Emergencias 2016;28:67-70

LETTERS TO THE EDITOR

On “Noninvasive and There is little evidence to support 3 Sabatier C, Monge I, Maynar J, Ochagavía A.
Valoración de la precarga y la respuesta car-
minimally invasive systematic CO monitoring of patients
diovascular al aporte de volumen. Med In-
in shock2. Continuous hemodynamic
hemodynamic monitoring in monitoring is recommended when
tensiva. 2012;36:45-55.
4 Almela-Quilis A, Millán-Soria J, Alonso-Íñigo JM,
critically ill patients in the there is persistent tissue hypoperfu- García-Bermejo P. Monitorización hemodinámi-
emergency department” sion within 3-6 hours from the start ca no invasiva o mínimamente invasiva en el
paciente crítico en los servicios de urgencias y
of treatment2. Almela et al.4 recom- emergencias. Emergencias. 2015; 27:386-95.
Comentarios al artículo: mend minimally invasive hemodyna- 5 Mateu-Campos ML, Ferrándiz-Sellés A,
“Monitorización hemodinámica no mic monitoring (MIHM) in the ED. Gruartmoner de Vera G, Mesquida-Febrer J,
invasiva o mínimamente invasiva en These systems based on analysis of Sabatier-Cloarec C, Poveda-Hernández Y, et
al. Técnicas disponibles de monitorización
el paciente crítico en los servicios de the arterial curve pressure are backed hemodinámica. Ventajas y limitaciones. Med
urgencias y emergencias” by few validation studies. For a co- Intensiva. 2012; 36:434-44.
rrect estimate of the parameters the
Sir, patient must be under controlled
Early identification of shock and mechanical ventilation without respi-
hemodynamic support are crucial ratory activity and in sinus rhythm, Author's Response
to prevent multiple organ failure, as and the values in the presence of
well for diagnosing its cause and arrhythmias, greatly diminished vas- Respuesta del autor
correcting it. The administration of cular resistors (sepsis), right ventricu-
oxygen, fluids and vasoactive drugs lar dysfunction and obesity are inac- Sir,
are the pillars of resuscitation1. Alte- curate 2,5 . Moreover, the artery Monitoring in critical patient ma-
ration of tissue perfusion markers channelling needed requires a lear- nagement should be multifactorial
(elevated lactate and/or central ve- ning curve, especially in patients in and dynamic in the various possible
nous oxygen saturation -SvcO 2 - shock. We disagree with its indica- scenarios1. It is critical to obtain the
<70%), accompanied of any clinical tion in the persistence of hypoperfu- classic variables defined as the objec-
signs of hypoperfusion (clammy sion 30-120 minutes after the start tives of the resuscitation process 1,2
skin, oliguria and impaired mental of treatment. Clinical symptoms, and repeated determination until sta-
status) defines shock; the presence physical examination, serial measure- ble normalization in time3.
of arterial hypotension is not neces- ments of lactate, SvcO2, P (vc-a) CO2 The target value of mean arterial
sary (mean arterial pressure -MAP- and its interpretation and early echo- pressure (MAP) 65 mmHg in sepsis
<65 mmHg) 1,2. Fluid therapy is the cardiography seems to provide suffi- has proven its worth at discerning
first line of treatment. However cient information for quality mana- between survivors and non-survi-
only 50% of critical patients res- gement of these patients in the ED. vors 4. However, in trauma patients
pond by increasing cardiac output The use of MIHM has considerable li- with uncontrollable bleeding or head
(CO). Hence the interest in monito- mitations. Inadequate interpretation trauma without serious systemic he-
ring fluid therapy to prevent edema of the parameters it provides may in- morrhage, MAP values of 40 and 90
by an excessive hydric balance and duce improper management and de- mmHg respectively are recommen-
early vasoactive drugs in case of in- lay in invasive monitoring and sup- ded5. Studies based on capillary vide-
sufficient response to fluids 1,2. The port in the intensive care unit. omicroscopy suggest individualizing
first objective is to achieve a MAP MAP according to its effect on the
65 mmHg followed by normaliza- Francisco Ramón Pampín-Huerta1, microcirculation.
tion of lactate and/or SvcO2 70%. Dolores Moreira-Gómez2 Mixed venous oxygen saturation
Arteriovenous difference of CO 2 [P 1
Medicina Intensiva y Medicina Familiar y (SvO2) is the best indicator of ade-
(vc-a) CO2], defined as the differen- Comunitaria, Unidad de Reanimación y Cuidados quate tissue oxygenation (DO2). Its
Intensivos, Hospital HM Modelo, A Coruña, Spain.
ce in venous blood pCO2 in central 2
Medicina Intensiva, Unidad de Reanimación y
incorporation as an objective has
and arterial blood of > 6 mmHg, is Cuidados Intensivos, Hospital HM Modelo, proven its beneficial impact, but it
indicative of persistent hypoperfu- A Coruña, Spain. has to be taken into account that in
sion, even in the presence SvcO2 [email protected] certain distributive shock situations,
70%. Thus standardization should the presence of elevated SvO 2 has
also be a goal in resuscitation2. Ta- been associated with increased mor-
king into account all the above, it is Conflict of interest tality6.
recommended to determine serial The authors declare no conflict of interest Lactate values correlate directly
in relation to this article. with mortality due to tissue hypoxia
lactate levels, SvcO 2 and P (vc-a)
CO2 to assess the response to treat- and anaerobic metabolism. But they
ment, and to perform an early also increase by the endogenous me-
echocardiogram, which provides References chanism of adaptation during adre-
non-invasive bedside information nergic stimulation, so there are au-
1 Vincent JL, De Backer D. Circulatory shock. thors that question the usefulness of
on the etiology of shock as well as N Engl J Med. 2013;369:1726-34.
to predict a positive response to 2 Ochagavía A, Baigorri F, Mesquida J, Ayuela JM, clearance as an ultimate goal of re-
fluids if the diameter of the inferior Ferrándiz A, García X, et al. Monitorización he- suscitation7,8.
vena cava (subxyphoid window on modinámica en el paciente crítico. Recomenda- Minimally invasive hemodynamic
ciones del Grupo de Trabajo de Cuidados Inten- monitoring systems (MIHM) used to
expiratory phase) is less than 12 sivos Cardiológicos y RCP de la Sociedad
mm and if the response is greater Española de Medicina Intensiva, Crítica y Unida- measure cardiac output (CO) along
than 20 mm1-3. des Coronarias. Med Intensiva. 2014;38:154-69. with echocardiography give us a bet-

