Breast etc Flashcards
Breast abscess MRSA?
– MRSA – trimethoprim 160-800mg BD PO
stellate mass on XR
Radical scar
Biopsy ± excision
clear / blood-stained discharge
Intraductal papilloma
Microdochectomy (removal or lactiferous duct) is the tx
Risk of BRCA?
o 1st degree relative premenopausal relative with breast cancer
o Paget’s disease of the nipple
An eczematoid change of the nipple associated with an underlying breast malignancy
Present in 1-2% of patients with breast cancer (in half of these patients, it is associated with an underlying mass lesion 90% = invasive carcinoma; 10% = carcinoma in situ)
Breast lymph drainage
75% to lateral axillary nodes
o Radiotherapy recommendations?
Recommended after WLE
Recommended after mastectomy if T3 or T4 or ≥4 +ve LNs
Coroner Referral
o Unexpected or sudden deaths
o Not seen within 14 days before death
o Death occurs within 24 hours of hospital admission
o Accidents, injuries and suicide
o Industrial injury or disease (e.g. asbestosis)
o Deaths occurring as a result of ill treatment, starvation or neglect
o Death occurred during an operation or before recovery from the effect of an anaesthetic
o Poisoning, including taking illicit drugs
o Stillbirths - if there is doubt as to whether the child was born alive
o Prisoner or people in police custody
o Service disability pensioners
Tetanus?
o Had full course of tetanus vaccines, with the last dose > 10yo:
Tetanus prone wound reinforcing dose of vaccine
High-risk wounds reinforcing dose of vaccine + tetanus IVIG
1st line for major bowel resection pain relief?
Spinal/epidural
o Painless ulcer (perianal) + painful lymphadenopathy
LGV
o Painful ulcer + painful lymphadenopathy
= chancroid
Haemophilus ducreyi; S/S: painful sharply defined and ragged ulcer with painful lymphadenopathy
Typhoid s/s
Cough (dry) Anorexia (WL +++)
Malaise, myalgia GI symptoms (by 2nd week; diarrhoea or constipation)
Sphygmothermic dissociation / Faget’s (fever, bradycardia)
Picture: splenomegaly, bradycardia, trunk rose-spots
Ix and mx?
Investigations:
Blood culture [diagnostic]
Other – FBC, LFTs, stool culture
Management:
1st line = IV ceftriaxone OR IV cefotaxime
2nd line = PO azithromycin
dengue
Primary infection:
* Headache (retro-orbital)
* Fine erythematous sunburn-like rash (50%)
* High fever and myalgia
Other = hepatomegaly, abdominal distension
Severe = low WCC, low platelets, haemorrhage
Ix & mx dengue?
supportive treatment
Neurological lesions HIV?
o Toxoplasmosis multiple lesions, ring enhancement, thallium SPECT -ve
o CNS lymphoma single lesion, homogenous enhancement, thallium SPECT +ve
Chlamydia tx?
Azithromycin stat♀️ or doxycycline
Gonorrhoea tx?
Azithromycin stat + ceftriaxone IM stat♀️
Chronic sickle cell?
hydroxyurea/hydroxycarbamide
Myasthenia Gravis Ix?
Antibodies and EMG
Thymomas are associated with what?
Thymomas
Tuberous sclerosis
AD; ash-leaf spots (fluoresce under UV), Shagreen patches, butterfly angiofibromas, subungual fibromata, cafe-au-lait spots
Eye. nerve palsies
CN IV palsy - eye up, vertical diplopia (trauma)
CN VI palsy - eye medial, horizontal diplopia (raised ICP)
Crohn’s tx?
Inducing remission - #1 steroids PO/IV, #2 infliximab IV
Maintaining remission - azathioprine PO
Isolated peri-anal disease - metronidazole PO
Refractory or fistulating disease - infliximab PO
SBP treatment?
Tx: cefotaxime IV
Prophylaxis: ciprofloxacin PO
LTOT in COPD?
LTOT if PaO2 <7.3 or PaO2 <8 with pulmonary hypertension, polycythaemia, nocturnal hypoxaemia or peripheral oedema
Causes of HAP?
