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Wang YW, Xu J, Ma L, Hu H, Chen HW, Hua JS, Kong XY, Li D, Li LW, Pan JY, Wu J. Safety and efficacy of PCSK9 inhibitor (evolocumab) in patients with non-ST segment elevation acute coronary syndrome and non-culprit artery critical lesions: a randomised controlled trial protocol (SPECIAL study). BMJ Open 2024; 14:e083730. [PMID: 39009458 PMCID: PMC11253731 DOI: 10.1136/bmjopen-2023-083730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 07/01/2024] [Indexed: 07/17/2024] Open
Abstract
INTRODUCTION Patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) and concomitant multivessel coronary artery disease (CAD) are considered patients with extremely high-risk atherosclerotic cardiovascular disease (ASCVD), and current guidelines specify a lower low-density lipoprotein cholesterol (LDL-C) target for this population. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been shown to effectively reduce LDL-C levels on a statin background. Additionally, several studies have confirmed the role of PCSK9 inhibitors in plaque regression and reducing residual cardiovascular risk in patients with ACS. However, those studies included coronary lesions with a degree of stenosis <50%. Whether the application of PCSK9 inhibitors in patients with NSTE-ACS with non-culprit artery critical lesions (stenosis degree between 50% and 75%) has a similar effect on plaque regression and improvement of cardiovascular outcomes remains unknown, with a lack of relevant research. This study aims to further investigate the safety and efficacy of evolocumab in patients with NSTE-ACS and concomitant multivessel CAD (non-culprit artery stenosis between 50% and 75%). METHODS AND ANALYSIS In this single-centre clinical randomised controlled trial, 122 patients with NSTE-ACS and concomitant multivessel CAD (non-culprit artery stenosis between 50% and 75%) will be randomly assigned to either the evolocumab treatment group or the standard treatment group after completing culprit vessel revascularisation. The evolocumab treatment group will receive evolocumab in addition to statin therapy, while the standard treatment group will receive standard statin therapy. At baseline and week 50, patients in the evolocumab treatment group will undergo coronary angiography and OCT imaging to visualise pre-existing non-lesional vessels. The primary end point is the absolute change in average minimum fibrous cap thickness (FCT) from baseline to week 50. Secondary end points include changes in plaque lipid arc, lipid length, macrophage grading, lipid levels and major adverse cardiovascular events during the 1-year follow-up period. ETHICS AND DISSEMINATION Ethics: this study will adhere to the principles outlined in the Helsinki Declaration and other applicable ethical guidelines. This study protocol has received approval from the Medical Research Ethics Committee of the First Affiliated Hospital of the University of Science and Technology of China (Anhui Provincial Hospital), with approval number 2022-ky214. DISSEMINATION we plan to disseminate the findings of this study through various channels. This includes publication in peer-reviewed academic journals, presentation at relevant academic conferences and communication to the public, policymakers and healthcare professionals. We will also share updates on the research progress through social media and other online platforms to facilitate the exchange and application of scientific knowledge. Efforts will be made to ensure widespread dissemination of the research results and to have a positive impact on society. TRIAL REGISTRATION NUMBER ChiCTR2200066675.
