Exam 2, heart gomez Flashcards
(204 cards)
1
Q
what causes foramen ovale to be a problem
A
when the R ventricular pressure overcomes the L
like in pulmonary HTN
2
Q
a
A
a
3
Q
what is unique about cardiac muscle cells
A
intercalated discs with gap junctions etc
4
Q
what occurs in heart chambers with age
A
increased left atrial size
decreased ventricula size
sigmoid shaped venricular septum
5
Q
what occurs in heart valves with age
A
aortic valve calcific deposits
mitral valve annular calcific deposits
fibrous thickening
6
Q
what occurs to the epicardial coronary arteries in an aging heart
A
tortuosity
7
Q
what happens to the myocardium in an aging heart
A
decreased pass, brown atrophy lipofuscin deposition (aging pigment)
8
Q
what happens to the aorta with an aging heart
A
dilated ascending aorta
9
Q
What are the five basic categories of cardiac disease
A
congenital heart disease HTN heart disease ischemic heart disease valvular heart disease nonischemic primary myocardial disease
10
Q
what is the cardiac reserve
A
the CO that is not used at rest
use 10-20% maximal output
11
Q
What are the six general causes of cardiac dysfunction
A
- pump failure
- obstruction to blood flow through the heart
- regurgitant flow
- shunted flow
- disorders of cardiac conduction
- disruption of continuity of circulatory system
12
Q
What are the six general causes of cardiac dysfunction
A
- pump failure
- obstruction to blood flow through the heart
- regurgitant flow
- shunted flow
- disorders of cardiac conduction
- disruption of continuity of circulatory system
13
Q
what are examples of pump failure
A
primary myocardiopathy
ischmic cardiac disease
14
Q
what are causes of obstruction blood flow through heart
A
valvular disease (stenosis) HTN disease
15
Q
what is an example of regurgitant flow
A
valvular disease (insufficiency)
16
Q
what is an example of shunted flow cardiac dysfunction
A
congenital heart disease (PDA ASD and VSD)
17
Q
what are examples of disruption to continuity of circulatory system
A
gunshot, ventricular rupture
18
Q
what are examples of disruption to continuity of circulatory system
A
gunshot, ventricular rupture
19
Q
what can cause an increased workload resulting in hypertrophy
A
increased physiologic need by a normal heart
or
overall decreased intrinsic myocardial contractility
20
Q
what is the difference of cardiac hypertrophy and cardio megaly
A
megaly is heart size and weight, hypertrophy is ventricular thickness or weight
21
Q
what is the normal weight for male and femal hearts
A
male 300-500 female 250-300
22
Q
what can cause a heart to weigh >800 gm
A
aortic regurgitation or hypertrophic cardiomyopathy
23
Q
what can cause a heart to weigh >400
A
pulmonary HTN, IHD, systemic HTN aortic stenosis, mitral regug, dilated cardiomyopathy
24
Q
what is the definition for cardiac dysfunction
A
inability to pump blood at a rate necessary for metabolizing tissues
25
What catecholamine is released in cardiac dysfunction
NE, neurohumoral stimulation, leads to more work for the heart. not good
26
What catecholamine is released in cardiac dysfunction
NE, neurohumoral stimulation, leads to more work for the heart. not good
27
What is the hearts response to pressure overload?
| volume overload?
