respiratory Flashcards
Caplan syndrome
RA and pneumoconioes with intrapulmonary nodules
Asbetosis
Affects lower lobes; ferruginous bodies (golden-brown fusiform rods resembling dumbbells) in alveolar sputum; “ivory white” calcified pleural plaques; high risk of lung cancer (bronchogenic carcinoma > mesothelioma)
berylliosis
Beryllium in aerospace and manufacturing industry; affects upper lobes; granulomatous on histolgy and thus, on occasion, responsive to steroids
Coal workers’ pneumoconiosis
Affects upper lobes; black lung disease 2/2 prolonged coal dust exposure; perilymphatic accumulation of coast dust-laden macrophages
Silicosis
Foundaries, sandblasting, mines; upper lobes; macrophages respond to silica and release fibrogenic factors, silica also disrupt phagolysosomes and impair macrophages which increase susceptibility to TB; birefringent silica particles surrounded by fibrous tissue and “eggshell” calcification of hilar lymph nodes; increase risk of bronchogenic carcinoma
Neonatal respiratory distress syndrome: diagnostic test, complications, treatment complications, treatment
Licithin:spingomyelin ratio <1.5 in amniotic fluid; persistently low O2 tension leads to risk of PDA; other complications include metabolic acidosis, necrotizing enterocolitis;therapeutic supplemental oxygen can result in retinopathy of prematurity, intraventricular hemorrhage, bronchopulmonary dysplasia; maternal steroids before birth, artificial surfactant for infant
Small cell carcinoma
Central; neoplasm of neuroendocrine Kulchitsky cells small dark blue cells; chromogranin A positive; amplification of myc oncogenes common; rx with chemo
Adenocarcinoma
Peripheral; most common lung cancer overall and most common among non-smokers; activiating mutations of KRAS, EGFR, ALK; associated with hypertrophic osteoarthropathy (and clubbing); histo: glandular pattern on histology, stains mucin positive;
Bronchioloalveolar subtype of adenocarcinoma
Grows along alveolar septa, apparent “thickening” of alveolar walls; CXR shows hazy infiltrates similar to pneumonia
Squamous cell carcinoma
Central: cavitation, cigarattes, hyperCalcemia 2/2 PTHrP; histo: keratin pearls and intracellular bridges
Large cell carcinoma
Peripheral; highly anaplastic undifferentiated tumor; poor prognosis; histo: pleomorphic giant cells, can secrete beta-hCG
Bronchial carcinoid tumor
Systems due to mass effective, occasionally carcinoid syndrome; histo: nests of neuroendocrine cells chromogranin A positive
TB drugs MOA: rifampin
inhibits bacterial DNA-dependent RNA polymerase, inhibiting transcription
Total airway resistance breakdown
UR tract (nasal passages, mouth, pharynx, larynx) account for half; in LR tract, first 10 out of 21 generations of bronchi contribute most with 2-5 being the highest; in contrast, airways <2 mm in diameters like bronchiolescontribute less to total airway frictional resistance
TB drugs MOA: isoniazid
inhibits mycolic acid (long branched-chain fatty acids in the outer peptidoglycan cell wall) and other mycobacterial virulence factors (sulfatides, wax D, cord factor)) synthesis
Lamellar bodies of type II pneumocytes function
Store and release pulmonary surfactant into fluid layer of the inner surface of alveloi and reduce surface tension; deficiency of this can lead to patchy alveolar atelectasis
Pathogenesis of centriacinar emphysema
Chronic, heavy smoking injures bronchioles, activates alveloar macrophages that attract PMN and macrophages to come and release proteases that degrade extracellular cellular matrix; the resultant protease-antiprotease imbalance leads to acinar wall destruction and irreversible airspace dilatation distal to the terminal bronchioles
Phrenic nerve referred pain MOA
Irritation of the mediastinal or diaphragmatic parietal pleura will cause sharp, inspirational pain in C3-C5 distribution (base of the neck and over shoulder)
Lung abscess 3 MOA
- oropharyngeal, with anaerobic oral flora, a.w. LOC, dysphagia; 2. complication of bacterial pneumonia, more common with immunosuppression, old age, chronic lung disease; 3. septicemia/infectious endocarditis, more common agents being Staph and Strep
Sarcoidosis pw
Erythema nodosum, arthrlagias, hilar LN, elevated serum ACE, liver involvement with scattered noncaseating granulomas
Mycobacterial resistance to isoniazid
Non-expression of the catalase-peroxidase enzyme or through genetic modification of the isoniazid binding site on the mycolic acid synthesis enzyme
TB med MOA: ethambutol
Inhibit synthesis of the mycobacterial cell wall; resistence develops when mycobacteria increases production of arabinosyl transferase
