I have to make an important correction to last night's post entitled "Drug Surplus": Putting me on Lipitor, a drug that decreases cholesterol production by inhibiting the enzyme 3-hydroxy-3-methylglutaryl CoA (HMG-CoA) reductase, was the right thing for my endocrinologist to do. The literature approves of the treatment and medication I received. Because I've been reviewing my medical biochemistry notes, I can tell you that HMG-CoA reductase forms 3-hydroxy-3-methylglutaryl from acetyl CoA which is only a few mind boggling steps away from becoming cholesterol--which is bad. Unless it's the good kind (HDL).
But more importantly, I can tell you how I misread the risk assessment flow chart. I thought diabetes was simply a serious additional risk factor for the development of cardiovascular heart disease (CHD). I wish. Our lecturer today--a "diabetologist"--informed our lecture hall that diabetes was equivalent to having a heart attack. This was surprising to me, as I regularly do not grip my chest and yell, "Elizabeth, I'm comin'."
An equally attentive student asked whether type I and type II diabetes were considered equally dangerous in terms of cardiovascular disease. The diabetologist said "yes" and continued on with his lecture. I threw my hands up. Really? I've had a heart attack? Well, in that case, I guess being on Lipitor isn't that bad, because clearly I'm going to die any day now. Imagine having your first heart attack at age 13. Fascinating.
After lecture, a girl in my same row remarked that during one of our clinical correlation anatomy lectures, the doctor had innocuously stated that women with congenital sclerosis were eight times as likely to develop breast cancer. Just rolled right over that. Didn't say much more about it after that. Just thought it would be a fun statistic for everyone to know--not to be tested on it, but to let that information sink in to some of us with the unpleasant likeness of an unwanted guest or a recurrent nightmare.
Ignorance is bliss.
It's like our professors don't realize that while we all want to be physicians, we are also human. It's not just a flaw in the schools of medicine. It's a problem with our society. Doctors need to be flawless. We expect more of them than we expect of our own family members. They need to know everything and they need to tell us everything. They are omniscient, otherwise they aren't worth going back to. In this way, we expect them to be less like traditional professionals and to be more like gods. Unfortunately, they have problems too. I can't say for sure, but I'm guessing about a third of my class went into medicine because they either had a close relationship with a friend or a relative who had a serious illness, or because they themselves had or continue to have a life altering medical condition.
But we're just people. We don't like being reminded of our imperfections. Especially when our imperfections are highly correlated with increased morbidity and mortality, death and disease.
I know we have to know all the intricate details of disease and life and how the one influences the other, but sometimes, just every once in a while, it'd be great if it was understood that we were human and, just like most of humanity, scared of our own passing. So instead of getting widely-believed, sadistic statistics crammed down our throats, perhaps those sadistic statistics could be sugar coated? Not too much, though. Or at least, not too much for me.
I'm diabetic and apparently I have to watch my cholesterol.
Sep 28, 2011
Sep 27, 2011
Drug Surplus
I am perusing the notes for tomorrow's clinical biochemistry lecture. We are going to be discussing high cholesterol and how to properly assess risk for the condition. I love cholesterol.
Let me tell you why:
High cholesterol runs in my family, on my mother's side (German). My great-grandmother, who passed away recently at the age of 101, lived most of her life with a total cholesterol level greater than 200 mg/dL. The healthy average is around 160 mg/dL. Hypertension runs on my dad's side of the family (Nigerian). His blood pressure was 200/140mm Hg (normal 120/80), before he cut salt out of his diet and it fell back to normal. My generation, a chimeric mix of German and Nigerian traits, is now at a high risk of getting both conditions, which is a well studied recipe for early death.
But so far, at age twenty-two, I'm pretty healthy. My blood pressure has always been normal. I exercise a lot. I am slightly overweight, but that's just because BMI is useless for people afflicted with big bones. My diet is pretty healthy; I eat many more servings of fruits and vegetables than the average American my age. But I am at an "increased risk" for heart disease because I have diabetes mellitus. I still do not understand why I am at an increased risk if I am a type I diabetic. I don't think I've ever been told or have ever read that type I diabetes puts people at an increased risk for cardiovascular disease. So why do I have to worry about my cholesterol?