```
pressure= concentric Hypertrophy
volume= eccentric
```
28
what are causes of concentric hypertrophy in each ventricle
L-- systemic HTN or aortic stenosis
| R-- cor pulmonale
29
what can cause a volume overload that results in eccentric hypertrophy
valve disorders and congenital heart disease
30
What can lead to CHF
insufficient pump rate
| pump can only meet demands with increase in filling pressure
31
What 2 type of dysfunction can lead to decreased CO (forward failure) leading to CHF
systolic dysfunction from progressive deterioration of myocardial contractility
diastolic dysfunction from inability of heart chambers to relax sufficiently to fill during diastole
32
describe fluid accumulation differences in left sided heart failure versus right
left leads to accumulation of fluid within the lungs and pleural cavities
right sided leads to accumulation of fluid in all other body sites and all body cavities
33
describe fluid accumulation differences in left sided heart failure versus right
left leads to accumulation of fluid within the lungs and pleural cavities
right sided leads to accumulation of fluid in all other body sites and all body cavities
34
L sided heart fialure is most commonly caused by
ischemic heart disease
HTN heart disease
aortic and mitral valvular disease
primary nonischemic myocardial disease (cardiomyopathy)
35
What are common physical findings in left-sided heart failure
cardiomegaly, hypertrophy, chamber dilation
| secondary enlargement of left atrium
36
what can lead to left atrial enlargement
atrial fib
| mural thrombus
37
What heart sound is heart with left sided heart failure
third heart sound S3 (gallop)
diastolic ventricular filling
mitral regurg will have systolic murmur
38
What occurs in lungs because of left sided heart failure
pulmonary congestion and edma that is heard as rales or crackles and possible effusions
flash pulmonary edema- extremely rapid onset
dyspnea, orthopnea, paroxysal nocturnal dyspnea
39
what occurs in kidney because of left sided heart failure
decreased CO leads to renal hypoperfusion
activates RAAS (fluid retention and expansion of vascular volume- a vicious cycle)
severe: prerenal azotemia
40
what occurs in brain because of left sided heart failure
hypoxic encephalopathy
41
when does right sided heart failure usually occur
consequence of left sided heart failure
42
what are examples of isolated right sided heart failure
cardiac hypertophy and dilation confined to right sides
| sequela of severe pulm HTN
43
what are the systemic effects of right sided heart failure
pitting edema in subcut tissue
liver and portal system congestion and slpeen leadting to HSM
pleural and pericardial cavities (effusions)
44
what are the systemic effects of right sided heart failure
pitting edema in subcut tissue
liver and portal system congestion and slpeen leadting to HSM
pleural and pericardial cavities (effusions)
45
What is BNP
produced by ventricles from increased P used to determine CHF
46
what is C type natriutetic peptide
made by endothelial cells from shear stress
47
what is the effect of natriutetic peptides
vasodilation, natriuresis and diuresis
48
What level of BNP makes it unlikely to be CHF
<100 pg/ml
49
what other conditions can cause an increase in BNP
right filling P increase, primary pulm HTN, end stage renal failure, cirrhosis, hormone replacement therapy
50
what other conditions can cause an increase in BNP
right filling P increase, primary pulm HTN, end stage renal failure, cirrhosis, hormone replacement therapy
51
when do ehart defects occur in development
between 3 and 8 weeks gestational age
52
what are envrironmental factors that can cause congenital heart disease
congenital rubella infection
53
what are the genetic contributions to congenital heart disease
familial forms
| trisomies 13 18 21 and turner syndrome
54
which trisomy has 40% associated with heart defects
21
55
What are the 3 most common congenital cardiac malformations
bicuspid aortic valve- 2% population!!!
ventricular septal defect
atrial septal defect
56
what is the most common cardiac anomaly first diagnosed in adulthood and more comman than VSD in adult population
ASD
| commonly Dx with onset pulmonary HTN
57
which gene is associated with cardiav outflow tract defects
TBX1 del 22q11.2
58
what gene is mutated in marfan syndrome
fibrillin
59
what gene is mutated in marfan syndrome
fibrillin
60
What gene is affected in digeorge syndrome
TBX1 del 22q11.2
61
what are the Sx of Digeorge syndrome
```
catch 22
cardiac
abnormal facies
thymic aplasia
cleft palate
hypocalcemia
```
62
what are the Sx of Digeorge syndrome
```
catch 22
cardiac
abnormal facies
thymic aplasia
cleft palate
hypocalcemia
```
63
what are examples of left to right shunt
ASD, VSD, PDA, AVSD
64
Are babies cyanotic with left to right shunts?