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Affiliation(s)
- Yu-Wei Wang
- The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology, Hefei, China
| | - Jie Xu
- The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology, Hefei, China
| | - Likun Ma
- The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology, Hefei, China
| | - Hao Hu
- The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology, Hefei, China
| | - Hong-Wu Chen
- The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology, Hefei, China
| | - Jing-Sheng Hua
- The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology, Hefei, China
| | - Xiang-Yong Kong
- The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology, Hefei, China
| | - Dan Li
- The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology, Hefei, China
| | - Long-Wei Li
- The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology, Hefei, China
| | - Jian-Yuan Pan
- The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology, Hefei, China
| | - Jiawei Wu
- The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology, Hefei, China
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Kang J, Park S, Han M, Park KW, Han JK, Yang HM, Kang HJ, Koo BK, Kim HS. Impact of Complete Revascularization for Acute Myocardial Infarction In Multivessel Coronary Artery Disease Patients With Diabetes Mellitus. Korean Circ J 2024; 54:54.e68. [PMID: 38956939 DOI: 10.4070/kcj.2024.0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 05/01/2024] [Accepted: 05/01/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The clinical benefits of complete revascularization (CR) in acute myocardial infarction (AMI) patients are unclear. Moreover, the benefit of CR is unknown in AMI with diabetes mellitus (DM) patients. We sought to compare the prognosis of CR and incomplete revascularization (IR) in patients with AMI and multivessel disease, according to the presence of DM. METHODS A total of 2,150 AMI patients with multivessel coronary artery disease were analyzed. CR was defined based on the angiographic image. The primary endpoint of this study was the patient-oriented composite outcome (POCO) defined as a composite of all-cause death, any myocardial infarction, and any revascularization within 3 years. RESULTS Overall, 3-year POCO was significantly lower in patients receiving angiographic CR (985 patients, 45.8%) compared with IR (1,165 patients, 54.2%). When divided into subgroups according to the presence of DM, CR reduced 3-year clinical outcomes in the non-DM group but not in the DM group (POCO: 11.7% vs. 23.2%, p<0.001, any revascularization: 7.2% vs. 10.8%, p=0.024 in the non-DM group, POCO: 24.3% vs. 27.8%, p=0.295, any revascularization: 13.3% vs. 11.3%, p=0.448 in the DM group, for CR vs. IR). Multivariate analysis showed that CR significantly reduced 3-year POCO (hazard ratio, 0.52; 95% confidence interval, 0.36-0.75) only in the non-DM group. CONCLUSIONS In AMI patients with multivessel disease, CR may have less clinical benefit in DM patients than in non-DM patients.
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Affiliation(s)
- Jeehoon Kang
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sungjoon Park
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Minju Han
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Woo Park
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
| | - Jung-Kyu Han
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Han-Mo Yang
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Jae Kang
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Hegazy MA, Mansour KS, Alzyat AM, Hegazy AA, Mohammad MA. Evaluation of Nonculprit Coronary Artery Lesions in Patients with Acute ST-Segment Elevation Myocardial Infarction. MEDICAL JOURNAL OF DR. D.Y. PATIL VIDYAPEETH 2024; 17:367-377. [DOI: 10.4103/mjdrdypu.mjdrdypu_728_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2024] Open
Abstract
ABSTRACT
Background:
Multivessel coronary artery disease is a common finding during the primary percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction (STEMI). It might be a cause for recurrent attacks. This study aimed to evaluate nonculprit lesions (NCLs) encountered in the three major epicardial coronary arteries.
Methods:
Patients with STEMI who underwent PPCI and matched the study inclusion criteria were enrolled. They were evaluated clinically, biomedically, and coronary angiographically. The coronary angiography analysis was examined by four cardiologists using the Quantitative Coronary Artery Analysis software. The data was analyzed statistically.
Results:
Of the 154 patients included in the study, 130 (84.4%) were males and 24 (15.6%) were females, with a mean age of 52.92 ± 13.14 years. Five hundred seventy-four NCLs were found in 132 (85.7%) patients. Nonobstructive lesions with stenosis less than 70% of vessel diameter were more frequent than obstructive lesions. The left circumflex coronary artery (LCX) was the first one of the three major arteries to be affected by obstructive NCLs. The obstructive NCLs were 128 in number; found in 78 (50.4%) patients; 65 (50.8%) of them were in LCX; 32 (25%) were in left anterior descending (25%); and 31 (24.2%) were in right coronary artery.
Conclusions:
NCLs are common among STEMI patients. LCX obstructive NCLs are comparable to those in the other two major epicardial coronary arteries, with respect to frequency and severity of luminal stenosis.
