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Qiu Y, Zhou L, Lu B, Lin X, Chen B, He Y, Zeng Z, Chen M, Li X, Mao R. Validation of disease severity index for predicting complicated disease in Crohn's disease: A comparison study with Lémann index. Dig Liver Dis 2024; 56:635-640. [PMID: 38143189 DOI: 10.1016/j.dld.2023.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/05/2023] [Accepted: 12/11/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND Disease Severity Index (DSI) provides comprehensive assessment of bowel damage (BD). AIMS To evaluate DSI in patients with Crohn's disease (CD) at high risk of disease progression, compared to Lémann Index (LI). METHODS Patients with CD in our center were reviewed consecutively between 2017 and 2019. DSI, LI, and complicated CD course were analyzed. RESULTS The median LI and DSI of included 300 patients were 1.63 (IQR 1.25-3.13) and 42 (IQR 32-51), respectively. 152 patients (50.7%) experienced a complicated disease course (median 5.1 months; IQR 1.1-20.2). DSI (AUC 0.66; 95% CI 0.60-0.72) better predicted a complicated course of CD over LI (AUC 0.56; 95% CI 0.50-0.63; P = 0.007). The cumulative probability of complicated CD course in severe patients was higher than those with 'mild CD' (P < 0.001). The Cox analysis identified DSI>43 (HR 2.18; 95% CI 1.54-3.09; P < 0.001), B2/3 vs. B1 (HR 2.80; 95% CI 1.99-3.94; P < 0.001), and a higher level of CRP (HR 1.01; 95% CI 1.00-1.02; P = 0.005) as independent prognostic factors for complicated CD. However, LI was not associated with complicated CD (P = 0.164). CONCLUSIONS Higher DSI was associated with complicated disease outcomes. DSI might play a better role than LI in identifying patients at high risks of disease progression.
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Affiliation(s)
- Yun Qiu
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China.
| | - Longyuan Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
| | - Baolan Lu
- Department of Radiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
| | - Xiaoqing Lin
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
| | - Baili Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
| | - Yao He
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
| | - Zhirong Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
| | - Xuehua Li
- Department of Radiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China.
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Rong Y, Hong G, Zhu N, Liu Y, Jiang Y, Liu T. Photodynamic Therapy of Novel Photosensitizer Ameliorates TNBS-Induced Ulcerative Colitis via Inhibition of AOC 1. Front Pharmacol 2021; 12:746725. [PMID: 34744725 PMCID: PMC8566348 DOI: 10.3389/fphar.2021.746725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 10/01/2021] [Indexed: 12/12/2022] Open
Abstract
Ulcerative colitis (UC), a chronic, nonspecific inflammatory bowel disease characterized by continuous and diffuse inflammatory changes in the colonic mucosa, requires novel treatment method. Photodynamic therapy (PDT), as a promising physico-chemical treatment method, were used to treat UC rats’ model with novel photosensitizer LD4 in this paper, the treatment effect and mechanism was investigated. LD4-PDT could improve the survival rate of 2,4,6-trinitrobenzene sulfonic acid (TNBS)-induced UC model rats, decrease expression of interleukin (IL)-6, IL-1, tumor necrosis factor (TNF)-α, malondialdehyde (MDA), myeloperoxidase (MPO) and increase the expression of glutathione (GSH) and superoxide oxidase (SOD), while protecting the integrity of the intestinal epithelium. LD4-PDT treatment could rebuild the intestinal microflora composition and reprogram the colonic protein profiles in TNBS-induced rats to almost the normal state. Proteomics analysis based upon TNBS-induced UC model rats revealed that Amine oxidase copper-containing 1 (AOC1) was a potential target of LD4-PDT. Novel photosensitizer agent LD4-PDT represents an efficient treatment method for UC, and AOC1 may be a promising target.