Pseudomonas - #1 HAP
Lights criteria
Lights criteria - assess cause if effusion if pleural protein 25-35g/L
Exudative if one of:
Pleural protein/serum protein >0.5 (relative)
Pleural LDH /serum LDH >0.6 (relative)
Pleural LDH >⅔ UL normal (absolute)
Diffuse scleroderma
Diffuse cutaneous - RF, anti-scl-70/anti-topoisomerase
Scleroderma (trunk, proximal limbs), hypertension, lung fibrosis, renal involvement
Diagnosing Sjorgren’s syndrome?
Schirmer’s test (<5mm wetting in 5m), bloods (RF, anti-Ro, anti-La)
Polymyositis antibody?
anti-Mi-2
tx of dermatomyositis?
Prednisolone
Treatment for Raynaud’s
Tx: nifedipine
Causes of osteomyelitis?
Staph aureus (unless sickle cell disease then salmonella)
tx of osteomyelitis?
Tx: flucloxacillin
tx of septic arthritis
gram pos - vancomycin; gram neg - ceftriaxone; MSSA/MRSA or strep - flucloxacillin
Criteria in septic arthritis?
Kocher criteria - fever >38.5, non-weight bearing, high ESR, high WCC
MARFAN’S SYNDROME
AD defect in fibrillin I
EHLERS-DANLOS SYNDROME
AD defect in type III collagen
Behcet’s syndrome
oral ulcers + genital ulcers + anterior uveitis
Polyarteritis nodosa
renal artery aneurysms
Takayasu’s arteritis
Inflammation of the aorta and major branches causing limb claudication, weak/absent pulses, uneven BP
Goodpasture’s syndrome
anti-GBM against type IV collagen, pulmonary haemorrhage → rapidly progressive crescentic glomerulonephritis
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)
pANCA, asthma + eosinophilia
Microscopic polyangiitis
cANCA, pANCA, rapidly progressive crescentic glomerulonephritis
Granulomatosis with polyangiitis (Wegener’s granulomatosis)
cANCA, epistaxis + haemoptysis + rapidly progressive crescentic glomerulonephritis
Saddle shaped nose
Prophylactic antibiotics in COPD?
Azithromycin
Mammary duct ectasia
Perimenopausal
Brown-green discharge
Nipple inversion
Areolar lump
Chemo in breast cancer
If node +ve offer chemo
Axillary node clearance
If lymphadenopathy → axillary node clearance
Surgery and radiotherapy indications in breast cancer?
Wide local excision + radiotherapy (solitary, peripheral, small in large breast, DCIS <4cm)
Mastectomy + radiotherapy if T3/T4 (multifocal, central, large in small breast, DCIS >4cm)
Post-partum thyroiditis tx?
Hyper phase - propranolol
Hypo phase - levothyroxine
Thyroid cancer monitoring?
thyroglobulin (Tg) levels ± calcitonin if medullary
Papillary thryoid cancer spread?
Lymphatic
Follicular thryoid cancer spread?
haemategenous
Branchial cyst
Lateral in anterior triangle by hyoid, develops in teens/young adults
Remnant of second branchial cleft, regular smooth mass, contains cholesterol-rich fluid
Hypernatraemia tx?
Correct water deficit
Hyponatraemia tx?
Hypovolaemic - 0.9% NaCl
Euvolaemic - fluid restrict
Hypervolaemic - fluid restrict ± loop diuretic
Cushing’s disease Ix?
- Low-dose overnight dexamethasone suppression test (low normal, high Cushing’s syndrome)
- Plasma ACTH (undetectable ACTH-indep, detectable ACTH-dep)
- High-dose overnight dexamethasone suppression test (low pituitary adenoma, high ectopic production)
Ix for prolactinoma?
- Serum prolactin
- MRI
Urate stones on scans?
Radioluscent
Markers in testicular cancer
Seminoma - LDH high
Teratoma - AFP high
hCG,
Prostate cancer normally originates where?
Adenocarcinoma of peripheral zone
Acute graft failure
<6mo, T-cell mediated, usually due to mismatched HLA or CMV, may be reversible with steroids and immunosuppressants
Alport’s syndrome
X-linked (defect in type IV collagen gene)
Sx: nephritic syndrome, bilateral sensorineural deafness, lenticonus, retinitis pigmentosa
NEPHRITIC SYNDROME
Hypertension + oliguria + haematuria
A 19 year old man has pain in the ulnar aspect of his right hand since he threw a punch with his right fist. Which structure is most likely to have been injured?