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ter understanding of the pathophy- ción hemodinámica en el paciente crítico.

siological changes that occur, hel- Recomendaciones del Grupo de Trabajo de
Cuidados Intensivos Cardiológicos y RCP de
ping us in the differential diagnosis la Sociedad Española de Medicina Intensiva,
of shock and to optimize treatment, Crítica y Unidades Coronarias. Med Intensi-
quantify its effects and avoid possible va. 2014;38:154-69.
complications arising during resusci- 2 Almela-Quilis A, Millán-Soria J, Alonso-Íñigo JM,
García-Bermejo P. Monitorización hemodinámi-
tation. Therefore, an early strategy is ca no invasiva o mínimamente invasiva en el
needed, multidisciplinary and multi- paciente crítico en los servicios de urgencias y
factorial, for critically ill patients in emergencias. Emergencias. 2015;27:386-95.
which evidence increasingly supports 3 Shafiro NI, Howell MD, Talmar D, Lahey D,
Ngo L, Buras J, et al. Im- plementation and
an individualized approach and whe- outcomes of the multiple urgent sepsis the-
re the impact of the MIHM does not rapies (MUST) protocol. Crit Care Med. Figure 1. Spleen hypodensity without
only depend on the reliability of ma- 2006;34:1025-32. peripheral uptake suggestive of splenic
nagement systems, but also kno- 4 Varpula M, Tallgren M, Saukkonen K, Voipio-
Pulkki LM. Hemody-namic variables related
infarction.
wledge of its limitations and unders- to outcome in septic shock. Crit Care Med.
tanding of the pathophysiologic 2005;31:1066-71. normal. The abdomen was distended, with
basis and interpretation of all varia- 5 Antonelli M, Levy M, Andrews PJD, Chastre normoactive and painful sounds on gene-
bles obtained and their correct use9. J, Hudson LD,Manthous C, et al. Hemodyna- ral shallow palpation. The blood count was
mic monitoring in shock andimplications for normal, as were biochemical test results.
MIHM should be simple, safe, ope- management. International Consensus Con- The only parameter of note was LDH 289
rator-independent, cost-effective and ference, Paris, France, 27-28 April 2006. In- IU/I. The electrocardiogram showed atrial
accurate10. However, no system meets tensive Care Med. 2007;33:575-90.
fibrillation with controlled ventricular res-
all these requirements, so the greater 6 Textoris J, Fouche L, Wiramus S, Antonini F,
Tho S, Martin C,et al. High central venous ponse. Chest and abdominal radiography
the severity and complexity of the pa- oxygen saturation in the latter stagesof sep- findings were unremarkable. Computed
tient, the greater the need for intensi- tic shock is associated with increased morta- abdominal tomography (CT) showed a lar-
ve treatment and invasiveness. We do lity. Crit Care. 2011;15:R176. ge hypodensity, which included more than
not agree with the comments of Pam- 7 Jones A, Shapiro N, Trzeciak S et al: Lactate 75% of the splenic surface, with triangular
clearance vs Central Venous Oxygen Satura- morphology, without peripheral uptake,
pín-Huerta and Moreira-Gómez, since tion as Goals of Early Sepsis Therapy: A rando- suggestive of splenic infarction (Figure 1).
non-invasive monitors can be useful in mized clinical Trial. JAMA. 2010;303:739-46.
less severe patients in the emergency 8 García-Álvarez, Marik P, Bellomo R. Sepsis asso-
Splenic infarction is the result of
department or conventional hospital ciated hyperlactatemia. Crit Care. 2014;18:503.
9 Gil Cano A, Monge García IM, Baigorri Gon- arterial or venous compromise of