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Affiliation(s)
- Yumei Rong
- Tianjin Key Laboratory of Biomedical Material, Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Ge Hong
- Tianjin Key Laboratory of Biomedical Material, Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Na Zhu
- Tianjin Key Laboratory of Biomedical Material, Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yang Liu
- Tianjin Key Laboratory of Biomedical Material, Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yong Jiang
- Department of Gastroenterology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Tianjun Liu
- Tianjin Key Laboratory of Biomedical Material, Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
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Zhu M, Feng Q, Xu X, Qiao Y, Cui Z, Yan Y, Ran Z. Efficacy of early intervention on the bowel damage and intestinal surgery of Crohn's disease, based on the Lémann index. BMC Gastroenterol 2020; 20:421. [PMID: 33308166 PMCID: PMC7733289 DOI: 10.1186/s12876-020-01575-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/07/2020] [Indexed: 01/12/2023] Open
Abstract
Background Clinicians aim to prevent progression of Crohn’s disease (CD); however, many patients require surgical resection because of cumulative bowel damage. The aim of this study was to evaluate the impact of early intervention on bowel damage in patients with CD using the Lémann Index and to identify bowel resection predictors.
Methods We analyzed consecutive patients with CD retrospectively. The Lémann Index was determined at the point of inclusion and at follow-up termination. The Paris definition was used to subdivide patients into early and late CD groups. Results We included 154 patients, comprising 70 with early CD and 84 with late CD. After follow-up for 17.0 months, more patients experienced a decrease in the Lémann Index (61.4% vs. 42.9%), and fewer patients showed an increase in the Lémann Index (20% vs. 35.7%) in the early compared with the late CD group. Infliximab and other therapies reversed bowel damage to a greater extent in early CD patients than in late CD patients. Twenty-two patients underwent intestinal surgery, involving 5 patients in the early CD group and 17 patients in the late CD group. Three independent predictors of bowel resection were identified: baseline Lémann index ≥ 8.99, disease behavior B1, and history of intestinal surgery. Conclusions Early intervention within 18 months after CD diagnosis could reverse bowel damage and decrease short-term intestinal resection. Patients with CD with a history of intestinal surgery, and/or a Lémann index > 8.99 should be treated aggressively and monitored carefully to prevent progressive bowel damage.
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Affiliation(s)
- Mingming Zhu
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Inflammatory Bowel Disease Research Center, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Qi Feng
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Inflammatory Bowel Disease Research Center, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Xitao Xu
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Inflammatory Bowel Disease Research Center, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Yuqi Qiao
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Inflammatory Bowel Disease Research Center, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Zhe Cui
- Department of Gastrointestinal Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yunqi Yan
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhihua Ran
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Inflammatory Bowel Disease Research Center, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China.
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Limsrivilai J, Aniwan S, Sudcharoen A, Chaisidhivej N, Prueksapanich P, Pausawasdi N, Charatcharoenwitthaya P, Pongprasobchai S, Manassatit S. Temporal trend of disease recognition, treatment paradigm, and clinical outcomes of Crohn disease in Thailand from 2000 through 2017: Is early use of thiopurines beneficial? Medicine (Baltimore) 2020; 99:e22216. [PMID: 32957358 PMCID: PMC7505316 DOI: 10.1097/md.0000000000022216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
The prevalence of Crohn disease (CD) is increasing in Asia, but data from Southeast Asian population are scarce.The databases of 2 university-based national tertiary referral centers located in Bangkok, Thailand, were retrospectively reviewed for adult patients diagnosed with CD during January 2000 to December 2017. Disease characteristics, diagnosis, treatment, and outcomes were described and compared between the 2000 to 2009 cohort (cohort A) and the 2010 to 2017 cohort (cohort B).One hundred eighty-two patients (mean age: 46.4 years, 50% male) with 993 patient-years of follow-up were included. Thirteen percent had a history of intestinal resection, but were not diagnosed until disease recurrence. Another 6% were diagnosed at the time of first surgery. There was no improvement in diagnostic proficiency between cohorts. Mesalamine, corticosteroids, thiopurines, and biologics were prescribed in 75.8%, 81.3%, 84.6%, and 13.7% of patients, respectively (P > .05 between cohorts). Notably, thiopurines were started earlier in cohort B. Median time to the start of thiopurines was 6.2 and 1.65 months in cohort A and B, respectively (P < .01). However, the cumulative 5-year rates of disease behavior progression (P = .43), hospitalization (P = .14), and bowel surgery (P = .29) were not significantly different between cohorts. Subgroup analysis including only patients who required thiopurines showed the early use of thiopurines to be associated with lower risk of intestinal surgery after diagnosis (hazard ratio: 0.30, 95% confidence interval: 0.11-0.85).Early disease recognition and early introduction of immunomodulators may prevent long-term complications and reduce unnecessary surgery in CD.