Fifth metacarpal
A 44 year old man is admitted for a day-case knee arthroscopy. He is first on the list and is scheduled for 09.00. He drank a cup of black coffee at 06.00. He has a history of oesophagitis and has suffered severe nausea and vomiting after general anaesthesia for a hernia repair. He is recovering from a cold but still has a hoarse voice.
His temperature is 37.2°C and BP 160/95 mmHg. His throat is inflamed. Which clinical feature is most likely to indicate postponing the operation?
Laryngitis
Ix for epidymo-orchitis?
USS to rule out other pathology
FBC, urine dipstick, GUM, Syphilis
Bloodborne virus screen
Mumps serology (if clinically indicated)
Blood cultures (if pyrexial)
Abx for epidydmo-orchitis?
STI related epididymo-orchitis:
Ceftriaxone, 500mg-1g, IM single dose AND
Doxycycline, 100mg BD, 10-14 days
Urinary pathogen-related epididymo-orchitis:
Ofloxacin, 200mg BD, 14 days OR
Levofloxacin, 500mg, OD, 10 days
Prostatitis cause?
E. coli
Imaging prostatitis?
MRI prostate: allows assessment of the prostate and to screen for the development of an abscess.
abx for prostatitis?
First line: Oral ciprofloxacin 500 mg twice daily or ofloxacin 200 mg twice daily
Second line: Oral levofloxacin 500 mg once daily, or co-trimoxazole 960 mg twice daily
BPH tx?
Alpha-blockers
5-alpha reductase inhibitors (e.g. Finasteride):
Haematuria - 2ww for what?
Cystoscopy is the diagnostic modality of choice.
Chronic prostatitis?
Features are those of > 3 months of urogenital pain, often associated with LUTS and sexual dysfunction.
Hydrocele?
USS
Epidydmal cyst?
An epididymal cyst is a harmless fluid-filled growth on a man’s testicle (testis). They are quite common and don’t usually require treatment. Many men feel them and are concerned that they have testicular cancer, but a doctor can usually tell the difference by examination and/or using an ultrasound scan.
Transilluminates
Ix testicular cancer?
Testicular USS is the diagnostic modality of choice.
Tumour markers testicular cancer?
LDH = bith seminoma and non-seminoma
AFP =
BCG =
Treatment for testicular cancer?
Orchidectomy must be performed via an inguinal approach.
Cremasteric reflex in testicular torsion?
Absent! (stroking thigh)
Prehn’s sign?
states that elevation of the affected testicle relives the pain of epididymitis but not of testicular torsion.
COPD vaccines?
Patients should have the pneumococcal and annual flu vaccine.
Asthma ix:
Fractional exhaled nitric oxide (FeNO)
Spirometry with bronchodilator reversibility
Where there is diagnostic uncertainty after initial investigations, the next step is testing the peak flow variability.
Where there is still uncertainty, the next step is a direct bronchial challenge test with histamine or methacholine.
Erythema multiforme
herpes simplex; target lesions; clobetasol 0.05% cream or prednisolone
Pyoderma gangrenosum
Crohn’s
Dermatophytosis/tinea - trichophyton rubrum; (athlete’s foot)
- terbinafine 1% cream
Marjolin’s ulcer
SCC that develops in a scar
Pityriasis rosea
HHV-7, after viral infection; herald patch → rash
Port-wine stain
present at birth, not raised, permanent
Strawberry haemangioma
develops after birth, raised, not permanent
Mumps ix?
PCR testing on a saliva swab. The blood or saliva can also be tested for antibodies to the mumps virus.
Gram negative diplococci
Neisseria gonorrhoeae.
Gonorrhoea ix?
Nucleic acid amplification tests (NAATs) are the principle diagnostic tests for gonorrhoea.
First-pass urine: equivalent sensitivity to urethral swabs, preferred method in men.
Vulv-vaginal swabs: first choice in women
Alternative to metronidazole BV?
Clindamycin
BV
Amsel criteria
pH > 4.5 is suggestive of BV.
Clue cells
Vaginal pH > 4.5
Typical discharge: thin, off-white/grey, homogenous and smoothly coats vaginal wall
Positive whiff-amine test: development of fishy odour with addition of 10% potassium hydroxide to vaginal discharge
Clue cells (on microscopy): vaginal epithelial cells studded with adherent coccobacilli
Painful ulcers?
