Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a leading cause of sudden cardiac death in young people and athletes. Prominent right ventricular remodelling can occur in highly trained endurance athletes, raising concern about underlying right ventricular pathology, such as ARVC. Distinguishing between physiological adaptation and cardiac pathology in athletes can be challenging, particularly in elite endurance athletes. This article describes a systematic approach used in sports cardiology to review the physiological adaptation of the right ventricle to exercise and the overlap with ARVC, focusing on the diagnostic investigations used to distinguish between athlete's heart and ARVC.
{"title":"Differentiating right ventricular remodelling from cardiac pathology in athletes","authors":"Richard P. Allwood","doi":"10.1002/sono.12299","DOIUrl":"https://doi.org/10.1002/sono.12299","url":null,"abstract":"Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a leading cause of sudden cardiac death in young people and athletes. Prominent right ventricular remodelling can occur in highly trained endurance athletes, raising concern about underlying right ventricular pathology, such as ARVC. Distinguishing between physiological adaptation and cardiac pathology in athletes can be challenging, particularly in elite endurance athletes. This article describes a systematic approach used in sports cardiology to review the physiological adaptation of the right ventricle to exercise and the overlap with ARVC, focusing on the diagnostic investigations used to distinguish between athlete's heart and ARVC.","PeriodicalId":29898,"journal":{"name":"Sonography","volume":"5 1","pages":"62 - 72"},"PeriodicalIF":0.4,"publicationDate":"2022-01-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75470266","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Ultrasound estimated fetal weight (EFW) is a vital part of prenatal care. We aimed to determine the accuracy of sonographic EFW at a regional Australian hospital, explore factors associated with EFW accuracy and review accuracy calculation methods.
{"title":"Ultrasound estimation of fetal weight accuracy in a regional hospital: A retrospective audit","authors":"J. Spurway, Casey Filce, G. Luscombe","doi":"10.1002/sono.12296","DOIUrl":"https://doi.org/10.1002/sono.12296","url":null,"abstract":"Ultrasound estimated fetal weight (EFW) is a vital part of prenatal care. We aimed to determine the accuracy of sonographic EFW at a regional Australian hospital, explore factors associated with EFW accuracy and review accuracy calculation methods.","PeriodicalId":29898,"journal":{"name":"Sonography","volume":"2085 1","pages":"33 - 39"},"PeriodicalIF":0.4,"publicationDate":"2022-01-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86551357","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Cranial ultrasound is frequently used for diagnostic and/or routine screening in neonates. Exploring factors associated with scan duration is warranted to ensure alignment to clinical guidelines.
颅超声常用于新生儿的诊断和/或常规筛查。探索与扫描时间相关的因素是必要的，以确保符合临床指南。
{"title":"Factors influencing duration of neonatal cranial ultrasound: A pilot study of retrospective data","authors":"Naomi Dare, Mary‐Anne Ramis","doi":"10.1002/sono.12297","DOIUrl":"https://doi.org/10.1002/sono.12297","url":null,"abstract":"Cranial ultrasound is frequently used for diagnostic and/or routine screening in neonates. Exploring factors associated with scan duration is warranted to ensure alignment to clinical guidelines.","PeriodicalId":29898,"journal":{"name":"Sonography","volume":"12 1","pages":"49 - 53"},"PeriodicalIF":0.4,"publicationDate":"2021-12-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84412280","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Various routine disclosure statements relating to the performance of ultrasound (US) during the COVID‐19 pandemic are finding their way into radiology reports. These statements usually suggest that US examinations during the pandemic, or on a COVID‐19 positive patient, are somehow limited and urge the clinicians to reflect on these considerations when accepting radiology reports. However, such disclosure statements are generally unhelpful to clinicians and are not consistent with the realities of current clinical US practice. This article provides a critique of these disclosure statements and concludes by discouraging sonographers and radiologists from making such statements as a routine part of their clinical ultrasound reports.