wards to confirm a preliminary diag- zález F. Evidencia de la utilidad de la moni- splenic vessels, either intraluminal
nosis, observe the response to volume torización hemodinámica en el paciente crí- or extraluminal 2. It can be caused
and the evolution of lower-risk pa- tico. Med Intensiva. 2012;36:650-5.
by different mechanisms, including
tients or for monitoring prior to ad- 10- Slagt C, Breuker RM, Groeneveld J. Choo-
sing patient-tailored he-modynamic monito- those found in hematological pro-
mission to the intensive care unit ring. Crit Care. 2010;14:208. cesses (myeloid metaplasia, polycy-
(ICU)1, as stated in the Intensive Care themia vera, myeloproliferative di-
Cardiac Working Group and CPR of seases, lymphomas, leukemias,
SEMICYUC1. In addition, also for an hemolytic anemias) 3 , portal vein
early assessment 1,10, a less invasive Embolic splenic infarction thrombosis, infectious diseases (en-
technique is preferable if it can be ob- docarditis), aneurysm of the abdo-
tained quicker and easier, even if it is minal aorta, artery or splenic vein
Infarto esplénico embólico
less accurate. thrombosis, septic embolism and
In conclusion, MIHM systems are thromboembolic disease 1. Making
another tool for monitoring the criti- Sir, the diagnosis requires diagnostic
cal that have the added value of Splenic infarction is one of the imaging tests. On abdominal ultra-
continuously determining these va- causes of acute or chronic pain loca- sound, triangular areas typically ap-
riables, regardless of the patient's lo- ted in left upper quadrant, although pear hypoechoic with a peripheral
cation and therefore also in the ED. sometimes it appears as febrile location, and on CT scan the pre-
syndrome or as constitutional sence of peripheral hypodense are-
syndrome1. We briefly describe a ca- as is typical without contrast1. Tre-
Javier Millán Soria1; se of embolic splenic infarction. atment is initially medical by
Amadeo Almela Quilis2
A 92-year-old woman with a history of analgesia and anticoagulation; sur-
1
Servicio de Urgencias-UCE, Hospital Lluís Alcanyís
de Xativa, Valencia, Spain. Grupo hemoSEMES. hypertension, duodenal ulcer, hypercholes- gery should only be reserved for
2
Servicio de Urgencias-UCE, Hospital Arnau de terolemia and atrial fibrillation. She was cases with complications (splenic
Vilanova de Valencia, Spain. Grupo hemoSEMES. treated with acenocoumarol, but that had abscess and rupture)1,3, or when the
[email protected] to be suspended because of recurrent falls diagnosis is imprecise.
with head injuries. The treatment used for
more than two months was: diltiazem,
simvastatin, digoxin, torasemide and raniti-
Conflict of interest Pedro Gargantilla1,
dine. The patient visited the ED for abdo-
The authors declare no conflict of interest Noelia Arroyo1,
minal pain much like menstrual cramp sin-
in relation to this article. José Fernando Madrigal2,
ce four days before, located in the upper
Ana Aymerich2
abdomen, accompanied by nausea and vo-
References miting. She reported no other symptoms.
1
Servicio de Medicina Interna, Hospital de
On physical examination, the patient was El Escorial, Madrid, Spain. 2Servicio de Urgencias,
Hospital de El Escorial, Madrid, Spain.
1 Ochagavía A, Baigorri F, Mesquida J, Ayuela conscious, oriented, well hydrated and per-
JM, Ferrándiz A, García X, et al. Monitoriza- fused. Cardiopulmonary auscultation was [email protected]