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Affiliation(s)
- Mustafa A. Hegazy
- Cardiology Department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt
| | - Kamal S. Mansour
- Cardiology Department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt
| | - Ahmed M. Alzyat
- Cardiology Department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt
| | - Abdelmonem A. Hegazy
- Human Anatomy and Embryology Department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt
- Medical Lab Department, Faculty of Allied Medical Sciences, Zarqa University, Zarqa City, Jordan
| | - Mohammad A. Mohammad
- Cardiology Department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt
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Wang J, Wang W, Yan C, Wang T. Ischemic postconditioning protects nonculprit coronary arteries against ischemia-reperfusion injury via downregulating miR-92a, miR-328 and miR-494. Aging (Albany NY) 2022; 14:2748-2757. [PMID: 35321943 PMCID: PMC9004578 DOI: 10.18632/aging.203971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/02/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Nonculprit lesions are closely related to the prognosis of patients with ST-segment elevation myocardial infarction (STEMI). Our previous research found that ischemic postconditioning (IP) could inhibit the progression of nonculprit lesions. However, the mechanism by which IP regulates the occurrence and development of nonculprit lesions remains unclear. METHODS Firstly, a rabbit ischemia-reperfusion (IR) model was constructed. Next, the morphological characteristics of the coronary arterial tissues and myocardial tissues of the rabbits were observed using hematoxylin-eosin (H&E) staining. Then, western blot was performed to detect the expressions of AT1, Cx43, β-tubulin, Bax, Bcl-2 and cleaved caspase 3. Finally, to further confirm the effect of IP on nonculprit coronary arterial tissues, an in vitro model of oxygen and glucose deprivation/reperfusion (OGD/R) was established. RESULTS IR notably induced the cells apoptosis in nonculprit coronary arterial tissues and in myocardial tissues, while IR-induced cell apoptosis was significantly inhibited by IP. In addition, IP protected nonculprit coronary arterial tissues against IR via downregulating miR-92a, miR-328 and miR-494 and mRNA AT1, Cx43 and β-tubulin. Consistently, OGD/R-induced injury of Human umbilical vein endothelial cells (HUVECs) was reversed by IP. CONCLUSIONS In this study, IP could protect nonculprit coronary arteries against IR injury via downregulating miR-92a, miR-328 and miR-494. Our findings may provide new directions for the treatment of nonculprit lesions.
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Affiliation(s)
- Jian Wang
- Department of Cardiology, Beijing Geriatric Hospital, Beijing 100095, Beijing, China
| | - Wu Wang
- Department of Cardiology, Xining First People's Hospital, Xining 810001, Qinghai, China
| | - Chengying Yan
- Department of Cardiology, Xining First People's Hospital, Xining 810001, Qinghai, China
| | - Tianzhen Wang
- Hengduan House, RDFZ Chaoyang Branch School, Beijing 100028, Beijing, China
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Chen L, Chen Q, Zhong J, Ye Z, Ye M, Yan Y, Chen L, Luo Y. Effect of Low-Density Lipoprotein Cholesterol Goal Achievement on Vascular Physiology Evaluated by Quantitative Flow Ratio in Patients Who Underwent Percutaneous Coronary Intervention. Front Cardiovasc Med 2021; 8:679599. [PMID: 34222375 PMCID: PMC8249848 DOI: 10.3389/fcvm.2021.679599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/20/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: The change in coronary physiology from lipid-lowering therapy (LLT) lacks an appropriate method of examination. Quantitative flow ratio (QFR) is a novel angiography-based approach allowing rapid assessment of coronary physiology. This study sought to determine the impact of low-density lipoprotein cholesterol (LDL-C) goal