Well, first, my cholesterol actually was a little high. The first time I can recall being conscious about my cholesterol was when my lipid panel was reviewed by my adult endocrinologist. She immediately put me on Lipitor. At the time I thought whatever would make me healthier, I'd do. As a "lay person," I trusted my physician entirely. When I did my lipid panel screening again, about a half year later, my numbers were lower--they were better--and she kept me on Lipitor. I became suspicious. So I checked my numbers. The lab results always provide a normal range, so I reviewed it. Both times, my numbers were excellent. I mean, not excellent, but they were normal and I was healthy.
So why the Lipitor?
A risk assessment is used to judge whether or not a patient should consider changing their lifestyle (eating, exercising) habits or if they need to be more pro-active and be placed on a drug-enhancing regimen (Lipitor), Diabetes--but they never say which type--is considered a high risk factor. But that's the only risk factor I have. The risk assessment formula says that if I have 0-1 risk factors, my low density lipoprotein (LDL, the bad cholesterol) goal should be: <160 mg/dL. Guess what? It was! HIPPA be damned, I'll tell you what my LDL cholesterol was: 132 mg/dL. If it had been above 160 mg/dL, according to the assessment chart, a lifestyle change would have been recommended. Only at 190 would I need a more intensive pharmaceutical intervention. So why was I put on Lipitor?
Well, it helped. My total cholesterol was 190, my HDL was 43, and my Triglyceride was 77. A year later with Lipitor, my total cholesterol was 195, my triglyceride was 56, as was my HDL. And my LDL was a greatly reduced 128 (sarcasm).
But you know what made me even healthier according to the scale and charts and assessments? First, I gave up on Lipitor after my second lipid panel screening. Why? Because the pharmacy said I didn't have any more prescriptions and I didn't feel like calling my doctor to get me more. Second, I turned twenty-one. And around six months into being twenty-one, I realized that I loved red wine. I also started cooking more often and realized that olive oil is a good substitute for butter in almost everything. At age twenty-two I had another lipid panel screening. This time, my total cholesterol was 167, HDL 64, triglyceride 55, LDL 92.
Hmmm....
I know they're just numbers, but "statistically" I was much healthier.
What am I suggesting? That diabetics be given red wine earlier than age twenty-one? No. Never. Although...
In all seriousness, drugs are great. But they aren't a cure-all. Especially when it's something that can be heavily modulated by simple lifestyle choices. Look at America. There are serious health issues we need to address. But should we prescribe drugs after a problem arises? Or should we try to tell people what they can change in their kitchen and in their lives to make them healthier by their own volition? Drugs are great, and I don't want to argue against their over prescription in America, but when I'm placed on a drug to lower cholesterol, it would be great if I was told how this problem arose and what I can do, myself, to make it better.
Boiled down, what happened to me was simply a problem with patient empowerment. If you give your patients advice that is comprehensive but also understandable, their adherence should be higher, and as a result, they should be healthier. Doctors are important. We need more of them. But perhaps what's even more vital than quantity is quality, specifically as it deals to communication. A patient should know that sometimes, they are their own best medicine.
Let me tell you why:
High cholesterol runs in my family, on my mother's side (German). My great-grandmother, who passed away recently at the age of 101, lived most of her life with a total cholesterol level greater than 200 mg/dL. The healthy average is around 160 mg/dL. Hypertension runs on my dad's side of the family (Nigerian). His blood pressure was 200/140mm Hg (normal 120/80), before he cut salt out of his diet and it fell back to normal. My generation, a chimeric mix of German and Nigerian traits, is now at a high risk of getting both conditions, which is a well studied recipe for early death.
But so far, at age twenty-two, I'm pretty healthy. My blood pressure has always been normal. I exercise a lot. I am slightly overweight, but that's just because BMI is useless for people afflicted with big bones. My diet is pretty healthy; I eat many more servings of fruits and vegetables than the average American my age. But I am at an "increased risk" for heart disease because I have diabetes mellitus. I still do not understand why I am at an increased risk if I am a type I diabetic. I don't think I've ever been told or have ever read that type I diabetes puts people at an increased risk for cardiovascular disease. So why do I have to worry about my cholesterol?