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Conflict of interest 66.6% after 1st dose of

The authors declare no conflict of interest
vernakalant
in relation to this article. 12 patients with AAF with 83.3%
reversion to sinus rhythm reverted to SR
(SR) criteria 16.6% mild adverse events (cough,
References dysgeusia, self-limiting atrial flutter)
Mean age: 56 years
1 Marcos Sánchez F, Castaño Albo I, Árbol Lin- Gender: male 91.3% NO SERIOUS ADVERSE EVENTS
de F, Viana Alonso A, Gómez Soto FM, Cu- Cardiovascular risk factors:
querella J, et al. Infarto esplénico embólico. 16.6% New AF
An Med Interna. 2003;20:58-9.
HBP 50%
DM 16.6% episode <4 weeks
2 Arenal Vera JJ, Said JA, Guerro A, Otero M,
Gil I. Infarto esplénico secundario a pancrea- Previous stroke 16.6%
titis aguda. Rev Esp Enferm Dig.
2008;100:300-3.
3 Gupta S, Kalar A. Splenic infact of unusual
aetiology. JIACM. 2004;5:310-4. Figure 1. Experience with vernakalant in an emergency department. AAF: acute atrial
fibrillation; HBP: high blood pressure; DM: diabetes mellitus, SR: sinus rhythm.

