1
|
Ansaripour A, Moloney E, Branagan-Harris M, Patrone L, Javanbakht M. Digital variance angiography in patients undergoing lower limb arterial recanalization: cost-effectiveness analysis within the English healthcare setting. J Comp Eff Res 2024; 13:e230068. [PMID: 38517149 PMCID: PMC11044957 DOI: 10.57264/cer-2023-0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 02/14/2024] [Indexed: 03/23/2024] Open
Abstract
Aim: Digital variance angiography (DVA) is a recently developed image processing method capable of improving image quality compared with the traditionally used digital subtraction angiography (DSA), among patients undergoing lower limb x-ray angiography. This study aims to explore the potential cost-effectiveness of DVA from an English National Health Service perspective. Materials & methods: A two-part economic model, consisting of a decision tree and a Markov model, was developed to consider the costs and health outcomes associated with the use of DVA as part of current practice imaging, compared with x-ray angiography using standard DSA. The model explored the impact of DVA on the development of acute kidney injury (AKI), chronic kidney disease and radiation-induced cancer over a lifetime horizon. Both deterministic and probabilistic analyses were performed to assess the cost per quality-adjusted life-year (QALY). Results: Base-case results indicate that DVA results in cost savings of £309 per patient, with QALYs also improving (+0.025) over a lifetime. As shown in sensitivity analysis, a key driver of model results is the relative risk (RR) reduction of contrast-associated acute kidney injury associated with use of DVA. The intervention also decreases the risk of carcinoma over a lifetime. Scenario analyses show that cost savings range from £310 to £553, with QALY gains ranging from 0.048 to 0.109 per patient. Conclusion: The use of DVA could result in a decrease in costs and an increase in QALYs over a lifetime, compared with existing imaging practice. The potential for this technology to offer an economically viable alternative to existing image processing methods, through a reduction in contrast media volume and radiation exposure, has been demonstrated.
Collapse
Affiliation(s)
- Amir Ansaripour
- Optimax Access Ltd, Hofplein, Rotterdam, 3032AC, The Netherlands
| | - Eoin Moloney
- Optimax Access Ltd, Kenneth Dibben House, Enterprise Rd, Chilworth, Southampton Science Park, Southampton, SO16 7NS, UK
| | - Michael Branagan-Harris
- Device Access Ltd, Market Access Consultancy, University of Southampton Science Park, Southampton, SO16 7NS, UK
| | - Lorenzo Patrone
- West London Vascular & Interventional Centre, London North West University Healthcare NHS Trust, Harrow, HA1 3UJ, UK
| | - Mehdi Javanbakht
- Optimax Access Ltd, Kenneth Dibben House, Enterprise Rd, Chilworth, Southampton Science Park, Southampton, SO16 7NS, UK
| |
Collapse
|
2
|
Paolucci L, De Micco F, Bezzeccheri A, Scarpelli M, Esposito G, Airoldi F, Focaccio A, Briguori C. Contrast media volume reduction with the DyeVert TM system to prevent acute kidney injury in stable patients undergoing coronary procedures. Catheter Cardiovasc Interv 2023; 102:655-662. [PMID: 37668067 DOI: 10.1002/ccd.30809] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/20/2023] [Accepted: 08/15/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Contrast associated acute kidney injury (CA-AKI) can lead to an increased risk of adverse events. Contrast media (CM) volume reduction has been advocated as a pivotal strategy to prevent CA-AKI in stable patients undergoing percutaneous coronary procedures. AIMS To compare the effectiveness of CM volume reduction with the DyeVertTM system versus conventional strategy in reducing the risk of CA-AKI. METHODS We prospectively collected data from 136 patients with stable coronary artery disease at high risk of CA-AKI treated with left ventricular end diastolic pressure (LVEDP)- guided hydration and undergoing interventions with the use of the DyeVertTM (Osprey Medical Inc.) system. Patients previously enrolled in the LVEDP-guided hydration arm of the "Renal Insufficiency Following Contrast MEDIA Administration triaL III" (REMEDIAL III) were considered as controls. Propensity score was used to perform 1:1 matching to adjust for major confounders. The primary outcome was the occurrence of CA-AKI, as defined by an absolute increase of creatinine values ≥0.3 mg/dL at 48 h. RESULTS Patients in the DyeVert group were treated with a significant lower CM volume (median: 47.5 vs. 84.0 mL, p < 0.001). The trend in creatinine increase was lower (p = 0.004) and the Δ of creatinine (0-48 h) showed a higher drop (-0.18 vs. -0.10 mg/dL, p = 0.036) in the DyeVert group. The risk of CA-AKI was significantly lower in DyeVert group compared to control group (5.1% vs. 16.8%; odds ratio 0.27, 95% confidence interval [0.12-0.61]). CONCLUSIONS CM volume reduction with the DyeVertTM system seems to be superior to conventional strategies in reducing the occurrence of CA-AKI.