TB med MOA: streptomycin
Aminoglycoside antibiotic that inhbitis mycobacterial protein synthesis by disabling ribosomal 30S subunit and disrupt translation
TB med MOA: pyranizamide
Converted to active form by mycobacterial enzyme pyrazinamidase, and after lowers the environmental pH in susceptible strains
Allergic asthma MOA and rx
Leukotrienes and ACh cause bronchospasm; leukotrienes infiltrate bronchial mucosa to cause bronchial constriction and yperreactivity, mucosal edema, mucus hypersecretion
Isoniazid monotherapy used for:
Positive PPD and negative CXR with no evidence of clinical disease
Pulmonary fibrosis pw, CXR, PFT, biopsy
Progressive dyspnea; b/l reticulonodular opacities; restrictive pattern (decreased FEV1/FVC, normal ratio, decreased diffusion capacity); lung biopsy showing patchy interstitial lymphocytic inflammation and fibrosis of alveolar walls
Viral bronchiolitis pw
Prodrome of low-grade fever, rhinorrhea, followed by progressive cough, tachypnea, and agitation with exam showing b/l wheezing, prolonged expiration, scattered rales; most commonly attributed to RSV infection; normally self-limited, if serious can give humidified oxygen, IV fluids, and ribavirin (nucleoside analog that inhibits guanine nucleotides)
Oseltamivir
Sialic acid analogue inhibitor of flu A/B viral neuraminidases
Ganciclovir
guanine nucleoside analogue, similar to acyclovir but that it exhibits greater activity against CMV DNA polymerase
Amantadine
Impaires uncoating of flu A virion after host cell endocytosis
High altitude exposure
Hypoxemia with chronic respiratory alkalosis, with corresponding decrease in bicarb 2/2 renal compensation
Nyastatin MOA
Binding to ergosterol in fungal cell membrane, causing formation of poors and leakage of fungal cell contents; not absorbed in GI tract and administered as an oral agent against oropharyngeal candidiasis
Dust particle clearance: 10-15 um, 2.5-10 um, < 2 um
Trapped in URT, cleared by mucociliary transport, phagocytized by macrophages in the terminal bronchioli and alveoli, who release PDGF and IGF to induce inflammation and fibroblasts (pneumoconiosis)
Extrinsic allergic asthma: sputum findings
Eosinophils (granule-containing cells) that are recruited and activated by IL-5 secreted by TH2 helper T cells, Charcot-Leyden crystals;
L/S and fetal lung development
Phosphatidylcholine (lecithin) and phosphatidylglycerol are major componenets of lung surfactant; fetal lung lecithin production increases sharply at 30 weeks gestation and phosphatidylglycerol production increases at 36. L/S ratio of >2 indicates adequate surfactant production
Chloride shift
Within RBC, carbonic anhydrase forms bicarb which diffuse into the plasma. To maintain, electrical neutrality, chloride ions diffuse into RBC
Anaphylaxis markers
Mast cell release of histamine and tryptase
Degranulation of mast cells MOA
Aggregation of IgE-Fc receptors on the mast cell surface
Ethambutol SE
optic neuritis that results in color blindness, central scotoma, and decreased visual acuity
ARDS histo
Diffuse injury to alveolocapillary membrain results in interstitial and intraalveolar edema, acute inflammation, alveolar hyaline membranes (fibrin exudate, plasma protein-rich edema fluid mixed with cytoplasmic and lipid remnants of necrotic epithelial cells)
PMN elastase
Major protease of extracellular elastin degradation; inhibited by alpha-1-antitrypsin
Alpha-1-antitrypsin deficiency
Unopposed action of PMN elastase on alveolar walls; a.w. panacinar emphysema and liver cirrhosis; smoking dramatically increases risk of panacinar emphysema as oxidant products of smoke inactivate edogenous a1-AT, producing a “functional” a-AT deficiency as well.
CF MOA
3-base pair deletion in CFTR gene at position 508; which impaires posttranslational processing of CFTR , degradation in proteosome and complete absence in affected epithelial cells
Vitamin E deficiecy
needed to maintain orderly differentiation of specialized epithelia, including mucus-secreting columnar epithelia of the ocular conjunctiva, respiratory tracts, urinary tracts, and pancreatic exocrine ducts. Deficiency can lead to squamous metaplasia of such epithelia to keratinizing epithelium
Arterial PaCO2 is a direct indicator of alveolar ventilation status: Hypocapnia and hypercapnia meanings
Alveolar hyperventilation; hypoventilation (upper airway obstruction, reduced ventilatory drive, respiratory muscle fatigue, and decreased chest wall compliance
Foreign body damage to what nerve causes damage to the cough reflex?