not initally once the pulmonary HTN gets high enough (shunt reversal) there is a shift from right to left and causes cyanosis
65
Describe a ventricular septal defect
```
pressures same in both ventricles
pressure ypertrophy in R ventricle
Volume hypertrophy in L
90% involve membranous septum
sypmtpms depend on size of anomaly
```
66
Describe a ventricular septal defect
```
pressures same in both ventricles
pressure ypertrophy in R ventricle
Volume hypertrophy in L
90% involve membranous septum
sypmtpms depend on size of anomaly
```
67
What are the 3 major types of ASD
secundum, primum and sinus venosus
68
what is the msot common ASD
secundum, involving patent foramen ovalis
69
untreated ASD coyld lead to what
pulmonary HTN
70
untreated ASD coyld lead to what
pulmonary HTN
71
what causes ductus arteriosus to close
increase in O2
dec pulm vasc R
dec PGE2
72
describe findings of PDA
90% isolated defets
continous harsh machine-like murmur
chornic= pulm HTN and cyanosis
73
What is a complete artioventricular septal defect
| AVSD
large combined AV septal defect and large common AV valve
all 4 chambers comunicating and 4 chamebr hypertrophy
1/3 have down syndrome
74
What is a complete artioventricular septal defect
| AVSD
large combined
75
What is the main cardiac defect associated with downs syndrome
AVSD>VSD>ASD>PDA>tetralogy of Fallot
76
what type of shunts cause cyanosis
right to left shunts
| decreased amount of blood going to lungs to be oxygenated
77
what are signs of right to left shunts
clubbing of tips of fingers and toes and polycythemia due to hypoxia
paradoxical embolism- emboli from periphery bypass lungs through cardiac defect and enter systemic circulation
78
what is the shape of the heart and why in tetralogy of fallot
embryologically anterosuperior displacement of infundibular septum so result is a boot shaped heart
79
what is the shape of the heart and why in tetralogy of fallot
embryologically anterosuperior displacement of infundibular septum so result is a boot shaped heart
80
the direction of shunting in tetralogy of fallot depends on what
severity of subpulmonic stenosis
81
What is pink tetralogy of fallot
when the subpulmonic stenosis is mild and so the lungs are perfused, behave slike VSD
82
what causes transposition of the great arteries
defect with truncal and aortapulmonary septae
| separation of pulmonary and systemic circulations
83
What makes transposition of great arteries somewhat compatibile with lfe
VSDm patent foramen ovale, or PDA
84
what is the most important thing to do in a patient with transposition of great arteries and PDA
give PGE2 to keep PDA open until surgery because keeping them alive
85
What is the infantile form of coarctation of aorta
hypoplasia of aorta prior to PDA (cyanosis of inferior body and weak femoral pulses)
86
What is the adult form of coarctaion of aorta
ride like fold opposite ligamentum arteriosus (HTN upper extremities with low P and pulses in lower extremities)
87
what are the types of congenital aortic stenosis or atresia
valvular- hypolastic dysplastic or abnormal # cusps
subaortic- ring or collar below cusps
aupravalvular- elastin gene mutation with aortic dysplasia (thickening)q
88
What is williams beuren syndrome
deletion of 28 genes from chrom 7 with elastin causing haploinsufficiency, hyperCa, glucose intolerance, facial and cognitive defects
have supravalvular aortic stenosis
89
coarcation of the aorta is mroe common in what pipulation
M:F 2:1 and more common in turners syndrome
90
coarctaion of arota is associated with what valvular defect
bicuspid aortic valve
91
what happends to the intercostal aa in coarctation of aorta
dilated
92
what type of murmur is heard in adult coarctaion of aorta
pansystolic mrumur from renatl HTN and blood flow through collaterals
93
What is the definition of cardiac ischmia
imbalance between the supply and demand of the hear for oxygenated blood
94
90% of IHD is due to what
atherosclerotic coronary arterial obstruction
95
What are common causes of IHD
```
athersclerosis narrowing of coronaries
thrombosis from dirupted plaque
localized platelel aggregation
vasospams
emboli
hypotension
coronary artery vasculitis
```
96
What are common causes of IHD
```
athersclerosis narrowing of coronaries
thrombosis from dirupted plaque
localized platelel aggregation
vasospams
emboli
hypotension
coronary artery vasculitis
```
97
what percent of fixed obstruction leads to Sx with exercise in IHD? what aobut lead to ischemia at rest?
