Endocrinologia, Diabetes y Nutricion最新文献

英文中文

New drugs in pituitary diseases

4区医学 Q3 Nursing

Endocrinologia, Diabetes y Nutricion

Pub Date : 2025-03-01 DOI: 10.1016/j.endinu.2025.501546

Fernando Cordido , Pedro Iglesias

引用次数: 0

Addendum a «La importancia de la técnica MLPA en el diagnóstico de la neoplasia endocrina múltiple tipo 1», Endocrinología, Diabetes y Nutrición 71 (2024) 221-225

4区医学 Q3 Nursing

Endocrinologia, Diabetes y Nutricion

Pub Date : 2025-03-01 DOI: 10.1016/j.endinu.2025.01.001

Antonio Bustos-Merlo, Carlos Javier García Calvente, Antonio Rosales-Castillo

引用次数: 0

Atypical development of hypopituitarism due to septic embolism: A case report

4区医学 Q3 Nursing

Endocrinologia, Diabetes y Nutricion

Pub Date : 2025-03-01 DOI: 10.1016/j.endinu.2024.09.005

Jordi Tortosa-Carreres , Lorena Hernández-Rienda , Susana Tenés-Rodrigo , Amparo Alba-Redondo , María Luisa Martínez-Triguero

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Tumor fibroso solitario en la glándula tiroides como hallazgo incidental

4区医学 Q3 Nursing

Endocrinologia, Diabetes y Nutricion

Pub Date : 2025-03-01 DOI: 10.1016/j.endinu.2024.09.002

Luis Francisco de Miguel Rodríguez , Julieta Romina Arbat , Katherine García Malpartida , Pablo Fernández Collazo , Carlos Morillas Ariño

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Estudio de la altura de las células en el subtipo de célula alta del carcinoma papilar de tiroides. ¿Es un factor clave en el pronóstico?

4区医学 Q3 Nursing

Endocrinologia, Diabetes y Nutricion

Pub Date : 2025-03-01 DOI: 10.1016/j.endinu.2024.09.006

Ricard Onieva Carbajo , Joan Carles Ferreres Piñas , Flavia Alberto , Ismael Capel Flores , Martina Pérez , María Rosa Bella Cueto

Introduction

The tall cell subtype of papillary thyroid carcinoma (PTC) is considered to have poor prognosis, but its diagnostic criteria have been modified on several occasions. The aim of our study was to find the best diagnostic criteria to relate the tall cell subtype with aggressiveness and poor prognosis.

Material and methods

In 171 cases of classic subtype and tall cell subtype of PTC, the percentage of cells between two and three times taller than wide (C2-3) and cells more than three times taller than wide (Cx3) was determined by two observers, after obtaining reference images. Groups were made based on the percentage of cells of each component (<2%, between 2 and 10%, between 11 and 30%, between 31 and 50% and > 50%) and were correlated with clinical and histopathological data. Interobserver agreement was also assessed.

Results

According to the current WHO classification criteria, only 8 cases (5%) of tall cell subtype were identified. The comparison of the risk of recurrence at 5 years based on the percentage and type of cells showed that it increased significantly from > 10% of the Cx3 cell component, while there were no significant differences in recurrence rate with any C2-3 cell percentages. Very good interobserver agreement was obtained (Kappa index: 0.83).

Conclusions

We consider relevant reporting the presence of Cx3 cells from 10% in PTC as it is associated with a significant increase in the recurrence rate at 5 years. Interobserver agreement is very good if reference images are available.

导言甲状腺乳头状癌（PTC）的高细胞亚型被认为预后较差，但其诊断标准曾多次被修改。材料与方法在171例典型亚型和高细胞亚型PTC病例中，在获得参考图像后，由两名观察者确定高度比宽度高2至3倍（C2-3）和高度比宽度高3倍以上（Cx3）的细胞百分比。根据各组细胞的百分比进行分组（2%、2-10%、11-30%、31-50% 和 50%），并与临床和组织病理学数据相关联。结果根据目前的世卫组织分类标准，仅发现 8 例（5%）高细胞亚型病例。根据细胞的百分比和类型对 5 年后的复发风险进行比较后发现，Cx3 细胞成分在 > 10% 以上的复发风险显著增加，而任何 C2-3 细胞百分比的复发率均无显著差异。结论我们认为，在 PTC 中，Cx3 细胞的比例从 10% 开始就应该报告，因为它与 5 年复发率的显著增加有关。如果有参考图像，观察者之间的一致性非常好。