Well, first, my cholesterol actually was a little high. The first time I can recall being conscious about my cholesterol was when my lipid panel was reviewed by my adult endocrinologist. She immediately put me on Lipitor. At the time I thought whatever would make me healthier, I'd do. As a "lay person," I trusted my physician entirely. When I did my lipid panel screening again, about a half year later, my numbers were lower--they were better--and she kept me on Lipitor. I became suspicious. So I checked my numbers. The lab results always provide a normal range, so I reviewed it. Both times, my numbers were excellent. I mean, not excellent, but they were normal and I was healthy.
So why the Lipitor?
A risk assessment is used to judge whether or not a patient should consider changing their lifestyle (eating, exercising) habits or if they need to be more pro-active and be placed on a drug-enhancing regimen (Lipitor), Diabetes--but they never say which type--is considered a high risk factor. But that's the only risk factor I have. The risk assessment formula says that if I have 0-1 risk factors, my low density lipoprotein (LDL, the bad cholesterol) goal should be: <160 mg/dL. Guess what? It was! HIPPA be damned, I'll tell you what my LDL cholesterol was: 132 mg/dL. If it had been above 160 mg/dL, according to the assessment chart, a lifestyle change would have been recommended. Only at 190 would I need a more intensive pharmaceutical intervention. So why was I put on Lipitor?
Well, it helped. My total cholesterol was 190, my HDL was 43, and my Triglyceride was 77. A year later with Lipitor, my total cholesterol was 195, my triglyceride was 56, as was my HDL. And my LDL was a greatly reduced 128 (sarcasm).
But you know what made me even healthier according to the scale and charts and assessments? First, I gave up on Lipitor after my second lipid panel screening. Why? Because the pharmacy said I didn't have any more prescriptions and I didn't feel like calling my doctor to get me more. Second, I turned twenty-one. And around six months into being twenty-one, I realized that I loved red wine. I also started cooking more often and realized that olive oil is a good substitute for butter in almost everything. At age twenty-two I had another lipid panel screening. This time, my total cholesterol was 167, HDL 64, triglyceride 55, LDL 92.
Hmmm....
I know they're just numbers, but "statistically" I was much healthier.
What am I suggesting? That diabetics be given red wine earlier than age twenty-one? No. Never. Although...
In all seriousness, drugs are great. But they aren't a cure-all. Especially when it's something that can be heavily modulated by simple lifestyle choices. Look at America. There are serious health issues we need to address. But should we prescribe drugs after a problem arises? Or should we try to tell people what they can change in their kitchen and in their lives to make them healthier by their own volition? Drugs are great, and I don't want to argue against their over prescription in America, but when I'm placed on a drug to lower cholesterol, it would be great if I was told how this problem arose and what I can do, myself, to make it better.
Boiled down, what happened to me was simply a problem with patient empowerment. If you give your patients advice that is comprehensive but also understandable, their adherence should be higher, and as a result, they should be healthier. Doctors are important. We need more of them. But perhaps what's even more vital than quantity is quality, specifically as it deals to communication. A patient should know that sometimes, they are their own best medicine.
Drug Shortage
Perhaps a continuing theme of my writing's will be concerned with how few doctors there are. As previously noted, there is a shortage of primary care physicians in America. There is also a shortage of podiatrists. But did you know, that there is also, right now, a shortage of drugs in America?
I was just watching the national news last week when Diane Sawyer told me that the lack of prescription drugs in America was having real health consequences in America, with an estimated 15 deaths caused from drug shortages in the last year. Fifteen deaths. It doesn't sound that terrifying or even wrong if it's applied to something expected to be deadly in America, like Swine Flu or even just the regular type of influenza. But fifteen is a lot of lives lost if you consider that these afflictions were 100% treatable. I know morality and ethics tend to devolve into an annoying morass of public opinion sometimes, but if these people wanted to be alive yet couldn't make it because their health care providers couldn't provide the appropriate medicine, and then they died, that's wrong. Blatantly, offensively, inexcusably wrong. If I want to live, I should be afforded as much help as medically possible.
And do you know some of the theories behind why there are suddenly drug shortages in the nation that has the best health care in the world? Like everything else that's wrong with this country's politics, it's because of money. One of the suspected reasons drugs are suddenly hard to come by is because patents for some of the largest drugs have run out, which means they can start being manufactured and sold as cheaper generics from the non-original company. This means that the original company stops making as much of their product because they know they will lose profit as other pharmaceutical companies increase supply by mass producing generics. Except when they don't. And then, well, you know, people die.