HSV
Treatment of Chancroid?
Single dose treatment with azithromycin should be avoided in patients who are co-infected with HIV. In these cases ciprofloxacin or erythromycin is usually preferred.
Single dose options:
Azithromycin 1 g orally as a single dose, OR
Ceftriaxone 500 mg intramuscularly as a single dose, OR
Multi-dose options:
Ciprofloxacin 500 mg orally twice daily for three days, OR
Erythromycin 500 mg orally four times a day for seven days
Serovars
C. trachomatis
Trachoma (A-C): contagious bacterial eye infection
Urogenital (D-K): classic chlamydia infection
LGV (L1-L3): genital ulcer disease
Chlamydia tx?
Doxycycline 100 mg twice daily for 7 days (first-line)
Azithromycin 1 g once only, followed by 500 mg orally for the next two days (second-line)
Erythromycin 500 mg twice daily for 10-14 days (if above two treatment contraindicated)
Granuloma inguinale?
Klebsiella granulomatis.
Patients usually develop a painless papule(s) or nodule(s) that has a ‘beefy red’ appearance due to the high vascularity. Lesions typically occur on the genital region (~90%) or inguinal region (~10%).
can cause chronic scarring with lymphoedema.
Granuloma inguinale tx?
a minimum three week course of azithromycin.
Gentamicin can be added in patients slow to respond. Relapse can occur up to 18 months following treatment.
LGV?
Doxycycline is considered the first line treatment for LGV.
First line:
Doxycycline 100 mg twice daily for 21 days, OR
Tetracycline 2 g once daily for 21 days
Second line:
Erythromycin 500 mg four times a day for 21 days, OR
Azithromycin 1 g weekly for 3 weeks
Pediculosis pubis
Pubic lice
Infection by Phthirus pubis (crab louse).
Pediculosis pubis is characterised by pruritus (itching).
s/s of pediculosis pubis
Pruritus
Visible lice
Small bluish macules (0.5-1.0 cm): due to prolonged infestation and injection of natural anticoagulant from lice saliva during feeding.
Lymphadenopathy (rarely)
Tx of pediculosis pubis?
Topical permethrin is the treatment of choice for pediculosis pubis.
Pyrethrins 0.33% with piperonyl butoxide 4%.
Rarely oral treatment is needed. The main option is Ivermectin given at 200 mcg/kg as two single doses seven days apart.
Trichomoniasis
Protozoan
Strawberry cervix
Trichomoniasis classically causes a malodorous, frothy green-yellow discharge.
Vulval inflammation
Syphillis serological tests?
Syphilis is diagnosed using serological tests.
Secondary syphillis
presentation with the classic maculopapular skin ras
Syphillis treatment?
The treatment of syphilis is with parenteral penicillin.
Early syphilis:
Benzathine penicillin 2.4 Million units, IM single dose.
Late syphilis (cardiovascular or gummatous):
Benzathine penicillin 2.4 million units, IM weekly for three weeks (3 doses)
Prednisolone 40-60 mg for three days if cardiovascular (see Jarisch-Herxheimer reaction)
Neurosyphilis:
Procaine penicillin 1.8-2.4 million units IM once daily plus probenecid 500 mg QDS for 14 days, OR
benzylpenicillin 10.8-14.4 g daily, given as 1.8-2.4 g IV every 4 hours for 14 days.
Prednisolone 40-60 mg for three days (see Jarisch-Herxheimer reaction)
Syphilis in pregnancy:
Benzathine penicillin 2.4 million units IM single dose in the first and second trimesters. Further dose in the third trimester followed by a second dose after one week.
Vulval candida?
Clotrimazole
Treatment for recurrent thrush?
Induction course: oral anti-fungal (e.g. fluconazole) or 10-14 day course of anti-fungal pessary
Maintenance course: oral anti-fungal or anti-fungal pessary given as needed if symptoms recur. Alternatively, give a six month maintenance course then review.
Case control study
In a case-control study, a sample of individuals are identified and divided into those with a particular characteristic and those without it.
Cross-sectional study
In a cross-sectional study, a sample of individuals is identified and information is collected often with participant completed questionnaires.