{"title":"Estudio de la altura de las células en el subtipo de célula alta del carcinoma papilar de tiroides. ¿Es un factor clave en el pronóstico?","authors":"Ricard Onieva Carbajo , Joan Carles Ferreres Piñas , Flavia Alberto , Ismael Capel Flores , Martina Pérez , María Rosa Bella Cueto","doi":"10.1016/j.endinu.2024.09.006","DOIUrl":"10.1016/j.endinu.2024.09.006","url":null,"abstract":"<div><h3>Introduction</h3><div>The tall cell subtype of papillary thyroid carcinoma (PTC) is considered to have poor prognosis, but its diagnostic criteria have been modified on several occasions. The aim of our study was to find the best diagnostic criteria to relate the tall cell subtype with aggressiveness and poor prognosis.</div></div><div><h3>Material and methods</h3><div>In 171 cases of classic subtype and tall cell subtype of PTC, the percentage of cells between two and three times taller than wide (C2-3) and cells more than three times taller than wide (Cx3) was determined by two observers, after obtaining reference images. Groups were made based on the percentage of cells of each component (<2%, between 2 and 10%, between 11 and 30%, between 31 and 50% and >50%) and were correlated with clinical and histopathological data. Interobserver agreement was also assessed.</div></div><div><h3>Results</h3><div>According to the current WHO classification criteria, only 8 cases (5%) of tall cell subtype were identified. The comparison of the risk of recurrence at 5 years based on the percentage and type of cells showed that it increased significantly from >10% of the Cx3 cell component, while there were no significant differences in recurrence rate with any C2-3 cell percentages. Very good interobserver agreement was obtained (Kappa index: 0.83).</div></div><div><h3>Conclusions</h3><div>We consider relevant reporting the presence of Cx3 cells from 10% in PTC as it is associated with a significant increase in the recurrence rate at 5 years. Interobserver agreement is very good if reference images are available.</div></div>","PeriodicalId":37725,"journal":{"name":"Endocrinologia, Diabetes y Nutricion","volume":"72 3","pages":"Article 101530"},"PeriodicalIF":0.0,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143519772","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Hyperglycemia-related risk factors in enteral nutrition in non-critically ill patients

4区医学 Q3 Nursing

Endocrinologia, Diabetes y Nutricion

Pub Date : 2025-03-01 DOI: 10.1016/j.endinu.2024.09.008

Esther Delgado-García , Juan José López-Gómez , Rebeca Jiménez-Sahagún , Emilia Gómez-Hoyos , Ana Ortolá-Buigues , Paloma Pérez-López , Beatriz Torres-Torres , Daniel A. De Luis-Román

Introduction

Carbohydrate metabolism can change in hospitalized patients due to stress, or the use of enteral nutrition (EN). The aim of this study was to determine the risk factors triggering these changes.

Material and Methods

We conducted a retrospective observational study in non-diabetic patients with low levels of stress on EN. Five groups were categorized based on changes to the metabolism of hydrocarbons produced before or after EN: plasma glycemia prior to EN >126 mg/dL (stress hyperglycemia – SH) (35.1%); plasma glycaemia prior to EN <126 mg/dL (non-HE) (64.89%). Hyperglycemia with EN (HyperEN): at least, two capillary blood glucose readings >140 mg/dL or 1 >180 mg/dL during EN (71%); non-HyperEN: capillary blood glucose readings with EN <140 mg/dL (29%).

Results

A total of 131 patients were included (45.8% men) with a median age of 81 (71–87) years. A total of 52 patients exceeded 180 mg/dL at one measurement, and 24 patients required insulin detemir with a median of 16 (12–27) IU per day. Risk factors for HyperEN were identified as patient age (OR, 1.186; 95% CI, 1.051–1.341; p < 0.01) and duration of nutritional treatment (OR, 1.320; 95% CI, 1.086–1.605; p < 0.01).

Conclusions

Our study shows a high prevalence of carbohydrate metabolism disorders in hospitalized patients on total EN, with age and duration of nutritional treatment being the main risk factors.

