress: Coping with everyday problems. National Mental Health Association.

http://www.nmha.org/go/information/get-info/stress/stress-coping-with-everyday-problems. Accessed April 5, 2013.

Signs of Stress Overload

• Frequent anxiety or panic attacks• An overwhelming sense of impending doom• Constant feelings of sadness, hopelessness, not feeling like you are ever good

enough• Feeling of being constantly pressured and hurried • Development of health problems: Hypertension, Diabetes, Depression,

Obesity, Eating disorders, Substance Abuse, Irritable Bowel, Memory Loss, Autoimmune Disease, Insomnia, Thyroid Problems, increased risk of poor birth outcome, and Infertility (result of allostatic load)

• “Weathering effect”- prolonged stress is thought to create this effect which prematurely ages the body thus leading to the development of chronic diseases and may contribute to results of poor birth outcomes. The body is prematurely aging as a result of chronic, longitudinal stress.

• Jackson,F. “Race, Stress, and Social Support: Addressing the Crisis in Black Infant Mortality,” Joint Center for Political and Economic Studies Health Policy Institute.

The Effects of StressStress triggers mental and emotional problems such as insomnia, headaches, Personality changes, irritability, anxiety, and depression.

Mouth ulcers and excessive dryness may be symptoms of stress

Cardiovascular disease and hypertension are linked to accumulatedStress.

High levels of emotional stress have can adversely affect asthmatics

Stress can affect the reproductive system causing menstrual disordersAnd recurrent vaginal infections, infertility and has been linked to prematurityIn men, it has been linked to impotence and premature ejaculation.Some individuals react to stress with

Skin outbreaks such as eczema and psoriasis

Digestive tract: stress has been associatedWith stomachaches, irritable bowel and weight gain/loss

Muscles: stress has been associated with pain in The neck and shoulders, tension, twitches, and Nervous tics.

Hair: high levels of stress may lead to Excessive hair loss or some form of baldness

Psychological Resilience

How stressed out are you? Take the test

• How many of the following statements or feelings apply to you?Little things make me angry.I don’t laugh as much as I used to.I feel sad and anxious most of the time.I am eating or drinking too much.I am engaging in risky behaviors.I can’t seem to remember things as well.I am having recurring headaches, stomachaches, tension in jaw, shoulders, back or chest.I recently got married, divorced, or separated.I was recently injured or have been sick.I am having major financial problems.I work more than 10 hours a day.I was recently fired, laid off from my job.I hate my job or some of the people I work with.I have not had a vacation in 3 years.I sleep less than 6 hours a night.I hardly have anytime for myself.I am always in a hurry and cannot manage to get anywhere on time.I don’t have an emotional support network.A close friend or relative is sick or recently died.

Brott, Armin. Your Head: An Owner’s Manual. Understanding and Overcoming Depression, Anxiety, and Stress.

How did you answer and what does this mean?

• Chances are, at least 5-6 of the above statements are true for you. This should not come as a surprise. Stress is so widespread that The American Institute for Stress estimates that 75-90 % of all visits to PCPs are for stress related issues.

• According to The American Psychological Association, American Institute of Stress, NY, the top causes of stress are:– Job pressure– Money– Health– Relationships– Poor nutrition– Media overload– Sleep deprivation

Statistics• According to American Psychological Association, American Institute of

Stress, NY,– 77% of people in the U.S. regularly experience physical symptoms caused by

stress– 73% of people in the U.S experience psychological symptoms caused by stress– 33% of people in the U.S. feel that they are living with extreme stress.– 48% of people in the U.S. feel their stress has increased over the past 5 years– 48% of people in the U.S. said that stress has had a negative impact on their

personal and professional life.– $300 billion dollars is being spent annually by employers on stress related

health care and missed work.– 51% of people in U.S. reported fatigue as the number 1 physical symptom – 50% of people in U.S. reported irritability and anger as the number 1

psychological symptom

Good and Bad News

• The good news is that we are not alone, the bad news is, is that it is costing us billions of dollars and making us sick!!

So…what do we do about it???

How do you handle stress?

• Positive vs. Negative

Maladaptive Coping Strategies• Alcohol abuse• Smoking• Drug Abuse• Over eating• Escapism• Spending sprees• Blaming others• Physical or verbal abuse• Overworking • Denial• Magnification• Drinking too much caffeine• Negative self talk

Dealing with Stress

• Stress Reduction Kit

Bang Head Here

Directions:1. Place Kit on FIRM surface2. Follow directions in circle of kit3. Repeat step 2 as necessary, or until

unconscious4. If unconscious, cease stress reduction

activity immediately!!!

OR………………….