achievement on coronary physiology through QFR. Methods: Cases involving percutaneous coronary intervention (PCI) and 1-year angiographic follow-up were screened and assessed by QFR analysis. Patients were divided into two groups according to the LDL-C level at the 1-year follow-up: (1) goal-achievement group (LDL-C < 1.8 mmol/L or reduction of ≥50%, n = 146, lesion = 165) and (2) non-achievement group (n = 286, lesion = 331). All QFR data and major adverse cardiovascular and cerebrovascular events (MACCEs) at 1 year were compared between groups. Results: No differences between the groups in quantitative coronary angiography (QCA) data or QFR post-PCI were found. At the 1-year follow-up, lower percentage diameter stenosis (DS%) and percentage area stenosis (AS%) were recorded in the goal-achievement group (27.89 ± 10.16 vs. 30.93 ± 12.03, p = 0.010, 36.57 ± 16.12 vs. 41.68 ± 17.39, p = 0.003, respectively). Additionally, a better change in QFR was found in the goal-achievement group (0.003 ± 0.068 vs. -0.018 ± 0.086, p = 0.007), with a lower incidence of physiological restenosis and MACCEs (2.1 vs. 8.4%, p = 0.018, 5.4 vs. 12.6%, p = 0.021, respectively). Conclusion: Evaluated by QFR, patients who achieved the LDL-C goal appear to have a better coronary physiological benefit. This group of patients also has a better clinical outcome.
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Affiliation(s)
- Long Chen
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China.,Fujian Institute of Coronary Artery Disease, Fuzhou, China.,Fujian Heart Medical Center, Fuzhou, China
| | - Qin Chen
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China.,Fujian Institute of Coronary Artery Disease, Fuzhou, China.,Fujian Heart Medical Center, Fuzhou, China
| | - Jiaxin Zhong
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China.,Fujian Institute of Coronary Artery Disease, Fuzhou, China.,Fujian Heart Medical Center, Fuzhou, China
| | - Zhen Ye
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China.,Fujian Institute of Coronary Artery Disease, Fuzhou, China.,Fujian Heart Medical Center, Fuzhou, China
| | - Mingfang Ye
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China.,Fujian Institute of Coronary Artery Disease, Fuzhou, China.,Fujian Heart Medical Center, Fuzhou, China
| | - Yuanming Yan
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China.,Fujian Institute of Coronary Artery Disease, Fuzhou, China.,Fujian Heart Medical Center, Fuzhou, China
| | - Lianglong Chen
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China.,Fujian Institute of Coronary Artery Disease, Fuzhou, China.,Fujian Heart Medical Center, Fuzhou, China
| | - Yukun Luo
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China.,Fujian Institute of Coronary Artery Disease, Fuzhou, China.,Fujian Heart Medical Center, Fuzhou, China
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Ma J, Chen X. Anti-inflammatory Therapy for Coronary Atherosclerotic Heart Disease: Unanswered Questions Behind Existing Successes. Front Cardiovasc Med 2021; 7:631398. [PMID: 33598482 PMCID: PMC7882495 DOI: 10.3389/fcvm.2020.631398] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/21/2020] [Indexed: 02/05/2023] Open
Abstract
Coronary atherosclerotic heart disease is a serious threat to human health. The results of the Canakinumab Anti-Inflammatory Thrombosis Outcome Study published in 2017 put an end to the perennial debate about the anti-inflammatory treatment of coronary atherosclerotic heart disease. In addition to interleukin 1β monoclonal antibody, interleukin 6 receptor antagonists and colchicine have also shown exciting results in clinical trials within the last 3 years. However, behind these successes, questions remain that need to be addressed. In this review, we summarize the successes and existing doubts of interleukin 1β antibodies, interleukin 6 receptor antagonists, and colchicine in the anti-inflammatory treatment of coronary atherosclerotic heart disease.