{"title":"Hyperglycemia-related risk factors in enteral nutrition in non-critically ill patients","authors":"Esther Delgado-García , Juan José López-Gómez , Rebeca Jiménez-Sahagún , Emilia Gómez-Hoyos , Ana Ortolá-Buigues , Paloma Pérez-López , Beatriz Torres-Torres , Daniel A. De Luis-Román","doi":"10.1016/j.endinu.2024.09.008","DOIUrl":"10.1016/j.endinu.2024.09.008","url":null,"abstract":"<div><h3>Introduction</h3><div>Carbohydrate metabolism can change in hospitalized patients due to stress, or the use of enteral nutrition (EN). The aim of this study was to determine the risk factors triggering these changes.</div></div><div><h3>Material and Methods</h3><div>We conducted a retrospective observational study in non-diabetic patients with low levels of stress on EN. Five groups were categorized based on changes to the metabolism of hydrocarbons produced before or after EN: plasma glycemia prior to EN >126mg/dL (stress hyperglycemia – SH) (35.1%); plasma glycaemia prior to EN <126mg/dL (non-HE) (64.89%). Hyperglycemia with EN (HyperEN): at least, two capillary blood glucose readings >140mg/dL or 1 >180mg/dL during EN (71%); non-HyperEN: capillary blood glucose readings with EN <140mg/dL (29%).</div></div><div><h3>Results</h3><div>A total of 131 patients were included (45.8% men) with a median age of 81 (71–87) years. A total of 52 patients exceeded 180mg/dL at one measurement, and 24 patients required insulin detemir with a median of 16 (12–27) IU per day. Risk factors for HyperEN were identified as patient age (OR, 1.186; 95% CI, 1.051–1.341; <em>p</em>  <0.01).</div></div><div><h3>Conclusions</h3><div>Our study shows a high prevalence of carbohydrate metabolism disorders in hospitalized patients on total EN, with age and duration of nutritional treatment being the main risk factors.</div></div>","PeriodicalId":37725,"journal":{"name":"Endocrinologia, Diabetes y Nutricion","volume":"72 3","pages":"Article 101534"},"PeriodicalIF":0.0,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143519771","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Short bowel syndrome and d-lactic acidosis: A case report with supplemental home parenteral nutrition and teduglutide

4区医学 Q3 Nursing

Endocrinologia, Diabetes y Nutricion

Pub Date : 2025-03-01 DOI: 10.1016/j.endinu.2024.09.009

Elena Carrillo-López, Maria Sara Tapia-Sanchiz, Sara Jiménez-Blanco, Begoña Molina-Baena

d-Lactic acidosis is an uncommon cause of acidosis that occurs in patients with short bowel syndrome (SBS). Reduced intestinal absorption surface leads to carbohydrate malabsorption, fermented by abnormal colonic bacterial flora, resulting in elevated d-lactate levels. It should be suspected in SBS patients who exhibit typical neurological symptoms without other apparent causes, along with metabolic acidosis with normal l-lactate levels. Treatment involves correcting acidosis and managing bacterial overgrowth with non-absorbable antibiotics.

This report presents a case of a patient on teduglutide for SBS who experienced an episode of d-lactic acidosis. To date, there are no documented cases in the literature of similar episodes in adult patients undergoing therapy with GLP2 analogs.

引用次数: 0

Recomendaciones de la Sociedad Española de Endocrinología y Nutrición (SEEN) sobre «qué no hacer» en la práctica clínica

4区医学 Q3 Nursing

Endocrinologia, Diabetes y Nutricion

Pub Date : 2025-03-01 DOI: 10.1016/j.endinu.2024.11.001

Juan José Díez , Emma Anda , Irene Bretón , Cintia González-Blanco , María Miguélez , Ana Zugasti , Alberto Fernández , en representación de la Sociedad Española de Endocrinología y Nutrición

Quality healthcare should be grounded on clinical practice with the highest benefit-risk ratio and cost-effectiveness according to the available scientific evidence. The overuse of unproven diagnostic or therapeutic procedures is common in our setting and leads to increased healthcare spending and even iatrogenic harm. Previous cost-effectiveness initiatives have proposed identifying diagnostic and therapeutic measures that are better ‘not done’ in certain clinical contexts under the lens of the available scientific evidence. In this regard, the Spanish Society of Endocrinology and Nutrition (SEEN) has compiled a series of ‘not-to-do’ recommendations from its various working groups. These recommendations cover common clinical situations classified into the following thematic areas: diabetes, nutrition, pituitary gland, neuroendocrine tumors, thyroid, and hormone replacement therapy in postmenopausal women.