Internal laryngeal nerve, located behind a thin mucosa overlying the piriform recess (where food gets caught)
Pulmonary artery hypertension two-hit hypothesis
First hit: abnormal BMPR2 gene; second hit: second insult (infection, drugs, ion channel defect results in vascular smooth proliferation in the pulmonary vasculature and elevated pulmonary pressure
Which parts of the respiratory tract are lined with pseudostratified, columnar mucus-secreting spithelium? Stratified squamous spithelium?
Nose, paranasal sinuses, nasopharynx, most of the larynx and the tracheobronchial tree; oropharynx, larygngopharynx, anterior epiglottis, upper half of the posterior epiglottis, and true vocal cords
Partial pressure of oxygen in alveolar air
150 - PaCO2/0.8
Thoracentesis location
Above 7th rib at midclavicular line, 8th rib along midaxillary line, and 11th rib along posterior scapular line; insertion of the needle below these points increases risk of penetrating abdominal structures; insertion of th eneedle on the inferior margin risks striking the subcostal neurovascular bundle
Adenocarcinoma in situ
Well-differentiated dysplastic columnar cells that line the alveolar septa without vascular or stromal invasion; can produce copius amounts of water sputum (bronchorrhea); imaging shows discrete msas or pneumonia-like consolidation
Cromolyn/nedocromil
Mast stabilizing agents that inhibit degranulation independent of stimuli present; less effective than inhaled GC, considered 2nd line.
COPD PFT
Decreased FEV1/FVC; emphysema also increases TLC/RV
Restrictive lung dz PFT
Decreased lung volume (TLC, vital capacity, FRC, RV); FEV1/FVC may be increased
How to minimize work of breathing in patients with increased elastic resistance (e.g. pulmonary fibrosis) and patients with increased airflow resistance (e.g. asthma, COPD)
Fast, shallow breaths (RR high and tidal volume low); slow, deep breaths (lower rate, higher volume)
Pulmonary edema effect on lung compliance
Decreases lung compliance to the point where normal inspiratory effort is not enough to distend the lungs; results in poor gas exchange
N-aetylcysteine MOA
Mucolytic agent used in CF, cleaves disulfide bonds within mucus glycoproteins and loosen thick sputum
Restrictive lung dz: Expiratory flow rates increased due to?
Increased elastic recoild 2/2 decreased lung compliance and increased radial traction exerted on the conducting airways by the fibrotic lung
CFTR MOA at mucus/exocrine glands and sweat glands
ATP-gated chloride channel that pumps against concentration gradient; at mucous membranes/exocrine glands, pumps Cl out, which creates electrical gradient that pulls Na and water with it; at eccrine sweat glands, salt is removed from the originally isotonic sweat (basis for the sweat choride test)
Integrated exercise response
Increases HR, CO, RR so that arterial blood gases remain relatively constant (venous oxygen decreased and venous CO2 increased)
MAC infection in HIV presentation, rx
Fever, weight loss, diarrhea, reticuloendothelial sx (marked anemia, HSM, elevated alk phos and lactate dehydrogenase); in contrast to TB, grows well at high temperatures; azithromycin
pO2 in LA is lower than that in the pulmonary capillaries: why?
Deoxygenated lood from the bronchial arteries mixes with oxygenated blood from the pulmonary veins
Cerebral circulation regulators
Systemic blood pressure (less important) and arterial blood gas levels, esp. CO2 (more important); Direct/linea relationship between CO2 and cerebral blood flow (O2 effect kicks in if O2 less than 50).
Bronchiolitis obliterans
Chronic rejection of lung transplants; lymphocytic inflammation, necrosis, and fibrosis of the bronchiolar wall eventually leading to occlusion of the bronchiolar lumen
Why clindamycin over metronidazole for lung abscess?