I was just watching the national news last week when Diane Sawyer told me that the lack of prescription drugs in America was having real health consequences in America, with an estimated 15 deaths caused from drug shortages in the last year. Fifteen deaths. It doesn't sound that terrifying or even wrong if it's applied to something expected to be deadly in America, like Swine Flu or even just the regular type of influenza. But fifteen is a lot of lives lost if you consider that these afflictions were 100% treatable. I know morality and ethics tend to devolve into an annoying morass of public opinion sometimes, but if these people wanted to be alive yet couldn't make it because their health care providers couldn't provide the appropriate medicine, and then they died, that's wrong. Blatantly, offensively, inexcusably wrong. If I want to live, I should be afforded as much help as medically possible.
And do you know some of the theories behind why there are suddenly drug shortages in the nation that has the best health care in the world? Like everything else that's wrong with this country's politics, it's because of money. One of the suspected reasons drugs are suddenly hard to come by is because patents for some of the largest drugs have run out, which means they can start being manufactured and sold as cheaper generics from the non-original company. This means that the original company stops making as much of their product because they know they will lose profit as other pharmaceutical companies increase supply by mass producing generics. Except when they don't. And then, well, you know, people die.
Sep 16, 2011
PMI
So the place on my chest where I sometimes hold my right hand to feel my heart beat to calm me down after I've been crying or after I've been shocked or if I'm bored and tired but can't go to sleep or if I simply want to know that I'm still alive, and if I am I'll just sit and wonder a little bit about life and death before the discussion loses me to delta wave sleep, that's the Point of Maximal Impulse, or PMI. It's where your stronger left ventricle strikes your chest wall when it pushes blood through your aorta, shortly after systole, your first heart sound. It is usually located in the mitral area of the heart, so named because the mitral valve separates the left atria from the left ventricle.
Sep 14, 2011
Writing for Anatomy
The first thing we knew about our cadaver was that we should not call it a cadaver. It was a person. But it wasn't alive. We didn't know how to use that in sentences, so we'd begin to refer to it as a cadav--, before catching ourselves and saying, "Our body," instead, like it was something we owned, which felt worse.
The second thing we knew about our body was that it was a she and that her name was Debbie. This helped, because now in reference, we could say something like, "Thank God Debbie looks fit," which simply meant we wouldn't be elbow deep in adipose tissue half way through the dissection. This taught us how to say “Thank You.”
The third thing we knew about our Debbie was that she died at age 46. We did not like knowing this. We tried to escape our feelings by immersing ourselves in a cerebral game of pursuit for a suitable cause of death. Subdural hematoma. Car accident, perhaps. Congenital heart failure. Aortic rupture. An uncommon medical malady? Someone in our group suggested cancer, said that one of their favorite professors had just been diagnosed with late stage breast cancer, absolutely devastating. That brought us back to our feelings.
We did not like knowing that Debbie died when she was 46.
The rest of the things we knew about Debbie we learned slowly. I noticed a hideous blue-green iridescent shade of nail polish on her fingernails. I wondered if she had decided on that color herself or if it was chosen by an out of touch mortician for the funeral service--if she had had one. But I learned I would always give Debbie the benefit of the doubt. The formalin she was awash in probably soaked into her nails and leached the original color, just as the 10% formaldehyde solution found its way under my nails, despite the barrier of vinyl gloves, and stayed with me.
We learned from Debbie that the process of cutting open a human body is not horrifying. We learned from Debbie that the skin on the middle of the back is thick, but not so thick that a fresh scalpel needs much pressure applied to it to get where it needs to go. I learned from Debbie that I am very good at removing fascia. I learned from Dr. Oblinger that fascia is only connective tissue. I learned that you can feel really good about yourself that first day for helping your group with the dissection, but when you look down at your hands and see off-white gloves covered in flecks of skin, hair, and connective tissue, you will no longer feel right. That day, I learned that the urge to drop scalpel and run, the fear of death, would reaffirm my own life. But thanks to Debbie, I soon realized that I would learn a lot about life from death.
So thank you Debbie.
Sep 13, 2011
Is Nothing Sacred Anymore?
It finally happened. I dreamed about the things I spent all week learning. Most surprising, it wasn't material that would easily translate into a traditional dream--like dissecting a human body or telling a patient they have inoperable cancer. Even moving through the trans-Golgi network would seem somewhat plausible. No. This dream was about biochemistry.