{"title":"Recomendaciones de la Sociedad Española de Endocrinología y Nutrición (SEEN) sobre «qué no hacer» en la práctica clínica","authors":"Juan José Díez , Emma Anda , Irene Bretón , Cintia González-Blanco , María Miguélez , Ana Zugasti , Alberto Fernández , en representación de la Sociedad Española de Endocrinología y Nutrición","doi":"10.1016/j.endinu.2024.11.001","DOIUrl":"10.1016/j.endinu.2024.11.001","url":null,"abstract":"<div><div>Quality healthcare should be grounded on clinical practice with the highest benefit-risk ratio and cost-effectiveness according to the available scientific evidence. The overuse of unproven diagnostic or therapeutic procedures is common in our setting and leads to increased healthcare spending and even iatrogenic harm. Previous cost-effectiveness initiatives have proposed identifying diagnostic and therapeutic measures that are better ‘not done’ in certain clinical contexts under the lens of the available scientific evidence. In this regard, the Spanish Society of Endocrinology and Nutrition (SEEN) has compiled a series of ‘not-to-do’ recommendations from its various working groups. These recommendations cover common clinical situations classified into the following thematic areas: diabetes, nutrition, pituitary gland, neuroendocrine tumors, thyroid, and hormone replacement therapy in postmenopausal women.</div></div>","PeriodicalId":37725,"journal":{"name":"Endocrinologia, Diabetes y Nutricion","volume":"72 3","pages":"Article 101531"},"PeriodicalIF":0.0,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143519774","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Analysis of hypercalcemia in hospitalized patients in Spain from 2001 through 2015

4区医学 Q3 Nursing

Endocrinologia, Diabetes y Nutricion

Pub Date : 2025-02-01 DOI: 10.1016/j.endinu.2024.08.005

Guillermo Ropero-Luis , Alberto Ruiz-Cantero , Ricardo Gómez-Huelgas

Introduction

Few studies have explored the characteristics of hospitalized patients with hypercalcemia. Our goal was to analyze clinical–epidemiological features, mortality, and incidence of hypercalcemia in Spanish adult inpatients.

Materials and methods

We conducted a retrospective study using Spain's nationwide hospital database (“Conjunto Mínimo Básico de Datos Hospitalización”, CMBD-H), analyzing all hospital discharges from 2001 through 2015. Hypercalcemia was defined according to ICD-9-CM code 275.42. We examined causes, sex, median age, length of stay, and in-hospital mortality. Annual rates, adjusted for age and sex, were analyzed too.

Results

A total of 41,103 cases of hypercalcemia were analyzed out of 59,978,703 hospital discharges. Median age was 70 (interquartile range [IQR], 59–79), with 51.3% males. Internal Medicine had the most discharges (32.8%). Hypercalcemia was the leading cause in 11.4% of cases. Most common etiologies were cancer (83.8%) and hyperparathyroidism (15.1%). Neoplasms were more prevalent in males and older patients. Mean incidence was 0.7/1000 admissions, with a 7.1% annual growth rate. The overall in-hospital mortality rate was 27.1%, which remained unchanged over the study period. Factors associated with mortality included increasing age (OR, 1.01; 95% CI, 1.01–1.02), male sex (1.60; 1.53–1.68), emergency admission (1.43; 1.34–1.52), hypercalcemia as main diagnosis (1.89; 1.74–2.06), and neoplasm (5.24; 4.92–5.58).

Conclusions

This is the largest and most comprehensive general study on in-hospital hypercalcemia conducted to this date. The rate of hypercalcemia in hospitalized patients is increasing, likely due to the growing number of cancer inpatients. Hypercalcemia was associated with high mortality.

{"title":"Analysis of hypercalcemia in hospitalized patients in Spain from 2001 through 2015","authors":"Guillermo Ropero-Luis , Alberto Ruiz-Cantero , Ricardo Gómez-Huelgas","doi":"10.1016/j.endinu.2024.08.005","DOIUrl":"10.1016/j.endinu.2024.08.005","url":null,"abstract":"<div><h3>Introduction</h3><div>Few studies have explored the characteristics of hospitalized patients with hypercalcemia. Our goal was to analyze clinical–epidemiological features, mortality, and incidence of hypercalcemia in Spanish adult inpatients.</div></div><div><h3>Materials and methods</h3><div>We conducted a retrospective study using Spain's nationwide hospital database (“Conjunto Mínimo Básico de Datos Hospitalización”, CMBD-H), analyzing all hospital discharges from 2001 through 2015. Hypercalcemia was defined according to ICD-9-CM code 275.42. We examined causes, sex, median age, length of stay, and in-hospital mortality. Annual rates, adjusted for age and sex, were analyzed too.</div></div><div><h3>Results</h3><div>A total of 41,103 cases of hypercalcemia were analyzed out of 59,978,703 hospital discharges. Median age was 70 (interquartile range [IQR], 59–79), with 51.3% males. Internal Medicine had the most discharges (32.8%). Hypercalcemia was the leading cause in 11.4% of cases. Most common etiologies were cancer (83.8%) and hyperparathyroidism (15.1%). Neoplasms were more prevalent in males and older patients. Mean incidence was 0.7/1000 admissions, with a 7.1% annual growth rate. The overall in-hospital mortality rate was 27.1%, which remained unchanged over the study period. Factors associated with mortality included increasing age (OR, 1.01; 95% CI, 1.01–1.02), male sex (1.60; 1.53–1.68), emergency admission (1.43; 1.34–1.52), hypercalcemia as main diagnosis (1.89; 1.74–2.06), and neoplasm (5.24; 4.92–5.58).</div></div><div><h3>Conclusions</h3><div>This is the largest and most comprehensive general study on in-hospital hypercalcemia conducted to this date. The rate of hypercalcemia in hospitalized patients is increasing, likely due to the growing number of cancer inpatients. Hypercalcemia was associated with high mortality.</div></div>","PeriodicalId":37725,"journal":{"name":"Endocrinologia, Diabetes y Nutricion","volume":"72 2","pages":"Article 101522"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143436519","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Terapia farmacológica hipolipemiante para la reducción del riesgo cardiovascular en la diabetes. Visión clínica del Grupo de Trabajo de Enfermedad Cardiovascular de la Sociedad Española de Diabetes