Dealing with Stress: The 4 A’s

• Avoid• Alter• Adapt• Accept

• Miller LH, et al. The Stress Solution: An Action Plan to Manage the Stress in Your Life. New York, N.Y.: Pocket Books; 1993:86.• Patel C. The Complete Guide to Stress Management. New York, N.Y.: Plenum Press; 1991:233.• Wheeler CM. 10 Simple Solutions to Stress. Oakland, Calif.: New Harbinger Publications, Inc., 2007:39.• Seaward BL. Essentials of Managing Stress. 3rd ed. Sudbury, Mass.: Jones & Bartlett Publishers; 2014:109.• How can I manage stress? American Heart Association.

http://www.heart.org/HEARTORG/GettingHealthy/StressManagement/Stress-Management_UCM_001082_SubHomePage.jsp. Accessed May 23, 2013.

Avoid• 1. Avoid unnecessary stress

– Not all stress can be avoided, nor is it healthy to avoid situations that need to be addressed but you may be surprised at the number of undo stressors you place on yourself• Learn to say “NO”- know your limits and stick with it both in your

personal and professional life, refuse to accept any added responsibilities that you do not have time for. Taking on more than you can handle is a recipe for unnecessary stress!

• Avoid people who cause you stress, or at least limit your time with them. Set limits. Understand that you cannot control someone else’s behavior but you do have control of your own.

• Take control of your environment. • Scale down your To-Do list- distinguish between your “shoulds” and the

“musts”

Alter• 2. Alter the situation: if you can’t avoid it, figure out a way

to change how you respond to the situation– Express your feelings instead of bottling them up. People are

not mind readers, you cannot expect people to look at your face or observe your body language and know how you are feeling• Communicate your feelings openly and respectfully otherwise feelings

of resentment will fester and the situation will likely remain the same• Compromise, if you are asking another person to make changes, then

you should be willing to bend yourself• Be more assertive- don’t take a backseat in your own life. Look out for

your own well being and deal with problems that arise head on. • Manage your time- don’t overextend yourself. Don’t make promises

you cannot keep, you will only feel badly about yourself.

Adapt• 3. Adapt to the stressor: if you can’t change the stressor, change

how you react to it.– Reframe the problem: try to see the positive in every situation (ex: stuck in

traffic jam, take a moment to listen to your favorite music)– Look at the big picture: “Don’t sweat the small stuff” Ask yourself will this

really matter in a few days, a month, a year, if the answer is no, then it is time to put your focus and energy somewhere else.

– Adjust your standards: stop comparing yourself to others, stop setting yourself up for failure by demanding perfection. Set reasonable goals for yourself. You are not a Super Hero, so don’t try to act like one.• (Sojourner Syndrome and Superwoman Complex)

– Focus on the positive: learn to be grateful and appreciative of what you do have in your life instead of focusing on what you don’t have. Be sure to take note of all of your own positive qualities and gifts that you have to share.

Accept• 4. Accept the things that you cannot change

– “it is what it is”, there are just some things and situations we cannot control, instead of stressing about these things, learn to focus on the things that you do have control over.

– Look for the upside: when faced with challenging circumstances, take a moment to look at how this is a chance for you to grow as a person. If you make a mistake, don’t see it as a failure but as a way to learn from it and move forward, look at it as if there are no mistakes just life lessons to learn along the journey

– Share your feelings: opening up about how you feel if nothing else makes you feel better even if you cannot change it

– Learn to forgive- accept that we live in an imperfect world and that people make mistakes, let it go. Freeing yourself from all of that negative energy and resentment leaves room for more positive experiences. It frees you up from time and energy spent on things you cannot change.

– Eliminate the words: “always, never, should, and must”. These are self defeating words that will only set you up for failure.

Achieving Inner Health through Stress Reduction Techniques

• Learn To:– Appreciate Yourself- value who you are and what

you do• Problem: Questioning your ability?• Solution: Do a self inventory of your skills, strengths

Ask for Help, seek out resources that are available• Problem: Feeling Pessimistic?• Solution: Keep a gratitude journal, do a self inventory, rent a funny,

uplifting movie, surround yourself with positive people• Problem: Worn out, Burned out?• Solution: Take care of you!! Eat Healthy, sleep, exercise, engage in

activities that make you happy

Achieving Inner Health through Stress Reduction Techniques

• Learn To:– Find Balance and Purpose

• Problem: Frequently Late?• Solution: Prioritize, map out your day: segment by segment

Get to the bottom of why you are really late!!• Problem: Angry and Irritated?• Solution: Pause, Breathe, Reflect, Regroup, and Choose

Don’t magnify or leap to conclusions• Problem: Overextended?• Solution: Decide what is important to you

Delegate

Achieving Inner Health through Stress Reduction Techniques

• Learn To:

• Connect with OthersProblem: Feeling Lonely?Solution: Volunteer, Strike up a conversation, connect on social media, phone a friend, avoid judging others, identify with your own racial, ethnic,

or cultural background, learn about other cultures surround yourself with people who respect and value you

Problem: Upset by conflict/Poor CommunicationSolution: Try Being more assertive, let your needs be known in a respectful way. Avoid words like “you always” or “you never” instead try saying

I feel _____ when you____.”