A small group of stock medical students and I completed biochemistry pathway challenges:
"We need to find the glyceraldehyde 3-phosphate dehydrogenase!"
"I don't think it exists."
"It should exist; we're hypoglycemic."
"I told you it doesn't exist!"
"Don't give me that crap Jenkins!"
And then most bizarre, at the end, Jay Leno or David Letterman would summarize the pathway for me.
I think I screamed out fructose in my sleep. I hate fructose. Has medical school devolved into a never ending nightmare?
A small group of stock medical students and I completed biochemistry pathway challenges:
"We need to find the glyceraldehyde 3-phosphate dehydrogenase!"
"I don't think it exists."
"It should exist; we're hypoglycemic."
"I told you it doesn't exist!"
"Don't give me that crap Jenkins!"
And then most bizarre, at the end, Jay Leno or David Letterman would summarize the pathway for me.
I think I screamed out fructose in my sleep. I hate fructose. Has medical school devolved into a never ending nightmare?
Sep 7, 2011
Hobbies
I've decided I won't be productive tonight. I don't feel bad about this. So I'm watching CSI on CBS. I get two "normal" channels: CBS and ABC. I also get the Korean Broadcasting Channel. But regardless, I saw a commercial for Lyrica. Lyrica is a prescription drug designed to treat Fibromyalgia. The commercial's heroine was a woman who worked at a jewelry store as a beader. Her selling statement, about why people who have chronic tenderness and pain in their muscles and joints should ask their doctors about Fibromyalgia was: "... So I can get back to what's really important in life."
Okay. I love beading. I regularly think of it as one of my preferred hobbies, next to creative writing, cooking, and sleeping. But I found this drug commercial absolutely ridiculous.
Keep in mind, I'm a pretty cynical person, and I'm aware that commercials are excellent manipulators, so I like to point out their unavoidable logical fallacies. When would beading ever be what's really important in life? It was the woman's job to make jewelry, to bead, but even then... what a lame job.
And then I realized something. It wasn't that I hated the fact that Fibromyalgia wouldn't allow someone to get back to "what's really important in life." It totally, maybe, probably can. What really bothered me about this commercial is that something as fun, yet unimportant, as jewelry making, could be someone's main reason in life...
Okay. I love beading. I regularly think of it as one of my preferred hobbies, next to creative writing, cooking, and sleeping. But I found this drug commercial absolutely ridiculous.
Keep in mind, I'm a pretty cynical person, and I'm aware that commercials are excellent manipulators, so I like to point out their unavoidable logical fallacies. When would beading ever be what's really important in life? It was the woman's job to make jewelry, to bead, but even then... what a lame job.
And then I realized something. It wasn't that I hated the fact that Fibromyalgia wouldn't allow someone to get back to "what's really important in life." It totally, maybe, probably can. What really bothered me about this commercial is that something as fun, yet unimportant, as jewelry making, could be someone's main reason in life...
Sep 3, 2011
This is only my Heart Beat
I was listening to my heart tonight. The first year medical students and podiatrists had the essentials of clinical reasoning lab this week, and we all had to mock running through a complete cardiac exam with a partner. What I learned in lab strengthened the self-taught lesson I've been constructing this week: everyone's different. This is obvious in anatomy lab during our dissection of a once living person when we become so careful with our scalpels we are frozen in stasis, not just because we are trying to be respectful of the human body lying before us--though we initiate each lab with protocols permeated with gratefulness--but because the bodies given to science look nothing on the inside like the computer model--also of a once living person. I also discovered during our clinical reasoning lab that my femoral artery is really close to my leg, as opposed to being more ventrally lateral... or laterally ventral.
So I was listening to my different heart tonight. In lecture we were told that there are usually just two heart sounds, S1 and S2. But sometimes, there are other noises that can be categorized as S3 and S4. I was shocked--as I held the bell of my stethoscope over my aorta--that I could definitively hear the S2 split.