{"title":"Routine disclosure statements about ultrasound examinations during Covid‐19 pandemic are unhelpful and should be avoided","authors":"M. Necas","doi":"10.1002/sono.12295","DOIUrl":"https://doi.org/10.1002/sono.12295","url":null,"abstract":"Various routine disclosure statements relating to the performance of ultrasound (US) during the COVID‐19 pandemic are finding their way into radiology reports. These statements usually suggest that US examinations during the pandemic, or on a COVID‐19 positive patient, are somehow limited and urge the clinicians to reflect on these considerations when accepting radiology reports. However, such disclosure statements are generally unhelpful to clinicians and are not consistent with the realities of current clinical US practice. This article provides a critique of these disclosure statements and concludes by discouraging sonographers and radiologists from making such statements as a routine part of their clinical ultrasound reports.","PeriodicalId":29898,"journal":{"name":"Sonography","volume":"2 1","pages":"3 - 6"},"PeriodicalIF":0.4,"publicationDate":"2021-11-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84434699","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Most high‐end ultrasound systems now incorporate three‐dimensional imaging as a standard feature. As such, the use of three‐dimensional ultrasound is becoming routine in many facets of medical ultrasound, especially obstetrics and gynaecology. Three‐dimensional ultrasound can enhance or even alter a diagnosis in many gynaecological pathologies. However, like any technique, the usefulness and accuracy of the application relies on the operator having adequate application knowledge and technical acquisition skills to be able to use it to its full potential. This is the first part of a two‐part series on this topic. This article serves to educate sonographers and other ultrasound users on how to incorporate a three‐dimensional ultrasound assessment into their routine gynaecological examinations, why this should be done and how to overcome some of the pitfalls encountered with this technique.
{"title":"Three‐dimensional gynaecological ultrasound, part one: How, when and why?","authors":"A. Deslandes, Anthea Croft, C. Panuccio","doi":"10.1002/sono.12294","DOIUrl":"https://doi.org/10.1002/sono.12294","url":null,"abstract":"Most high‐end ultrasound systems now incorporate three‐dimensional imaging as a standard feature. As such, the use of three‐dimensional ultrasound is becoming routine in many facets of medical ultrasound, especially obstetrics and gynaecology. Three‐dimensional ultrasound can enhance or even alter a diagnosis in many gynaecological pathologies. However, like any technique, the usefulness and accuracy of the application relies on the operator having adequate application knowledge and technical acquisition skills to be able to use it to its full potential. This is the first part of a two‐part series on this topic. This article serves to educate sonographers and other ultrasound users on how to incorporate a three‐dimensional ultrasound assessment into their routine gynaecological examinations, why this should be done and how to overcome some of the pitfalls encountered with this technique.","PeriodicalId":29898,"journal":{"name":"Sonography","volume":"172 1","pages":"15 - 7"},"PeriodicalIF":0.4,"publicationDate":"2021-11-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74547883","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Three‐dimensional ultrasound (3DUS) is becoming a standard part of obstetric and gynaecological ultrasound examinations. With most high‐end ultrasound systems now incorporating three‐dimensional functionality, the technology can be used to enhance and/or confirm a diagnosis in many gynaecological pathologies. Part one of this two‐part series covered the technical aspects of performing three‐dimensional gynaecological ultrasound. This paper, part two, presents a pictorial essay of 3DUS in gynaecological imaging serving to educate sonographers and other ultrasound users on the typical appearance of some common, and not so common ultrasound findings.