This type of study is commonly used for the provision of official statistics. In the United Kingdom, studies include the Health Survey for England and the Adult Dental Health Survey.
A 43 year old man is rescued from a house fire. There are no signs of burns to the face or neck, but he has soot deposits in his nose and mouth.
His temperature is 37.5°C, pulse rate 120 bpm, BP 135/86 mmHg, respiratory rate 20 breaths per minute and oxygen saturation 97% breathing air. He has widespread wheeze.
Which is the most appropriate management?
Non-rebreather mask and 100% oxygen
A 42 year old man reports that his left testicle has been swollen for the past 3 weeks. He is otherwise well. There is a firm, round swelling at the upper pole of the left testis.
Which is the most likely diagnosis?
Epididymal cyst
A 64 year old man with a two year history of intermittent claudication presents with worsening lumbar back pain, not related to movement. He has type 2 diabetes mellitus.
Examination of his abdomen and spine is normal, but he has an absent right popliteal pulse and absent pulses in his left foot.
Which is the most appropriate initial investigation?
Abdo USS
An 80 year old woman has recurrent abdominal pain approximately 20 minutes after she has a meal. She has noticed weight loss of 14 kg over the past six months.
She is thin and has tarstained fingers. Her temperature is 36.5°C and pulse rate 85 bpm. She has an abdominal bruit.
Which is the most likely diagnosis?
Mesenteric angina
A 69 year old woman has constant dribbling of urine and has had to wear pads continuously for the last 12 month. She had radiotherapy for carcinoma of the cervix when she was 48 years old.
Her temperature is normal. Her bladder is not palpable or tender and neurological examination is normal.
Which is the most likely cause of her symptoms?
Vesicovaginal fistula
A 62 year old woman has blurred vision and extreme pain in her right eye of sudden onset. She is nauseated, has a headache and is seeing haloes around bright lights. The ocular pressure is reduced with drugs. The ophthalmologist explains to the patient that medical management alone is likely to be insufficient to reverse the problem.
Which I the most appropriate surgical treatment?
Laser peripheral iridectomy
A 40 year old man has an extensive rash that started 2 days ago and is worsening. He is shivering and feeling generally unwell. He has no past medical history, but has recently been treated for a chest infection.
His skin is now red over most of the body, with some large blisters and some areas of erosion. There is extensive ulceration in the mouth, and the conjunctivae are injected.
Which is the most likely diagnosis?
TEN
A 20 year old man has 14 weeks of cervical lymphadenopathy. He has a cough and has been sweating at night, and has lost 10% of his body weight. A lymph node biopsy reveals a proliferation of lymphoid cells, with scattered, large binucleate cells and prominent nucleoli.
Which is the most likely diagnosis?
Hodgkin lymphoma
A 70 year old man has 24 hours of cramping abdominal pain, bloating and complete constipation. He has had 2 months of intermittent diarrhoea.
His abdomen is distended, with lower abdominal tenderness. He has an appendicectomy scar. Abdominal X-ray shows large bowel obstruction.
Which is the most likely underlying cause for his presentation?
Adhesions – more likely in small bowel obstruction
Colorectal cancer – more likely in large bowel obstruction
A 29 year old man presents after a fall on to his outstretched left arm.
The left shoulder is deformed and there is sensory loss over the deltoid muscle. The radial pulse is palpable and the patient is able to extend his wrist.
What nerve is most likely to have been damaged?
Axillary
Calcaneal fracture imaging to plan for surgery?
CT
A 35 year old man has pain in his left foot for three months; it is worse after playing football but improves when he keeps his foot still. Recently, the pain has become more persistent. He is unable to recall any specific injury that may have brough on the pain. He plays sport several times a week. He is otherwise fit and well. There is tenderness over the mid-foot.
What is the most likely diagnosis?
Metatarsal stress fracture
A 60 year old man has been unable to hear with his left ear for 6 months.
Examination of both ear canals is normal. Tuning fork tests suggest sensorineural hearing loss in the left ear.
Which is the most likely diagnosis?
Acoustic neuroma
Gram positive bacteria
Gram-positive cocci include Staphylococcus (catalase-positive), which grows clusters, and Streptococcus (catalase-negative), which grows in chains
High LDH haem?