S1 is the first heart sound, created by the closing of the mitral and tricuspid valves, the borders between the left and right atria and ventricles, respectively. This is the low beat that haunts miscreants and murderers. S2 is the softer of the heart sounds, created when the aortic and pulmonic valves close, successfully closing off re-entrance to the heart by expelled blood. S2 heart sounds are often split. But in my heart, it almost sounded as if there were three heart beats. Am I so musical that even my organs fill with syncopation? Or maybe I'm still very young. Splitting disappears in advanced age, apparently. Just like I had a heart murmur when I was little--noticeable in the slight whoosh sounded by blood passing through my intraventricular septum--that ultimately disappeared.
When I moved my stethoscope to the mitral auscultatory area, which in most people centers over their left ventricular wall, the S2 split disappeared. Physics. The distance from the base of the heart to the pulmonary artery and aorta split is not huge, but it makes a difference, especially when you consider the medium that sound is traveling through isn't air--it's mostly water. The closing valves, a quarter of a second off each other before, are now almost synchronized. My heart, antagonized for years by swimming, asthma, anemia, and a minor septal defect, is now a little large. Not too large. But it's hypertrophic. Its beating is resplendent.
How weird it was for me to hear my heart, to feel it push against my stethoscope--forcing my hand up into the wiring of my bra--as strong as a magnet or gravity or some other force which is strong but invisible. For the last week, we've been talking about the heart--how it forms in embryos and further develops in fetuses, how it can be used to explain many confusing differential diagnoses. I've seen the inside of a baby's heart beating rapidly, around one-hundred-and-twenty beats per minute, as a laser pointer indicated where the ventricular septum didn't grow fully through the heart's chamber, sectioning off right from left. I wonder if the images we saw were from babies who made it. I'm committed to being pro-choice and plan to stay that way for the rest of my life--it seems like the only rationale position to take as a physician who respects her patients. But, in silence, I wished that the babies that graciously allowed us to learn from their ultrasound videos made it fully into life. After all, I have seen into their hearts. Defective or not, a beating heart is rather miraculous. Especially if you believe that evolution, and only evolution alone, got us to this point where there are a mere 20 heart defects in 1000 births.
So I was listening to my different heart tonight. In lecture we were told that there are usually just two heart sounds, S1 and S2. But sometimes, there are other noises that can be categorized as S3 and S4. I was shocked--as I held the bell of my stethoscope over my aorta--that I could definitively hear the S2 split.
S1 is the first heart sound, created by the closing of the mitral and tricuspid valves, the borders between the left and right atria and ventricles, respectively. This is the low beat that haunts miscreants and murderers. S2 is the softer of the heart sounds, created when the aortic and pulmonic valves close, successfully closing off re-entrance to the heart by expelled blood. S2 heart sounds are often split. But in my heart, it almost sounded as if there were three heart beats. Am I so musical that even my organs fill with syncopation? Or maybe I'm still very young. Splitting disappears in advanced age, apparently. Just like I had a heart murmur when I was little--noticeable in the slight whoosh sounded by blood passing through my intraventricular septum--that ultimately disappeared.
When I moved my stethoscope to the mitral auscultatory area, which in most people centers over their left ventricular wall, the S2 split disappeared. Physics. The distance from the base of the heart to the pulmonary artery and aorta split is not huge, but it makes a difference, especially when you consider the medium that sound is traveling through isn't air--it's mostly water. The closing valves, a quarter of a second off each other before, are now almost synchronized. My heart, antagonized for years by swimming, asthma, anemia, and a minor septal defect, is now a little large. Not too large. But it's hypertrophic. Its beating is resplendent.
How weird it was for me to hear my heart, to feel it push against my stethoscope--forcing my hand up into the wiring of my bra--as strong as a magnet or gravity or some other force which is strong but invisible. For the last week, we've been talking about the heart--how it forms in embryos and further develops in fetuses, how it can be used to explain many confusing differential diagnoses. I've seen the inside of a baby's heart beating rapidly, around one-hundred-and-twenty beats per minute, as a laser pointer indicated where the ventricular septum didn't grow fully through the heart's chamber, sectioning off right from left. I wonder if the images we saw were from babies who made it. I'm committed to being pro-choice and plan to stay that way for the rest of my life--it seems like the only rationale position to take as a physician who respects her patients. But, in silence, I wished that the babies that graciously allowed us to learn from their ultrasound videos made it fully into life. After all, I have seen into their hearts. Defective or not, a beating heart is rather miraculous. Especially if you believe that evolution, and only evolution alone, got us to this point where there are a mere 20 heart defects in 1000 births.
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