{"title":"Three‐dimensional gynaecological ultrasound part two: A pictorial essay","authors":"A. Deslandes, Anthea Croft, C. Panuccio","doi":"10.1002/sono.12293","DOIUrl":"https://doi.org/10.1002/sono.12293","url":null,"abstract":"Three‐dimensional ultrasound (3DUS) is becoming a standard part of obstetric and gynaecological ultrasound examinations. With most high‐end ultrasound systems now incorporating three‐dimensional functionality, the technology can be used to enhance and/or confirm a diagnosis in many gynaecological pathologies. Part one of this two‐part series covered the technical aspects of performing three‐dimensional gynaecological ultrasound. This paper, part two, presents a pictorial essay of 3DUS in gynaecological imaging serving to educate sonographers and other ultrasound users on the typical appearance of some common, and not so common ultrasound findings.","PeriodicalId":29898,"journal":{"name":"Sonography","volume":"15 1","pages":"73 - 82"},"PeriodicalIF":0.4,"publicationDate":"2021-11-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90127041","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
I read with interest the narrative review article on the detection of congenital heart disease (CHD) in the first trimester by Dudnikov, Quinton and Alphonse published in the June issue of Sonography. Undoubtedly, a great deal of work has gone into preparing this article, and I commend the authors for this. Still, I feel that the high detection rates quoted are overstated, particularly for the low-risk population. The authors do state this and some other limitations, but these limitations need more emphasis. In addition, the methodologies of some of the reviewed articles vary greatly and pooling heterogeneous studies increases the risk of significant bias. For example, the detection rate calculation included studies that used only cardiac imaging signs, whereas other studies included non-cardiac signs, for example, nuchal translucency (NT), ductus waveform. Another paper compared 2D imaging and 4D STIC in detecting CHD in a high-risk population. Some congenital cardiac anomalies evolve during pregnancy and are not evident in the first trimester (e.g., aortic senosis). Additionally, other anomalies are present and easily diagnosable (e.g., hypoplastic left heart syndrome) compared to those that are less obvious (e.g., atrioventricular defect). The skill level of sonographers performing first trimester combine screening (FTCS) is also an important consideration. To perform this type of imaging NT certification is required, and to maintain it, sonographers need to demonstrate an ongoing high standard via annual audits. Not all sonographers performing obstetric imaging have this certification. This system does not exist for morphology imaging and could partially explain the discrepancy in detection rates between the two examinations. There is also a need to differentiate between a screening examination (where the heart is thought to be abnormal) and fetal echocardiography (where a cardiac diagnosis is made and counselling of the condition provided) in the first trimester. Most patients referred for early fetal echocardiography are due to concerns at a screening examination, and only a few are because of a previous baby with CHD. In a recent meta-analysis and systematic review, Yu et al. reported a detection rate for CHD at 75% using fetal echocardiography in a high-risk population. This rate also includes false positive and false negative diagnoses. In my 20+ years of performing fetal and paediatric echocardiography with some very experienced paediatric cardiologists, a definitive diagnosis in complex cases is not made until the postnatal period and/or at cardiac surgery. Another potential confounder is the lack of post-mortem data if a pregnancy is terminated based on scan findings alone. Results of detection of CHD at routine FTCS in the low-risk population are quoted at 60%–63%. Of note, none of the reviewed studies was on an Australian or American population where obesity is more prevalent than in Europe. I support screening for CHD at the first-
{"title":"Detection of congenital heart disease (CHD) in the first trimester","authors":"A. Lee‐Tannock","doi":"10.1002/sono.12290","DOIUrl":"https://doi.org/10.1002/sono.12290","url":null,"abstract":"I read with interest the narrative review article on the detection of congenital heart disease (CHD) in the first trimester by Dudnikov, Quinton and Alphonse published in the June issue of Sonography. Undoubtedly, a great deal of work has gone into preparing this article, and I commend the authors for this. Still, I feel that the high detection rates quoted are overstated, particularly for the low-risk population. The authors do state this and some other limitations, but these limitations need more emphasis. In addition, the methodologies of some of the reviewed articles vary greatly and pooling heterogeneous studies increases the risk of significant bias. For example, the detection rate calculation included