Collapse
Affiliation(s)
- Luca Paolucci
- Interventional Cardiology Unit, Mediterranea Cardiocentro, Naples, Italy
| | - Francesca De Micco
- Interventional Cardiology Unit, Mediterranea Cardiocentro, Naples, Italy
| | - Andrea Bezzeccheri
- Interventional Cardiology Unit, Mediterranea Cardiocentro, Naples, Italy
| | - Mario Scarpelli
- Interventional Cardiology Unit, Mediterranea Cardiocentro, Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Science, Division of Cardiology, "Federico II", University of Naples, Naples, Italy
| | - Flavio Airoldi
- Interventional Cardiology Unit, Istituto di Ricerca a Carattere Scientifico Multimedica MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Amelia Focaccio
- Interventional Cardiology Unit, Mediterranea Cardiocentro, Naples, Italy
| | - Carlo Briguori
- Interventional Cardiology Unit, Mediterranea Cardiocentro, Naples, Italy
| |
Collapse
|
3
|
Mehta R, Sorbo D, Ronco F, Ronco C. Key Considerations regarding the Renal Risks of Iodinated Contrast Media: The Nephrologist's Role. Cardiorenal Med 2023; 13:324-331. [PMID: 37757781 PMCID: PMC10664334 DOI: 10.1159/000533282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/23/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The administration of iodinated contrast medium during diagnostic and therapeutic procedures has always been associated with the fear of causing acute kidney injury (AKI) or an exacerbation of chronic kidney disease. This has led, on the one hand, to the deterrence, when possible, of the use of contrast medium (preferring other imaging methods with the risk of loss of diagnostic power), and on the other hand, to the trialling of multiple prophylaxis protocols in an attempt to reduce the risk of kidney injury. SUMMARY A literature review on contrast-induced (CI)-AKI risk mitigation strategies was performed, focussing on the recognition of individual risk factors and on the most recent evidence regarding prophylaxis. KEY MESSAGES Nephrologists can contribute significantly in the CI-AKI context, from the early stages of the decision-making process to stratifying patients by risk, individualising prophylaxis measures based on the risk profile, and ensuring appropriate evaluation of kidney function and damage post-procedure to improve care.
Collapse
Affiliation(s)
- Ravindra Mehta
- Division of Nephrology-Hypertension University of California – San Diego, San Diego, CA, USA
| | - David Sorbo
- Nephrology, Dialysis and Transplantation Unit, St. Bortolo Hospital, ULSS8 Berica, Vicenza, Italy
| | - Federico Ronco
- Interventional Cardiology – Department of Cardiac Thoracic and Vascular Sciences Ospedale dell’Angelo – Mestre (Venice), Venice, Italy
| | - Claudio Ronco
- Nephrology, Dialysis and Transplantation Unit and International Renal Research Institute, St Bortolo Hospital, ULSS8 Berica, Vicenza, Italy
| |
Collapse
|
4
|
Klancik V, Kočka V, Sulzenko J, Widimsky P. The many roles of urgent catheter interventions: from myocardial infarction to acute stroke and pulmonary embolism. Expert Rev Cardiovasc Ther 2023; 21:123-132. [PMID: 36706282 DOI: 10.1080/14779072.2023.2174101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Cardiovascular diseases (CVDs) are the leading cause of cardiovascular mortality and a major contributor to disability worldwide. The prevalence of CVDs is continuously increasing, and from 1990 to 2019, it has doubled. Global cardiovascular mortality has increased from 12.1 million in 1990 to 18.6 million cases in 2019. The development of therapeutic options for these diseases is at the forefront of interest concerning the extensive socio-economic consequences. Modern endovascular transcatheter therapeutic options contribute to the reduction of cardiovascular morbidity and mortality. AREAS COVERED The article concentrates on the triad of the most common causes of acute cardiovascular mortality and morbidity - myocardial infarction, ischemic stroke, and pulmonary embolism. Current evidence-based indications, specific interventional techniques, and remaining unsolved issues are reviewed and compared. A personal perspective on the possible implications for the future is provided. EXPERT OPINION Primary angioplasty for ST-segment elevation myocardial infarction is a well-established therapeutic option with proven mortality benefits. We suppose that catheter-based interventions for acute stroke will spread quickly from centers of excellence to routine clinical practice. We believe that ongoing research will provide a basis for the expansion of interventional treatment of pulmonary embolism soon.