with exercise >75%
| at rest >90%
98
What are the characteristics of unstable plaques
the ones with large cores and thin caps
99
what are the acute plaque changes
rupture.fissuring
erosion/ulceration
hemorrhage into atheroma (plaque)
100
where does acute plaqu change not usually occur
in severely stenoic portions of aa
101
What aa to plaques tend to involve
proximal LAD and LCX
| entire RCA
102
what syndrome has an occlusive plaque-associated thormbus
transmural myocardial infarction
103
plaque disruption is common in what coronary artery syndromes
unstavle angina and transmural MI
104
stenoses is severe in what coronary artery syndrome
sudden death
105
What are the levels of moderate risk CRP
1-3mg/L
106
what is prinzmetal angina (variant)
sustained vasospasm causing angina
107
What is cardiac raynaud
cold or emotion induced cardiac vasospasm
| if vasospasm >20 minutes can lead to myocardial infarction
108
what is takotsubo cardiomyopathy
dilated cardiomyopathy secondary to emotional or physical stress with normal coronary angiogram
109
what is apprpriate Tx for angina pectoris of any etiology
nitro
110
What is the definition of sudden cardiac death
unexpected death from cardiac causes early afeter onset of symptoms (1-24 hours) or sudden death from cardiac cause without antecedent acute symptoms
111
what is the mechanism of death in sudden cardiac death
lethal arrhythmia from electrical instability (irritability) v fib (80%) or asystole
112
what is the most common cause of sudden cardiac death
IHD
113
Channelopathies of heart are most likely what inheritance pattern
autosomal dominant
114
What channelopathies can lead to long QT syndrome
K channel KCNQ1 of KCNH2
| SCN5A Na channel
115
what channelopathies can lead to short QT syndrome
K channels KCNQ1
| KCNH2
116
What channelopathies can lead to catecholamingergic polymorphic ventricular tachycardia
RYR2
CASQ2
diastolic Ca release
117
What channelopathies can lead to catecholamingergic polymorphic ventricular tachycardia
RYR2
CASQ2
diastolic Ca release
118
What population is non ishchemic sudden cardiac death seen in
<40 y/o
| young people
119
What are common causes of SCD in young adults
hypertrophic cardiomyopathy
coronary artery anomalies
myocarditis
120
What is chronic ischemic heart disease
insidious onset of CHF in patients with past MIs or anginas
cardiomegaly with L ventricular hypertophy and dilation
evidence of previous MIs (myocardial fibrosis)
arrhythmias
121
chronic ischemia that does not lead to necrosis can lead to what other remodeling
hypokinetic myocardium with myocyte hibernation
122
Angina PEctoris usually presents how
paroxysmal and usually recurrent substernal or precordial chest discomfort
123
What can cause angina pectoris
transient MI that falls short of causing necrosis
124
What is a stable angina
decreased perfusion from narrowing
most common
provoked by exercise or emotion
relived by rest or sublingual nitro
125
what is unstable angina
cresendo, have acute plaque change
progressive increase in frequency and severity of attacks
provoked by less effort and sometimes at rest
relieved by sublingual nitro and sometimes rest
126
what is prinzmetal angina
episodic angina from coronary artery spasm
| relieved by rests, nitro, or CaChblockkers CCBs
127
what is the definition of a MI
death of cardiac muscle from ischemia
128
what factors account for 50-60% MIs
lipid risk factors
129
what genetic risk factors account for 10-20% MIs
prothrombin mutations, hyperhomocystenemia
130
What is a transmural infarction
ishcemic necrosis that involves more than 50% centricular thickness (acute plaque changes)
131
what is a subendocardial infarction
area of ischemic necrosis liminted to the inner 1/3 or at most the inner 1/2
may occur as resul tof acute plaque change and thrombosis or prolonged and severe recution in systemic blood pressure
132
What is the typical sequence of events in an MI
sudden change in plaque
formation initial platelet plug over plaque
vasospasm from platelet adhesion
propagation of platelt plug into stable clot from extrinsic clotting system
clot occludes lumen of involved vessel
133
Describe causes of transmural MI with NO atherosclerosis
vasospasm (cocaine)
embolie L atrium (a fib) ventricl (mural thrombus), valve vegetations, paroxysmal embolie
vasulitis, hemoglobinopathy
134
What type and when does adrenergic stimualtion induce MI
intense emotional stress
| peak incidenc between 6 am and noon
135
When does dec in ATP occur in I
within seconds
136
whtn does irreversible cell injury occur in MI
20-40 minutes
137
when does microvascular injury occur in MI
>1 hr
138
when is there complete unsalvageable necrosis in I
6 hours
139
When are gross features seen in MI
around 12 hours. sometimes between 4 and 12 but usually around 12 hours or more (dark discoloration
140
what is the earliest light microscopy can pick up on MI
4 hours, variable waviness of fibers at border
141
With MI how does neutrophilia help Dx
because around 12-24 hours the first cells to infiltrate are the neutrophils
142
When does granulation tissue begin to form in MI duration
7-10 days
143
can pathologist tell how long ago MI occured if scarring already done
no
144
can pathologist tell how long ago MI occured if scarring already done
no
145
What days of MI are neutrophils bery prominent
3-4 days
146
What coronary a is most commonly obstrcuted second?