studies that used only cardiac imaging signs, whereas other studies included non-cardiac signs, for example, nuchal translucency (NT), ductus waveform. Another paper compared 2D imaging and 4D STIC in detecting CHD in a high-risk population. Some congenital cardiac anomalies evolve during pregnancy and are not evident in the first trimester (e.g., aortic senosis). Additionally, other anomalies are present and easily diagnosable (e.g., hypoplastic left heart syndrome) compared to those that are less obvious (e.g., atrioventricular defect). The skill level of sonographers performing first trimester combine screening (FTCS) is also an important consideration. To perform this type of imaging NT certification is required, and to maintain it, sonographers need to demonstrate an ongoing high standard via annual audits. Not all sonographers performing obstetric imaging have this certification. This system does not exist for morphology imaging and could partially explain the discrepancy in detection rates between the two examinations. There is also a need to differentiate between a screening examination (where the heart is thought to be abnormal) and fetal echocardiography (where a cardiac diagnosis is made and counselling of the condition provided) in the first trimester. Most patients referred for early fetal echocardiography are due to concerns at a screening examination, and only a few are because of a previous baby with CHD. In a recent meta-analysis and systematic review, Yu et al. reported a detection rate for CHD at 75% using fetal echocardiography in a high-risk population. This rate also includes false positive and false negative diagnoses. In my 20+ years of performing fetal and paediatric echocardiography with some very experienced paediatric cardiologists, a definitive diagnosis in complex cases is not made until the postnatal period and/or at cardiac surgery. Another potential confounder is the lack of post-mortem data if a pregnancy is terminated based on scan findings alone. Results of detection of CHD at routine FTCS in the low-risk population are quoted at 60%–63%. Of note, none of the reviewed studies was on an Australian or American population where obesity is more prevalent than in Europe. I support screening for CHD at the first-","PeriodicalId":29898,"journal":{"name":"Sonography","volume":"36 1","pages":""},"PeriodicalIF":0.4,"publicationDate":"2021-11-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89141244","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The authors of the article “The detection of first trimester ultrasound in the diagnosis of congenital heart defects: A narrative review” published in Sonography, would like to thank the author/s of the letter to the editor for their kind comments and for taking the time to respond to our work. We agree the studies reviewed were heterogenous in nature and for this reason the results were not pooled but were presented as mean values and ranges as has been recommended. We presented a list of congenital heart defects (CHD) that were detected or missed in the first trimester stating fetal heart size as one reason CHD is missed. We acknowledge evolution of CHD as suggested would have strengthened our argument. We also agree that lack of follow-up after CHD diagnosis is problematic when reporting the results of studies. While the skill level of a sonographer performing a first trimester ultrasound and the use of first trimester combined screening by a nuchal translucency ultrasound education and monitoring program (NTUEMP) certified sonographer, utilising tools such as nuchal translucency, ductus venosus and nasal bone assessment may improve the detection of CHD, we are unaware of any evidence that suggests a relationship between NTUEMP certification and the ability to scan the fetal heart. Furthermore, NTUEMP does not include formal assessment of the fetal heart in the course content nor in reaccredidation. Of the 6908 Australian accredited sonographers only 23% are currently nuchal translucency accredited. Indeed, operator training for heart screening views appears to be a major determinant for successful screening for CHD. Recent work suggests intention to perform screening is also important. This highlights the importance of education for sonographers for first trimester screening of the fetal heart. We agree there is a need to differentiate between screening for CHD and a diagnostic fetal echocardiography scan in the first trimester. We also agree that claiming high-detection rates for CHD screening in the first trimester is problematic. Our review of the current literature concluded the results would not be generalisable to low-risk general radiology or obstetric practices as the majority of first trimester CHD studies were performed by paediatric cardiologists. Further research is needed to determine if education, training, and intention to assess the fetal heart in the first trimester will improve detection rates in low-risk populations when scans are performed by general sonographers.