Collapse
Affiliation(s)
- Viktor Klancik
- Department of Cardiology, Ceske Budejovice Hospital, Inc, Ceske Budejovice, Czech Republic.,Department of Cardiology, Charles University, Czech Republic
| | - Viktor Kočka
- Department of Cardiology, Charles University, Czech Republic.,Department of Cardiology, University Hospital Kralovske Vinohrady, Czech Republic
| | - Jakub Sulzenko
- Department of Cardiology, Charles University, Czech Republic.,Department of Cardiology, University Hospital Kralovske Vinohrady, Czech Republic
| | - Petr Widimsky
- Department of Cardiology, Charles University, Czech Republic.,Department of Cardiology, University Hospital Kralovske Vinohrady, Czech Republic
| |
Collapse
|
5
|
Damluji AA, Forman DE, Wang TY, Chikwe J, Kunadian V, Rich MW, Young BA, Page RL, DeVon HA, Alexander KP. Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e32-e62. [PMID: 36503287 DOI: 10.1161/cir.0000000000001112] [Citation(s) in RCA: 62] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Diagnostic and therapeutic advances during the past decades have substantially improved health outcomes for patients with acute coronary syndrome. Both age-related physiological changes and accumulated cardiovascular risk factors increase the susceptibility to acute coronary syndrome over a lifetime. Compared with younger patients, outcomes for acute coronary syndrome in the large and growing demographic of older adults are relatively worse. Increased atherosclerotic plaque burden and complexity of anatomic disease, compounded by age-related cardiovascular and noncardiovascular comorbid conditions, contribute to the worse prognosis observed in older individuals. Geriatric syndromes, including frailty, multimorbidity, impaired cognitive and physical function, polypharmacy, and other complexities of care, can undermine the therapeutic efficacy of guidelines-based treatments and the resiliency of older adults to survive and recover, as well. In this American Heart Association scientific statement, we (1) review age-related physiological changes that predispose to acute coronary syndrome and management complexity; (2) describe the influence of commonly encountered geriatric syndromes on cardiovascular disease outcomes; and (3) recommend age-appropriate and guideline-concordant revascularization and acute coronary syndrome management strategies, including transitions of care, the use of cardiac rehabilitation, palliative care services, and holistic approaches. The primacy of individualized risk assessment and patient-centered care decision-making is highlighted throughout.
Collapse
|
6
|
Sukul D, Gurm HS. Personalized Contrast Dosing: Not Quite Ready For Primetime, But We're Getting Closer. Circ Cardiovasc Qual Outcomes 2023; 16:e009569. [PMID: 36475461 DOI: 10.1161/circoutcomes.122.009569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Devraj Sukul
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI (D.S.)
| | - Hitinder S Gurm
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI (H.S.G.)