first is LAD
| 2nd is RCA
147
What is the goal of reperfusion after MI
salvage ischemic myocardium from potential infarction by restoration of tissue perfustion as quickly as possive
148
what are problemes with cardiac reperfusion after MI
can cause an increase release of ROS and cause damage
can lead to arrhythmias
myocardial hemorrhage iwth contraction bands
endothelial swelling
reversible :myocardial stunning"
149
What are the intervention techniques for MIs
lysis of thrombus with fibrinolytic meds like streptokinase, urokinase or tPA
balloon angioplasy
coronary artery bypass graft
150
what is myocardial stunning
when there is prolonged ischemic dysfuntiong.
| although reeprfused wll take mycardiocytes longer to recover and gain function
151
what are the clinical Sx of an MI
severe substernal chest pain with radiation of pain down left arm, neck, jaw, epigastrium, weak rapid pulse, sweating, nausea, dyspnea
152
How are asymptomatic MIs detected
STEMI and NSTEMI on EKG
153
What are the most useful cardiac markers
troponins
154
what cardiac markers do you use to detect MI a few days ago
troponins
| TnT can go longer than TnI
155
what percent of MI patients have one or more complications of acute MI
75%
156
what are the physiologic complications of acute MI
contractile dysfunction: severe pump failure in 10-15% patients
arrhythmias: conduction distrubances along myocardial irritability
papillary muscle dysfunction with mitral regurgitation
157
what are the pathologic complications of acute MI
```
fmyocardial rupture
pericarditis
right ventricular infarction
infarct extension and expansion
mural thrombus
ventricular aneurysm
progressive late heart failuer
```
158
what are the types of myocardial ruptures that are complications of acute MI
```
free wall (anterior) leading to cardiac tamponade
interventricular septum leading to VSD and ASD
papillary muscle leading to acute valvular regurg
```
159
what is the criteria for Dx of left sided HTN heart disease
have to have Hx of systemic HTN and then also L ventricular hypertrophy without other CV path that could induce it
160
L sided HTN heart disease may present clinically with what other syndromes.signs
CHF and atrial arrhythmias
161
R sided HTN heart disase occurs with what disorders
pulmonary parenchyma disorders (COPD and diffuse interstitial lung disease)
pulmonary vessel disorders (recurrent pulmonary embolism, primary pulmonary HTN)
chest movement disorders (kyphoscoliosis)
162
what is an example of right sided HTN heart disease
cor pulmonale from pulmonary disorders with chornic severe pulm HTN
163
What disease of pulm parenchyma presdispose to core pulmonale
```
COPD
diffuse pulm interstitial fibrosis
pneumoconioses
cystiv fibrosis
bronchectasis
```
164
what diseases of pulm vessels could lead to cor pulmonale
```
recurrent pulm thromboembolism
orimary puml HTN
extensive pulmonary aa (wegener)
drug, toxin or radiation induced obstruction
extensibe pulmonary tumore microembolis
```
165
what disorders infcuing pulm arterial constrction may predispose to cor pulmonale
```
metabolic acidosis
hypoxemia
chronic altitiude sickness
obstruction major airways
idiopathic alveolar hypoventilation
```
166
what disorders infcuing pulm arterial constrction may predispose to cor pulmonale
```
metabolic acidosis
hypoxemia
chronic altitiude sickness
obstruction major airways
idiopathic alveolar hypoventilation
```
167
What are the 2 major types of cardiac valve dysfunctions
stenosis and insufficiency
168
stenosis is always what type of disease
chronic
169
what is functional regurgitation
normal valve leaflets but there is a dilated annulu from ventricular dilation that spreads apart valve leaflets
170
what is a pure vs mixed cardiac valve dysfunction
pure is only stenosis or insufficiency present
| mixed is when both are present in same valve
171
what is the most common acquired heart valve disease
mitral stenosis from rheumatic heart disease
172
What stenoses account for 2/3 valvular diseases
aortic and mitral valves
173
what is most frequent cause of aortic stenosis
calcification of anatmoically normal and congenital bicuspid aortic valves
174
what is most common cause aortic insufficiency
dilation of ascending aorta due to HTN and agin