Autoimmune haemolytic anaemia
Direct antiglobulin test
A 47 year old man has nausea and epigastric pain. He undergoes endoscopy and biopsy, and he is found to have a carcinoma of the lesser curve of the gastric body. His case is discussed at the multidisciplinary team meeting.
Which lymph node group is most likely to be the site of metastasis?
Coeliac
A 24 year old man has had a high speed motorcycle crash. A cervical spine fracture is suspected and a series of cervical spine X-rays is requested.
Which X-ray view is most likely to reveal a vertebral body crush facture?
Lateral
A 75 year old man develops difficulty speaking and swallowing two days after a right carotid endarterectomy.
On examination of his cranial nerves, his tongue deviates to the right on protrusion.
Which is the most likely cause of this problem?
Damage to the hypoglossal nerve
A 75 year old man has increased urinary frequency, nocturia (four times per night), poor urine flow and reduced urinary volumes over the past six months. Urinalysis shows glucose trace, blood and protein negative.
Investigations: electrolytes: normal
serum creatinine 387 µmol/L (60-120)
random blood glucose 5.6 mmol/L
Which is the most likely cause of his renal impairment?
Obstructive uropathy - BPH
A 67 year old woman has weakness in her left arm and shoulder. She has recently undergone a left mastectomy and lymph node dissection for breast carcinoma.
She has reduced abduction in her left shoulder and winging of the scapula.
Which nerve is most likely to have been damaged?
Long thoracic nerve
(Innervates serratus anterior)
A 65 year old woman attend for routine breast screening. She has no symptoms of breast disease, no relevant family history and is not on any medication. She has a normal breast examination. The mammogram shows and area of focal microcalcification.
Which is the most common pathological cause?
Ductal carcinoma in situ (DCIS)
Hemiarthroplasty?
Replacement of the head and neck of the femur
A 66 year old man has had left sided abdominal discomfort for the pat 1 month.
He has widespread purpura and a palpable spleen measuring 17 cm from the left costal margin. There is no hepatomegaly or lymphadenopathy.
Investigations:
Haemoglobin 85 g/L (130-175)
White cell count 0.5 x 109/L (3.0-10.0)
Platelet count 38 x 109/L (150-400)
INR 1.0 (1.0)
Activated partial thromboplastin time 31 s (22-41)
Which is the most likely diagnosis?
Myelofibrosis
Monitoring for FAP
Sigmoidoscopy or colonoscopy every 1 to 2 years starting at age 10 to 12 for people with FAP. Individuals with AFAP should undergo colonoscopy beginning at age 18 to 20.
Yearly colonoscopy once polyps are found until a colectomy is planned
A 70 year old man has bright red rectal bleeding. Rigid sigmoidoscopy reveals a smooth and pedunculated polyp, 1 cm in diameter and 3 cm from the anal margin.
Which type of tumour is this polyp most likely to be?
Adenoma
Membranous nephropathy
Nephrotic syndrome
A 40 year old woman attends the ear, nose and throat clinic with a series of episodes of vertigo over the past 3 years. Each episode is preceded by a feeling of fullness in her left ear. The attacks last several hours and leave her with left sided tinnitus and deafness. She sometimes vomits during the attacks. An audiogram shows a left sided sensorineural hearing loss.
Which is the most likely diagnosis?
Ménière’s disease
A 22 year old woman has a painless swelling in the left side of her neck. She first discovered the lump several months ago and noticed that it became slightly more prominent after a recent cold.
She looks well. Her temperature is 37.2°C. There is a 3 cm x 4 cm oval, non-tender, fluctuant mass along the lower third of the anteromedial border of the sternocleidomastoid muscle.
Which is the most likely diagnosis?
Brachial cyst
A 28 year old man has a headache, intermittent fever, sore throat and diarrhoea.
He has a temperature of 37.7°C. His facies are red and there are two small aphthous ulcers on his left buccal mucosa. He also has a maculopapular erythematous rash on his upper trunk, red hands and folliculitis on his chest. His liver and spleen are just palpable and he has mild neck stiffness.
Investigations:
haemoglobin 135 g/L (130-175)
white cell count 3.3 x 109/L (3.0-10.0)
platelets 84 x 109/L (150-400)
Which next investigation is most likely to lead to a diagnosis?
HIV serology??
Palpable loin mass?
Polycystic kidney disease
Measles transmission?
Respiratory droplet