| |
Collapse
|
7
|
Yuan N, Zhang J, Khaki R, Leong D, Bhoopalam C, Tabak S, Elad Y, Pevnick JM, Cheng S, Ebinger J. Implementation of an Electronic Health Records-Based Safe Contrast Limit for Preventing Contrast-Associated Acute Kidney Injury After Percutaneous Coronary Intervention. Circ Cardiovasc Qual Outcomes 2023; 16:e009235. [PMID: 36475471 PMCID: PMC9858238 DOI: 10.1161/circoutcomes.122.009235] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 09/13/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Contrast-associated acute kidney injury (CA-AKI) after percutaneous coronary intervention is associated with increased mortality. We assessed the effectiveness of an electronic health records safe contrast limit tool in predicting CA-AKI risk and reducing contrast use and CA-AKI. METHODS We created an alert displaying the safe contrast limit to cardiac catheterization laboratory staff prior to percutaneous coronary intervention. The alert used risk factors automatically extracted from the electronic health records. We included procedures from June 1, 2020 to October 1, 2021; the intervention went live February 10, 2021. Using difference-in-differences analysis, we evaluated changes in contrast volume and CA-AKI rates after contrast limit tool implementation compared to control hospitals. Cardiologists were surveyed prior to and 9 months after alert implementation on beliefs, practice patterns, and safe contrast estimates for example patients. RESULTS At the one intervention site, there were 508 percutaneous coronary interventions before and 531 after tool deployment. At 15 control sites, there were 3550 and 3979 percutaneous coronary interventions, respectively. The contrast limit predicted CA-AKI with an accuracy of 64.1%, negative predictive value of 93.3%, and positive predictive value of 18.7%. After implementation, in high/modifiable risk patients (defined as having a calculated contrast limit <500ml) there was a small but significant -4.60 mL/month (95% CI, -8.24 to -1.00) change in average contrast use but no change in CA-AKI rates (odds ratio, 0.96 [95% CI, 0.84-1.10]). Low-risk patients had no change in contrast use (-0.50 mL/month [95% CI, -7.49 to 6.49]) or CA-AKI (odds ratio, 1.24 [95% CI, 0.79-1.93]). In assessing CA-AKI risk, clinicians heavily weighted age and diabetes but often did not consider anemia, cardiogenic shock, and heart failure. CONCLUSIONS Clinicians often used a simplified assessment of CA-AKI risk that did not include important risk factors, leading to risk estimations inconsistent with established models. Despite clinician skepticism, an electronic health records-based contrast limit tool more accurately predicted CA-AKI risk and was associated with a small decrease in contrast use during percutaneous coronary intervention but no change in CA-AKI rates.
Collapse
Affiliation(s)
- Neal Yuan
- School of Medicine, University of California, San Francisco, CA; Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Justin Zhang
- School of Medicine, University of California, Los Angeles, CA
| | | | - Derek Leong
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Chandrashekhar Bhoopalam
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
- Division of Informatics, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| | - Steven Tabak
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Yaron Elad
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
- Division of Informatics, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joshua M Pevnick
- Division of Informatics, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Susan Cheng
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Joseph Ebinger
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| |
Collapse
|
8
|
Chen S, Turco M, Reisman M, Finn AV. Novel Catheter Device Using Renal Artery Protection to Reduce Contrast-Associated Acute Kidney Injury. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 45:15-17. [PMID: 35810112 DOI: 10.1016/j.carrev.2022.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/15/2022] [Accepted: 06/20/2022] [Indexed: 01/04/2023]
Affiliation(s)
- Shmuel Chen
- Weill-Cornell Medical Center/NewYork-Presbyterian Hospital, New York, NY, USA; Cardiovascular Research Foundation, New York, NY, USA
| | - Mark Turco
- Diastole Consulting, Providence, RI, USA.
| | - Mark Reisman
- Weill-Cornell Medical Center/NewYork-Presbyterian Hospital, New York, NY, USA; Cardiovascular Research Foundation, New York, NY, USA
| | - Aloke V Finn
- CVPath Institute, Inc., Gaithersburg, MD, USA; University of Maryland, Baltimore, MD, USA.