175
what is most common cause mitral stenosis
rheumatic heart disease
176
what is most common cause mitral insufficiency
myxomatous degeneration
177
What is the most common of all valvular abnormalities
calcific aortic stenosis from aging
178
what are the pathologic findings of calcific aortic stenosis (Senile)
nodular masses of Ca are heaped up within sinuses of valsalva
179
what are the clincal features of calcific aortic stenosis
around 60s-80s
pressure hypertrophy from flow obstruction and patient has Lconcentric hypertrophy
L ventricular cardiac mass tends to be ischemic and leads to CHF syncope and angina pectoris
180
bicuspid aortic valves are more prone to what
progressive degenerative calcification, develops earlier
181
What types of patients does mitral annular calcification occur in
women over 60
individuals with myxomatous mitral valves
patients with elevated L ventricular P (HTN)
182
What condition is mitral annular calcification
associated with arrhythmias
183
when are mitral annular calcifications Dx
with radiography done for other reasons
184
What is myxomatou degeneration of mitral valve
mitral valve prolapse
185
What murmur do you hear with mitral valve prolapse
mid systolic click and regurgitant murmu
186
is mitral valve prolpase more commoin in young women or men
7:1 W:M
187
mitral valve prolapse is seen in what other condition assocaited with cardiac anomlalies
marfans
188
What are the serious complicatinos with mitral valve prolapse
infective endocarditis, mitral insufficiency, strok or other systemic infarct, arrhythmias, atypical chest pain
189
when is mitral valve prolapse Dx
Echocardiography
190
what are the pathologic changes in mitral valve prolapse
intercordal ballooning of mitral valve leaflets
affected ones are enlarged thick and rubbery
concomitant involvemnt tricuspid valve
thinned fibrosa lyaer with thickend spongiosa layer and depsition of mucoid or (myxoid) material
191
what are jet leasions
fibrosis of valve leaglets and endocardial surfaces of atrium and ventricl in mitral valve prolapse form wehre it hits close
192
what are jet leasions
fibrosis of valve leaglets and endocardial surfaces of atrium and ventricl in mitral valve prolapse form wehre it hits close
193
what are the steps of rheumatic carditis
begins with strep pharyngitis that leads to production of Ab against self and then infects all layers of heart, pancarditis
194
when does chronic rheumatic valvular heart disease begin
10 days-6 weeks post strep throat
195
what cells are pathoneumonic of rheumatic heart valve disease
aschoff bodies which are colelcitons of activated histocytes
antischkow cells (mononuclear)
aschoff cells- multinucleated forms
caterpillar cells- unique linear chromatin pattern
196
what 5 major clinical signs are assoc with acute rheumatic fever
migratoyr polyarthritis of large joints
acute carditis with cardiac enlargement and diminshed fucntion
subcutaneous nodules
erythema marginatum of skin
sydenham chorea (involuntary, purposeless movements of extremities)
197
what is criteria for Dx acute rheumatic fever
evidence of prior group A strep infection with either 2 major sytem findings or 1 major finding plus 2 minoe
198
what are the minor findings with acute prheumatic fever
fever, arthralgia, evidence of acute phase reactants( inc sed rate or inc CRP
199
After intial attack of acute rheumatic fever what is risk and Tx
risk for repeat group A strep infections
| should receive long term PCN prophylaxid well into adulthood and perhaps life
200
When does rheumatic heart disease occur
years of decades ater episodes of acute rheumatic fever
201
what valves are commonlay affected by rheumatic valvular disease
mitral and aortic valves
uncommonly tricuspid
rarely pulmonic
202
99% of all mitral stenosis is caused by what
Rheumatic heart disease
203
what percent of RHD patients have mitral and aortic valve problems
25%
204
what are hallmarks of rheumatoid heart disease
cardiac involvemtn in 20-40% cases rheumatoid arthritis
fibrinous pericarditis is most common
rheumatoid nodules in myocardium, endocardium, valves and aortic root may be present
rheumatoid valvulitis with fibrous thickeing and calcificaiton of aortic valve cusps