diabetes and 16.6% prior stroke. In rela- References

tion to the current episode of AAF: in
58.3% this was the first episode, 83.3% 1 Camm AJ, Lip GY, De Caterina R, Savelieva I,
Vernakalant for atrial reverted to sinus rhythm, 66.6% with the Atar D, Hohnloser SH, et al. 2012 focused
first dose of vernakalant. From the group update of the ESC Guidelines for the mana-
fibrillation in an emergency gement of atrial fibrillation: an update of the
of patients who did not show reversion to
department sinus rhythm with vernakalant, electrical 2010 ESC Guidelines for the management of
atrial fibrillation. Developed with the special
cardioversion was successful in one of contribution of the European Heart Rhythm
Vernakalant en fibrilación auricular: them bit not in the other, with maintai- Association. Eur Heart J. 2012;33:2719-47.
experiencia en un servicio de ned atrial fibrillation at discharge. This 2 Roy D, Rowe BH, Stiell IG, Coutu B, Ip JH,
urgencias patient reverted to sinus rhythm 48 hours Phaneuf D, et al. A randomized, controlled
later at home with beta blockers. Two of trial of RSD1235, a novel anti-arrhythmic
the patients had AAF relapse within 4 we- agent, in the treatment of recent onset atrial
Sir, eks after reversion to sinus rhythm. No fibrillation. J Am Coll Cardiol. 2004;21:2355-
The 2012 European Guidelines serious adverse event was found, al- 61.
recommend the use of vernakalant 3 Roy D, Pratt CM, Torp-Pedersen C, Wyse
though 2 patients reported cough and DG, Toft E, Juul-Moller S, et al. Vernakalant
for reversion to sinus rhythm in pa- dysgeusia (mild and limited to the dura- hydrochloride for rapid conversion of atrial
tients with acute atrial fibrillation tion of IV infusion effects), and in one ca- fibrillation: a phase 3, randomized, placebo-
(AAF) of less than 48 hours’ dura- se conversion to self-limiting atrial flutter controlled trial. Circulation. 2008;117:1518-
tion, excluding patients with blood of less than 2 minutes’ duration: no ac- 25.
tion was considered necessary. 4 Camm AJ, Capucci A, Hohnloser SH, Torp-
pressure lower than 100 mmHg, Pedersen C, Van Gelder IC, Mangal B, et al;
ejection fraction ≤ 35%, NYHA type ACT and ACT 3 studies have de- AVRO Investigators. A randomized active
I-II heart failure, severe aortic steno- monstrated the safety of vernakalant controlled study comparing the efficacy and
sis and prolonged QT1. Vernakalant safety of vernakalant to amiodarone in re-
with low rates pf pro-arrhythmia cent-onset atrial fibrillation. J Am Coll Car-
is a selective atrial antiarrhythmic and hypotension2,3. The AVRO study diol. 2011;57:313-21.
administered intravenously that pro- demonstrated the safety of this 5 Heldal M, Atar D. Pharmacological conver-
longs the refractory period, with mi- drug in patients with moderate sion of recent-onset atrial fibrillation: A syste-
nimum effects on ventricular repola- matic review. Scand Cardiovasc J Suppl.
structural heart disease, excluding 2013;47:2-10.
rization, which has proven to be patients with obstructive cardiomyo- 6 Juul-Möller S. Vernakalant in recently develo-
effective in randomized studies2-4. It pathy, severe valvular disease or re- ped atrial fibrillation: How to translate phar-
is faster acting than other drugs cent heart attack, among others4. In macological trials into clinical practice. Eur J
used in FAA 5 as well as safer and Cardiovasc Med. 2013;2:226-33.
our experience, vernakalant has pro-
with lower rate of recurrence than ven to be a safe, effective and fast-
electrical cardioversion6. We wish to acting drug, reversing more than
show the results obtained in our use half of the patients with the first in-
of vernakalant in patients with AAF fusion. By reducing the time spent
within 48 hours of evolution, for si- in the ED, organizational benefits Focused basic clinical
nus rhythm reversal in an emer- are obtained and ED resources are ultrasound in the emergency
gency department. optimized. department: a dream come
We performed a retrospective, obser-
vational, single-center study, from July 1, Amós Urtubia Palacios, true?
2014 to September 1, 2015. We included Mª Ángeles Carbonell Torregrosa
12 patients with AAF who received verna- Servicio de Urgencias, Hospital General Universitario La ecocardiografía clínica básica
kalant. The 12 patients were administered Virgen de la Salud de Elda, Alicante, Spain. en urgencias:
an initial dose of 3.0 mg/kg of vernaka- [email protected] ¿una utopía hecha realidad?
lant in 10 minutes followed by 15 minu-
tes of observation, and a second dose of Sir,
2 mg/kg in 10 minutes if there was no
Ultrasound has become an essen-
reversion to sinus rhythm with the first
dose. The treated patients had a mean Conflict of interest tial imaging tool in many medical
age of 56 years, and most were men The authors declare no conflict of interest specialties and in the emergency de-
(91.6%). 50% had hypertension, 16.6% in relation to this article. partment (ED) 1. In recent years we

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have witnessed the development of