| |
Collapse
|
9
|
Effect of contrast administration on the renal function of predialysis patients undergoing fistuloplasty. J Vasc Surg 2022; 76:1066-1071. [PMID: 35709861 DOI: 10.1016/j.jvs.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/23/2022] [Accepted: 06/03/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The aim of this study was to investigate if administration of iodinated contrast during endovascular interventions in arteriovenous fistula (AVF) in patients not requiring dialysis (predialysis patients) (1) negatively affects their renal function and (2) if oral hydration has a protective effect. METHODS All pre-dialysis patients who underwent endovascular interventions in AVF between August 2010 and April 2019 were included in the study. During the procedures, 35-50mL of Iodixanol were administered. A pre-hydration protocol was introduced in March 2015. Data were grouped before and after this date. The difference between pre- and post-contrast estimated glomerular filtration rate (eGFR) and the difference between the eGFR of hydrated and non-hydrated groups were calculated. RESULTS Eighty four patients who underwent 151 procedures were included in the study. In 60.3% of procedures a mean decrease of 1.35 mL/min/1.73 m2 in eGFR was noted (95%CI 1.02, 1.69), while in 35.1% there was a mean increase of 1.06 mL/min/1.73 m2 (95%CI 0.84, 1.28). The mean difference between pre- and post-procedure eGFR was -0.44 mL/min/1.73 m2 (95% CI -0.72, -0.16) (p=.002). Oral hydration was associated with a smaller mean change in eGFR of -0.32 mL/min/1.73 m2 (95%CI -0.62, -0.03) compared to the non-hydrated group with mean change of -0.47 mL/min/1.73 m2 (95% CI -0.91, -0.03), but this was not statistically significant (p=.586). CONCLUSIONS This study demonstrates that administration of up to 50mL of iodinated contrast for endovascular interventions in AVF in predialysis patients has minimal adverse effect on the eGFR with questionable clinical significance. In addition, oral hydration before and after the procedure has only a mild protective effect against a decrease in eGFR.
Collapse
|
10
|
Yuan N, Latif K, Botting PG, Elad Y, Bradley SM, Nuckols TK, Cheng S, Ebinger JE. Refining Safe Contrast Limits for Preventing Acute Kidney Injury After Percutaneous Coronary Intervention. J Am Heart Assoc 2020; 10:e018890. [PMID: 33325246 PMCID: PMC7955500 DOI: 10.1161/jaha.120.018890] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Contrast‐associated acute kidney injury (CA‐AKI) is associated with substantial morbidity and may be prevented by using less contrast during percutaneous coronary intervention (PCI). However, tools for determining safe contrast volumes are limited. We developed risk models to tailor safe contrast volume limits during PCI. Methods and Results Using data from all PCIs performed at 18 hospitals from January 2015 to March 2018, we developed logistic regression models for predicting CA‐AKI, including simpler models (“pragmatic full,” “pragmatic minimum”) using only predictors easily derivable from electronic health records. We prospectively validated these models using PCI data from April 2018 to December 2018 and compared them to preexisting safe contrast models using the area under the receiver operating characteristic curve (AUC). The model derivation data set included 20 579 PCIs with 2102 CA‐AKI cases. When applying models to the separate validation data set (5423 PCIs, 488 CA‐AKI cases), prior safe contrast limits (5*Weight/Creatinine, 2*CreatinineClearance) were poor measures of safety with accuracies of 53.7% and 56.6% in predicting CA‐AKI, respectively. The full, pragmatic full, and pragmatic minimum models performed significantly better (accuracy, 73.1%, 69.3%, 66.6%; AUC, 0.80, 0.76, 0.72 versus 0.59 for 5 * Weight/Creatinine, 0.61 for 2*CreatinineClearance). We found that applying safe contrast limits could meaningfully reduce CA‐AKI risk in one‐quarter of patients. Conclusions Compared with preexisting equations, new multivariate models for safe contrast limits were substantially more accurate in predicting CA‐AKI and could help determine which patients benefit most from limiting contrast during PCI. Using readily available electronic health record data, these models could be implemented into electronic health records to provide actionable information for improving PCI safety.
Collapse
Affiliation(s)
- Neal Yuan
- Smidt Heart InstituteCedars-Sinai Medical Center Los Angeles CA
| | | | | | - Yaron Elad
- Smidt Heart InstituteCedars-Sinai Medical Center Los Angeles CA
| | - Steven M Bradley
- Minneapolis Heart Institute and Minneapolis Heart Institute FoundationAbbott Northwestern Hospital Minneapolis MN
| | - Teryl K Nuckols
- Department of MedicineCedars-Sinai Medical Center Los Angeles CA
| | - Susan Cheng
- Smidt Heart InstituteCedars-Sinai Medical Center Los Angeles CA
| | | |
Collapse
|