4区医学 Q3 Nursing

Endocrinologia, Diabetes y Nutricion

Pub Date : 2025-02-01 DOI: 10.1016/j.endinu.2024.09.001

Juan Pedro-Botet , Francisco Arrieta , Manuel Botana , José A. Gimeno-Orna , José I. Martínez-Montoro , Emilio Ortega-Martínez de Victoria , Josep Ribalta , Víctor Sánchez-Margalet , Antonio Pérez-Pérez , en nombre del Grupo de Trabajo de Enfermedad Cardiovascular de la Sociedad Española de Diabetes

Patients with type 2 diabetes mellitus managed in both hospital and out-ofhospital settings usually have a high/very high cardiovascular risk, with a high burden of cardiovascular disease. All this justifies that the reduction of low-density lipoprotein cholesterol is the main therapeutic goal in diabetes. However, residual cardiovascular risk is very prevalent in type 2 diabetes, and is usually associated with atherogenic dyslipidemia and hyperlipoproteinemia(a); therefore, it is also necessary to reverse these lipoprotein abnormalities to achieve effective cardiovascular prevention. Given the considerable armamentarium of lipid-lowering drugs currently available, the Cardiovascular Disease Working Group of the Spanish Diabetes Society has considered it appropriate to carry out a narrative review and update of the effectiveness of these lipid-lowering drugs in the population with type 2 diabetes taking into account their effect on the lipoprotein profile and their potential impact on glycemic control.

{"title":"Terapia farmacológica hipolipemiante para la reducción del riesgo cardiovascular en la diabetes. Visión clínica del Grupo de Trabajo de Enfermedad Cardiovascular de la Sociedad Española de Diabetes","authors":"Juan Pedro-Botet , Francisco Arrieta , Manuel Botana , José A. Gimeno-Orna , José I. Martínez-Montoro , Emilio Ortega-Martínez de Victoria , Josep Ribalta , Víctor Sánchez-Margalet , Antonio Pérez-Pérez , en nombre del Grupo de Trabajo de Enfermedad Cardiovascular de la Sociedad Española de Diabetes","doi":"10.1016/j.endinu.2024.09.001","DOIUrl":"10.1016/j.endinu.2024.09.001","url":null,"abstract":"<div><div>Patients with type 2 diabetes mellitus managed in both hospital and out-ofhospital settings usually have a high/very high cardiovascular risk, with a high burden of cardiovascular disease. All this justifies that the reduction of low-density lipoprotein cholesterol is the main therapeutic goal in diabetes. However, residual cardiovascular risk is very prevalent in type 2 diabetes, and is usually associated with atherogenic dyslipidemia and hyperlipoproteinemia(a); therefore, it is also necessary to reverse these lipoprotein abnormalities to achieve effective cardiovascular prevention. Given the considerable armamentarium of lipid-lowering drugs currently available, the Cardiovascular Disease Working Group of the Spanish Diabetes Society has considered it appropriate to carry out a narrative review and update of the effectiveness of these lipid-lowering drugs in the population with type 2 diabetes taking into account their effect on the lipoprotein profile and their potential impact on glycemic control.</div></div>","PeriodicalId":37725,"journal":{"name":"Endocrinologia, Diabetes y Nutricion","volume":"72 2","pages":"Article 101523"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143436523","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

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