{"title":"The detection of first trimester ultrasound in the diagnosis of congenital heart defects: A narrative review","authors":"A. Quinton, J. Alphonse, Oleksandr Dudnikov","doi":"10.1002/sono.12292","DOIUrl":"https://doi.org/10.1002/sono.12292","url":null,"abstract":"The authors of the article “The detection of first trimester ultrasound in the diagnosis of congenital heart defects: A narrative review” published in Sonography, would like to thank the author/s of the letter to the editor for their kind comments and for taking the time to respond to our work. We agree the studies reviewed were heterogenous in nature and for this reason the results were not pooled but were presented as mean values and ranges as has been recommended. We presented a list of congenital heart defects (CHD) that were detected or missed in the first trimester stating fetal heart size as one reason CHD is missed. We acknowledge evolution of CHD as suggested would have strengthened our argument. We also agree that lack of follow-up after CHD diagnosis is problematic when reporting the results of studies. While the skill level of a sonographer performing a first trimester ultrasound and the use of first trimester combined screening by a nuchal translucency ultrasound education and monitoring program (NTUEMP) certified sonographer, utilising tools such as nuchal translucency, ductus venosus and nasal bone assessment may improve the detection of CHD, we are unaware of any evidence that suggests a relationship between NTUEMP certification and the ability to scan the fetal heart. Furthermore, NTUEMP does not include formal assessment of the fetal heart in the course content nor in reaccredidation. Of the 6908 Australian accredited sonographers only 23% are currently nuchal translucency accredited. Indeed, operator training for heart screening views appears to be a major determinant for successful screening for CHD. Recent work suggests intention to perform screening is also important. This highlights the importance of education for sonographers for first trimester screening of the fetal heart. We agree there is a need to differentiate between screening for CHD and a diagnostic fetal echocardiography scan in the first trimester. We also agree that claiming high-detection rates for CHD screening in the first trimester is problematic. Our review of the current literature concluded the results would not be generalisable to low-risk general radiology or obstetric practices as the majority of first trimester CHD studies were performed by paediatric cardiologists. Further research is needed to determine if education, training, and intention to assess the fetal heart in the first trimester will improve detection rates in low-risk populations when scans are performed by general sonographers.","PeriodicalId":29898,"journal":{"name":"Sonography","volume":"25 1","pages":""},"PeriodicalIF":0.4,"publicationDate":"2021-11-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83951231","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Ultrasound is a common first‐line examination in acute abdominal pain in children. In rural and regional areas, ultrasound is an important factor in decisions to transfer paediatric patients for tertiary care. Transfers can be over a considerable distance, by road and air, and at great cost. This audit reviewed ultrasound findings in children transferred to an Australian paediatric hospital for acute abdominal pain.
{"title":"An audit of inter‐hospital transfers of children with abdominal pain and their associated medical imaging findings","authors":"T. Reddan, Toni Halligan, J. Corness","doi":"10.1002/sono.12291","DOIUrl":"https://doi.org/10.1002/sono.12291","url":null,"abstract":"Ultrasound is a common first‐line examination in acute abdominal pain in children. In rural and regional areas, ultrasound is an important factor in decisions to transfer paediatric patients for tertiary care. Transfers can be over a considerable distance, by road and air, and at great cost. This audit reviewed ultrasound findings in children transferred to an Australian paediatric hospital for acute abdominal pain.","PeriodicalId":29898,"journal":{"name":"Sonography","volume":"131 1","pages":"23 - 28"},"PeriodicalIF":0.4,"publicationDate":"2021-10-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75909104","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Christopher Hayes, Ya.G. Shvarts, Randhir Sewgolam, Tri Nguyen, S. Ussher
With the growing investigative imaging techniques available in medicine, increasing numbers of thyroid lesions are being identified, either symptomatically or as incidental findings. Ultrasonography remains a key first‐line investigation into evaluating these lesions, and accurately stratifying whether further investigation or management is required.
{"title":"Reducing unnecessary thyroid fine needle aspirations using American College of Radiology's thyroid imaging reporting and data system: A 5‐year retrospective audit","authors":"Christopher Hayes, Ya.G. Shvarts, Randhir Sewgolam, Tri Nguyen, S. Ussher","doi":"10.1002/sono.12289","DOIUrl":"https://doi.org/10.1002/sono.12289","url":null,"abstract":"With the growing investigative imaging techniques available in medicine, increasing numbers of thyroid lesions are being identified, either symptomatically or as incidental findings. Ultrasonography remains a key first‐line investigation into evaluating these lesions, and accurately stratifying whether further investigation or management is required.","PeriodicalId":29898,"journal":{"name":"Sonography","volume":"15 1","pages":"29 - 32"},"PeriodicalIF":0.4,"publicationDate":"2021-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87493139","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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