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Affiliation(s)
- Julajak Limsrivilai
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Satimai Aniwan
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Asawin Sudcharoen
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Natapat Chaisidhivej
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Piyaphan Prueksapanich
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Nonthalee Pausawasdi
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phunchai Charatcharoenwitthaya
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Supot Pongprasobchai
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sathaporn Manassatit
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Bayoumy AB, van Liere ELSA, Simsek M, Warner B, Loganayagam A, Sanderson JD, Anderson S, Nolan J, de Boer NK, Mulder CJJ, Ansari A. Efficacy, safety and drug survival of thioguanine as maintenance treatment for inflammatory bowel disease: a retrospective multi-centre study in the United Kingdom. BMC Gastroenterol 2020; 20:296. [PMID: 32917155 PMCID: PMC7488521 DOI: 10.1186/s12876-020-01441-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 09/03/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Thioguanine (TG) is a thiopurine which has been used for patients with inflammatory bowel disease (IBD), who have failed azathioprine (AZA) or mercaptopurine (MP) due to adverse events or suboptimal response. Its widespread use has been hampered due to concerns about nodular regenerative hyperplasia (NRH) of the liver. The aim of this study was to investigate the long-term efficacy and safety of low-dose TG therapy in IBD patients failing AZA and MP. METHODS A retrospective multicentre study was performed in IBD patients who failed prior treatment with conventional thiopurines with or without following immunomodulation (thiopurine-allopurinol, biologicals, methotrexate, tacrolimus) and were subsequently treated with TG as rescue monotherapy between 2003 and 2019 at three hospitals in the United Kingdom. Clinical response, adverse events, laboratory results, imaging and liver biopsies were retrospectively collected. RESULTS A total of 193 patients (57% female and 64% Crohn's disease) were included, with a median daily TG dose of 20 mg (range: 20-40 mg), a median treatment duration of 23 months (IQR 10-47) and a median follow-up of 36 months (IQR 22-53). The clinical response rate at 12 months was 65 and 54% remained on TG until the end of follow-up. Adverse events consisted primarily of elevated liver tests (6%), myelotoxicity (7%) and rash (5%). NRH was histologically diagnosed in two patients and two other patients (1%) developed non-cirrhotic portal hypertension. The median 6-TGN and TPMT levels were 953 pmol/8 × 105 RBC (IQR 145-1761) and 47 mu/L (IQR 34.5-96). CONCLUSIONS Long-term follow-up suggests that TG can be an effective and well-tolerated therapy in more than half of difficult-to-treat and multi-therapy failing IBD patients. Findings of this study indicate that TG can be used safely and the occurrence of hepatotoxicity was low. The incidence rate of NRH was within the background incidence.
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Affiliation(s)
- Ahmed B Bayoumy
- Department of Gastroenterology and Hepatology, Amsterdam UMC, VU University Medical Centre, Amsterdam, The Netherlands. .,Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK. .,Department of Gastroenterology, Queen Elizabeth Hospital, Woolwich, UK. .,Department of Gastroenterology, Surrey and Sussex NHS, Easy Surrey Hospital, Surrey, UK.