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Affiliation(s)
- Jun Ma
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China.,Department of Cardiology, The General Hospital of Western Theater Command, Chengdu, China
| | - Xiaoping Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
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Wang J, He SY. Effect of ischemic postconditioning on cell apoptosis and expression of relevant genes in non-culprit coronary arteries. J Investig Med 2020; 68:1276-1281. [PMID: 32784207 PMCID: PMC7525782 DOI: 10.1136/jim-2020-001328] [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] [Subscribe] [Scholar Register] [Accepted: 06/23/2020] [Indexed: 11/04/2022]
Abstract
This study was performed to determine the effect of ischemic postconditioning on cell apoptosis and angiotensin II receptor type 1 (AT1), connexin 43 (Cx43), and β-tubulin mRNA expression in non-culprit arteries. Non-culprit arterial tissues were isolated from a rabbit myocardial ischemia-reperfusion model and randomly divided into sham, ischemia-reperfusion, and ischemic postconditioning groups. Cell apoptosis was detected by terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) staining. Expression of angiotensin II, AT1, Cx43, and β-tubulin mRNA was evaluated by quantitative real-time polymerase chain reaction (qRT-PCR). TUNEL analysis indicated significantly higher ratios of apoptotic cells in the ischemia-reperfusion group than in the sham group. However, significantly fewer apoptotic cells were observed in the ischemic postconditioning group than in the ischemia-reperfusion group. The qRT-PCR results indicated significantly higher expression of AT1, Cx43, and β-tubulin mRNA in the ischemia-reperfusion group than in the sham group. However, expression of AT1, Cx43, and β-tubulin was lower in the ischemic postconditioning group than in the ischemia-reperfusion group. The ratios of apoptotic cells and mRNA expression of AT1, Cx43, and β-tubulin in non-culprit arteries were increased after ischemia-reperfusion. Ischemic postconditioning may decrease these features and inhibit the progression of non-culprit arteries.
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Affiliation(s)
- Jian Wang
- Department of Cardiology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Song-Yuan He
- Department of Cardiology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China
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The Predictors of Target Lesion Revascularization and Rate of In-Stent Restenosis in the Second-Generation Drug-Eluting Stent Era. J Interv Cardiol 2019; 2019:3270132. [PMID: 31772522 PMCID: PMC6739790 DOI: 10.1155/2019/3270132] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/27/2019] [Accepted: 06/12/2019] [Indexed: 11/29/2022] Open
Abstract
Objectives The aim of our study was to investigate the predictors of target lesion revascularization (TLR) and to compare the in-stent restenosis (ISR) progression rates of different 2nd-generation drug-eluting stents (DES). Background The predictors of early and late TLR after 2nd-generation DES implantation have not been fully evaluated. Methods We analyzed 944 stented lesions from 394 patients who had at least two serial follow-up angiograms, using quantitative coronary angiography (QCA) analysis. The study endpoints were TLR and the velocity of diameter stenosis (DS) progression. Results TLR occurred in 58 lesions (6.1%) during the first angiographic follow-up period and 23 de novo lesions (2.4%) during the following second interval. Independent predictors for early TLR were diabetes mellitus (DM) (HR 2.58, 95% CI 1.29–5.15, p=0.007), previous percutaneous coronary intervention (PCI) (HR 2.41, 95% CI 1.03–5.65, p=0.043), and postprocedure DS% (HR 1.08, 95% CI 1.05–1.11, p<0.001, per 1%), while predictors of late TLR were previous PCI (HR 9.43, 95% CI 2.58-34.52, p=0.001) and serum C-reactive protein (CRP) (HR 1.60, 95% CI 1.28-2.00, p<0.001). The ISR progression velocity (by DS%) was 12.1 ±21.0%/year and 3.7 ±10.1%/year during the first and second follow-up periods, respectively, which had no significant difference (p>0.05) between the four types of DESs. Conclusions Our data showed that predictors for TLR may be different at different time intervals. DM, pervious PCI, and postprocedure DS could predict early TLR, while previous PCI and CRP level could predict late TLR. Contemporary DESs had similar rates of ISR progression rates. Trial Registration This study was retrospectively registered and approved by the institutional review board of Seoul National University Hospital (no. 1801–138-918).
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