ultrasound systems of high quality,
affordable and portable (Figure 1A),
which allow scans to be performed at
the bedside1-3. Basic clinical echocar-
diography (BCE) is increasingly used
in the ED since it is a non-invasive
technique that provides useful, fast
and accurate information to add to
that of the anamnesis and physical
examination and to facilitate diagno-
sis and optimize patient handling
(improves diagnostic capacity betwe-
en 20-40%), as evidenced by several
studies4,5.
Case 1: Male, 55, consumer of 100 g Figure 1. A) GE Vscan hand-held ultrasound machine. B) Long parasternal plane sho-
alcohol/day, visited the ED after dyspnea
wing dilated left ventricle (LV) and left atrium (LA) with reduced thickness of the inter-
during a week, lower limb edema and or-
thopnea. On physical examination, there ventricular septum; right ventricle (RV) and aorta (Ao). C) Short parasternal plane in
were third sounds, crackles and bilateral which severe pericardial effusion is shown (arrow).
lower limb edema. Echocardiography per-
formed with a portable ultrasound device
(General Electric Vscan) showed dilated left he/she can determine the size and ment. Emerg Med J. 2009;26:82-6.
function of both ventricles, the pre- 2 Conthe P, Cepeda JM. Posibilidades de la
atrium and ventricle, septal and anterolate- ecocardiografía clínica en el paciente con in-
ral hypokinesia and depressed systolic sence of significant pericardial effu- suficiencia cardiaca: algunos ejemplos extrai-
function (Figure 1B). He was transferred to sion, guide the diagnosis of severe dos de la práctica clínica. Med Clin (Barc).
the department of internal medicine whe- valvulopathy and estimate central ve- 2014;142(Supl 1):32-5.
re he was diagnosed with alcoholic dilated nous pressure by diameter and the 3 Egan M, Ionescu A. The pocket echocardio-
cardiomyopathy. graph: a useful new tool? Eur J Echocardiogr.
state of the inferior vena cava2,8,9. In 2008;6:721-5.
Case 2: An 85-year-old male with addition, BCE examination is simpli- 4 Kirkpatrick JN, Vannan MA, Narula J, Lang
hypertensive heart disease and colon ade-
nocarcinoma with liver metastases interve-
fied between 2 and 4 planes in B RM. Echocardiography in heart failure: appli-
mode, which provide the necessary cations, utility, and new horizons. J Am Coll
ned two years before. He was taking 20 Cardiol. 2007;50:381-96.
mg/24 h of enalapril and 40 mg/12 h fu- information 10. Therefore, BCE is a 5 Liu SC, Chang WT, Huang CH, Weng TI, Ma
rosemide. He visited the ED for recurrent procedure available to the emer- Matthew HM, Chen WJ. The value of porta-
syncope related with coughing and after gency physician after short training ble ultrasound for evaluation of cardiome-
getting up from a seated position. Auscul- periods which will facilitate patient galy patients presenting at the emergency
tation showed muted heart sounds. Chest management and will be essential department. Resuscitation. 2005;64:327-31.
radiography showed increased cardiotho- 6 Kobal S, Trento BS, Baharami S, Tolstrup K,
for the development of their care Naqvi TZ, Cercek B, et al. Comparison of ef-
racic index and electrocardiography sho- practice in the future. fectiveness of hand-carried ultrasound to
wed low voltages with flattening of the T
bedside cardiovascular physical examination.
wave. An echocardiogram performed with José Gómez Rubio1, Am J Cardiol. 2005;96:1002-6.
a portable echocardiogram showed severe Ana Belén Bárcena Atalaya2, 7 Randazzo MR, Snoey ER, Levitt MA, Binder
pericardial effusion (22 mm) with swinging María del Rosario Erostarbe Gallardo1, K. Accuracy of emergency physician assess-
heart and diastolic collapse of the right Carlos Alonso Ortiz del Río1 ment of left ventricular ejection fraction and
chambers (Figure 1C). He was admitted to central venous pressure using echocardio-
1
Servicio de Medicina Interna, Hospital de Valme, graphy. Acad Emerg Med. 2003;10:973-7.
the department of internal medicine and
Sevilla, España. 2Servicio de de Urgencias, Hospital 8 Lucas B, Candotti C, Margeta B, Evans AT,
following the withdrawal of diuretics was de Valme, Sevilla, Spain.
asymptomatic. Given his functional status Mba B, Baru J, et al. Diagnostic accuracy of
[email protected] hospitalist-performed hand-carried ultra-
the study was not continued, and the
sound echocardiography after a brief trai-
most plausible etiology was considered to ning program. J Hosp Med. 2009;4:340-9.
be malignancy. 9 Labovitz AJ, Noble VE, Bierig M, Goldstein
Conflict of interest SA, Jones R, Kort S, et al. Focused cardiac ul-
The authors declare no conflict of interest trasound in the emergent setting: a consen-
BCE allows the emergency physi- in relation to this article. sus statement of the American Society of
cian to assess specific aspects of car- Echocardiography and American College of
diac structure and function with high Emergency Physicians. J Am Soc Echocar-
reliability (high sensitivity and negati- diogr. 2010;23:1225-30.
References 10 Noble VE, Nelson B, Sutingco AN. Manual
ve predictive value) without long le- of emergency and critical care ultrasound.
arning curves6,7. After a brief period 1 Wright J, Jarman R, Connolly J, Dissmann P. Nueva York, EE.UU.: Cambridge University
of theoretical and practical training, Echocardiography in the emergency depart- Press; 2007.

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