Other Solutions to Stress• Create a worry box- great for children• Meditation- clears your mind of all the clutter, helps to find an inner calmness and inner peace (

www.how-to-meditate.org)• Deep Breathing: Less than a minute• Count down slowly from 10-0: takes 2 minutes• Self Massage: 5 minutes or less• Find your happy place: 10 minutes or less• Yoga• Engage your senses• Drive in the slow lane• Pray• Before work, sit in the car for a minute and plan out your day, leaving behind any negativity that happened

before coming to work• After work, sit in car and reflect on your day, let go of the negativity that happened during your work day• Take a break from technology, unplug• Ask for help, Dial 2-1-1

(adapted from www.dbsalliance.org) Healthy Lifestyles: Improving and Maintaining the Quality of your Life.

Tips for Health Care Providers • When dealing with a difficult or stressed patient, remember

to:– Observe- voice, words, attitude– Connect- Ask open ended questions– Be an active listener– Validate their feelings: (examples: “What I hear you saying is..”)

– Show Respect: make eye contact– Slow down– Address their basic human needs– Focus on feelings– Be safe, know when to de-escalate and know when to terminate

Benefits of Effectively Managing Your Own Level of Stress

• Improved physical and emotional health• Improved memory and cognitive functioning• Increase in energy during the day and more restful sleep at night• Increase in emotional connectedness, feeling of contentment

and satisfaction with life• Decrease in impatience, irritability, depression and sadness.• Increase in positive attitude and in joy of everyday activities,

finding humor in situations• The acknowledgement that managing stress is a lifestyle, not just

a single event.• (adapted from www.dbsalliance.org) Healthy Lifestyles: Improving and Maintaining the Quality of your Life.

The Role of Public Policy in Stress Reduction

• Investments in Women’s Health– push for better access, affordability, and quality of health

care across the lifespan (loss of Medicaid coverage at 60 days postpartum even if poor pregnancy outcome)

– a multidisciplinary approach in treatment, so that there is follow through and follow up services, a continuity of care is needed.

– push to educate women before their reproductive years( preconception education) (Healthy women beget healthy children)

– Lu, M and Halfon, N (2003). “Racial and Ethnic Disparities in Birth Outcomes: A Life –Course Perspective,” Maternal and Child Health Journal, Vol. 7, No. 1, March. pp. 13-30.

The Role of Public Policy in Stress Reduction

• Investments in Community Health– Create a comprehensive health care system that takes preventative steps to illness and

injury, that maintains the well being of those who are already sick– Offer full services (medical ,dental ,vision, screening and diagnostic services and disease

management) all within the communities where people live (Prevention institute)– push for what influences our health outside of this, which is where we live, work, play,

socialize, and learn(location, location, location)• Creating affordable and decent housing• Safe neighborhoods that allow for parks and recreation• Provide clean air and water• Provide access to healthier foods (farmers markets that accept food stamps), there is a problem

when there are more liquor stores and fast food restaurants than there are grocery stores.• Make bus routes more accessible and safer

– Lu, M and Halfon, N (2003). “Racial and Ethnic Disparities in Birth Outcomes: A Life –Course Perspective,” Maternal and Child Health Journal, Vol. 7, No. 1, March. pp. 13-30.

The Role of Public Policy in Stress Reduction

• Investments in improving social conditions:– Create programs that address drug and alcohol issues without prejudice or

punitive charges– Decrease domestic violence– Engage fathers and encourage them to be active, positive role models in their

children’s lives by including them in preconception education, the pregnancy and the parenting. Giving them value and place in the future of their children.

– Create better working conditions for women by decreasing work load, creating flexibility in work schedules, offering daycare options so that women can work. Create neighborhoods that foster a sense of connectedness that create opportunities that foster positive community relationships ( it takes a village)

McEwen, B and Gianaros, P (2010). “Central role of the brain in stress and adaptation: Links to socioeconomic status, health, and disease,” Ann NY Acad Sci., February: 1186. pp. 190-222.Lu, M and Halfon, N (2003). “Racial and Ethnic Disparities in Birth Outcomes: A Life –Course Perspective,” Maternal and Child Health Journal, Vol. 7, No. 1, March. pp. 13-30.

Visualization/Guided Imagery

Conclusion• Your Heart is Free…. Have the courage to follow it!!• “Your time is limited, so don’t waste it living someone else’s

life. Don’t be trapped by dogma-which is living with the results of other people’s thinking. Don’t let the noise of other’s opinions drown out your inner voice. And most important have the courage to follow your heart and intuition. They somehow know what you truly want to become. Everything else is secondary.”

by Steve Jobs

Thank You!!!