| | - Elsa L S A van Liere
- Department of Gastroenterology and Hepatology, Amsterdam UMC, VU University Medical Centre, Amsterdam, The Netherlands.,Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Gastroenterology, Queen Elizabeth Hospital, Woolwich, UK.,Department of Gastroenterology, Surrey and Sussex NHS, Easy Surrey Hospital, Surrey, UK
| | - Melek Simsek
- Department of Gastroenterology and Hepatology, Amsterdam UMC, VU University Medical Centre, AG&M Research Institute, Amsterdam, The Netherlands
| | - Ben Warner
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Jeremy D Sanderson
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Simon Anderson
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jonathan Nolan
- Department of Gastroenterology, Surrey and Sussex NHS, Easy Surrey Hospital, Surrey, UK
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, Amsterdam UMC, VU University Medical Centre, AG&M Research Institute, Amsterdam, The Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, Amsterdam UMC, VU University Medical Centre, Amsterdam, The Netherlands
| | - Azhar Ansari
- Department of Gastroenterology, Surrey and Sussex NHS, Easy Surrey Hospital, Surrey, UK
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Yu H, Wang Y, Wang Z, Li J, Lu J, Hu D. Prospective comparison of diffusion-weighted magnetic resonance enterography and contrast enhanced computed tomography enterography for the detection of ileocolonic Crohn's disease. J Gastroenterol Hepatol 2020; 35:1136-1142. [PMID: 31785602 DOI: 10.1111/jgh.14945] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 11/20/2019] [Accepted: 11/26/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Crohn's disease (CD) is a chronic and relapsing course with various status of different segments, and there were no investigations comparing the lesion detection between magnetic resonance (MR) and computed tomography (CT) in term of the severity of CD. We aim to assess the performances of diffusion-weighted MR enterography (DW-MRE) and contrast enhanced CT enterography (CTE) for detecting different grade lesions in ileocolonic CD. METHODS Forty-one consecutive patients finally diagnosed with ileocolonic CD were included. All the patients prospectively underwent DW-MRE, contrast enhanced CTE, and ileocolonoscopy within 2 weeks. DW-MRE and CTE images were interpreted for the presence or absence of active CD segments by two experienced radiologists independently. Ileocolonic segments (terminal ileum, right colon, transverse colon, left colon, and rectum) were graded as inactive (0-2), mild (3-6), or moderate-severe (≥ 7) by the simplified endoscopic score for CD (SES-CD). Diagnostic efficiencies of DW-MRE and CTE for mild and/or moderate-severe CD segments were calculated and compared, using ileocolonoscopy as reference standard. RESULTS According to SES-CD, 190 ileocolonic segments from 41 CD patients were scored as 91 inactive, 68 mild, and 31 moderate-severe CD lesions. The sensitivity of DW-MRE for detecting active from inactive segments was higher than that of CTE, and the specificities of them had no significant differences. As for the subgroup analysis, DW-MRE was more sensitive for mild CD lesions than CTE (76.5% vs 60.3%; P = 0.019), while the sensitivities for moderate-severe CD were similar between these two modalities (96.8% for DW-MRE and 93.5% for CTE; P = 1.00). CONCLUSIONS Both DW-MRE and CTE had comparably excellent performances for moderate-severe CD detection; DW-MRE demonstrated better sensitivity in mild lesions compared with CTE and could be more suitable for the diagnosis of mild CD.
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Affiliation(s)
- Hao Yu
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yanchun Wang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zi Wang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jianjun Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jingyu Lu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Daoyu Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Editorial A. CROHN'S DISEASE. CLINICAL RECOMMENDATIONS (PRELIMINARY VERSION). KOLOPROKTOLOGIA 2020; 19:8-38. [DOI: 10.33878/2073-7556-2020-19-2-8-38] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
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Florin THJ, Wright JD, Jambhrunkar SD, Henman MG, Popat A. A well-tolerated and rapidly acting thiopurine for IBD? Drug Discov Today 2018; 24:37-41. [PMID: 30196006 DOI: 10.1016/j.drudis.2018.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/08/2018] [Accepted: 09/03/2018] [Indexed: 02/07/2023]
Abstract
Thiopurine drugs continue to be a cornerstone of inflammatory bowel disease (IBD) treatment. Thiopurines are economical compared with many newer medical treatments for IBD, other chronic inflammatory diseases and leukaemia, although they are not without their shortcomings. These include a slow-onset therapeutic action and many adverse drug reactions. This feature article surveys published data, unpublished in vitro and in vivo experiments, as well as clinical experience, underpinning a rationale for bringing a novel thiopurine drug formulation to market. This formulation has a rapid action making it suitable for the induction and maintenance treatment of IBD and avoids most thiopurine-associated adverse reactions.
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Affiliation(s)
- Timothy H J Florin
- Mater Research - University of Queensland, Translational Research Institute, Australia.
| | - John D Wright
- School of Veterinary Science, The University of Queensland, Australia
| | | | - Michael G Henman
- Sullivan and Nicholaides Pathology, Brisbane, Queensland, Australia
| | - Amirali Popat
- Mater Research - University of Queensland, Translational Research Institute, Australia; NHMRC Early Career Fellow, Pharmacy Australia Centre of School of Pharmacy, Australia
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