Because it covers aerobic organisms like s. pneumonia and s. aureus as well
Type II pneumocyte function
Regeneration of alveloar lining following injury, surfactant production, and serve as progenitor for type I pneumocytes
Azoles MOA, SE
Inhibit fungal cytochrome P450 enzyme synthesis of ergosterol; inhibit human P450 system and cause drug-drug interactions
Idiopathic pulmonary fibrosis surgical biopsy
Extensive interstitial fibrosis with paraseptal and subpleural cystic airsplace enlargement (honeycomb lung)
Amphtericin B MOA
Binds ergosterol in fungal cell membran to create pores and lyse cell
Terbinafine MOA
Inhibits fungal enzyme squalene-2,3-epoxidase, decreasing synthesis of ergosterol
Griseofulvin MOA
Binds microtubules, inhibits mitosis; only effective in dermatophyte fungi as it accumulates in keratin-containing tissues
Flucytosine MOA; used with what other agent to treat what condition?
inhibit both DNA/RNA synthesis in fungal cells; combined with amphotericin B to treat cryptococcal meningitis
Meconium ileus MOA
Abnormally dehydrated meconium (inspissated green mass) leads to distal small bowel obstruction in a neonate (bilious vomiting, abdominal distention, air fluid levels, and small bowel diltation)
CF mortality cause
Persistent, treatment-resistent infectious pneumonias, bronchiectasis, bronchitic obstructive pulmonary disease and associated cor pulmonale
ARDS characterized by:
Increased pulmonary capillary permeability, leaky alveolocapillary membrane; interstitial/intra-alveolar edema, inflammation, hyaline membrane formation leads to decreased lung compliance, increased WOB, and decreased oxygen difusoin capacity. More severe involvement can also cause V/Q mismatch.
ARDS has what normal finding?
PCWP (indicates lack of cardiogenic cause)
Respiratory tract changes in structure/function
Bronchi: psuedostratified columnar ciliated epithelium with goblet cells, submucosal mucoserous glands, and cartilage; bronchioles, terminal bronchiols, and respiratory bronchiols have ciliated simple cuboidal cells (no goblet cells, glands, cartilage); epitheliail cilia persist up to the end of the respiratory bronchioles
Asbetosis CXR
fibrocalcific parietal pleural plaques in the posterolateral mid-lung zones and over the diaphragm
Emphysema
Decreased FEV1/FVC, increased total lung volume, and decreased diffusing capacity 2/2 destruction of alveoli and adjoining capillary beds
Pulmonary HTN MOA
- Medial hypertrophy (increased arteriolar smooth muscle thickness); 2. Intimal fibrosis (onion skinnin); 3. Luminal narrowing; 4. Plexiform lesions (interlacing tufts of small vascular channels)
Pulmonary arterial hypertension (PAH) mutation
Inactivating mutations involving pro-apoptotic BMPR2 gene
Pulmonary arterial hypertension temporizing measure until transplant
Bosentin, an endothelin-receptor antagonist that blocks endothelin (potential vasoconstrictor that also stimulates endothelial proliferation)
Pyrazinamide requires what environment?
Acidic environment (i.e. within macrophage phagolysosomes); other agents are more effective against extracellular mycobacteria
Methacholine
Muscarinic cholinergic agonist that causes bronchoconstriction and increased airway secretoins; decrease in FEV1 by more than 20% after challenge indicates bronchial asthma
Antifungals
Polyenes (binds to ergosterol, creates pores), azoles (inhibit ergosterol synthesis), echinocandins (inhibit glucan synthesis and inhibit cell wall formation), pyrimidines (interferes with fungal DNA/RNA synthesis)
Amphotericin B SE
Binds to cholesterol; dose-dependent nephrotoxicity 2/2 decreased GFR; hypokalemia, hypomagnesemia; anemia
Bronchiolitis obliterans organizing pneumonia (BOOP) MOA
Inflammation, granulation tissue proliferation that obstructs small bronchioles and airways and consolidate the alveoli
S. pneumo pneumonia MOA
1.Congestion 2/2 fluid extravation into alveolar space, lobe is red, heavy, and boggy, first 24 hrs; 2. “red hepatization” as PMN, RBC accumulate in alveolar space, red/firm lobe, days 2-3; 3. “gray hepatization” due to deposition of fibrinous material in the alveolar space (RBCs disintegrate), gray-brown firm lobe, days 4-6; 4. elimination of S. pneumoniae
TB caseous necrosis MOA
T-lymphocyte delayed type hypersensitivity reaction; T-lymphocyte stimulation of macrophages and CD8 T cells; macrophages undergo epithelioid and Langhans giant cell transformation and fibroblasts are activated
Theophylline intoxication, rx
Abdominal pain, vomiting, diarrhea, cardiac arrhythmias, seizures; activated charcol, cathartics, beta-blockers
Functional residual capacity
Center of the airway PV curve: the intrapleural pressure is negative (-5 cm H20)
TB: Locations of extrapulmonary disease
Basal meninges (tuberculous meningitis), lumbar spine (Pott disease), psoas muscle (posas abscess), and serous membranes like pericardium and pleura; in extreme cases, miliary TB everywhere
TB: primary infection
Aerosolized respiratory secretions fall into the lower lobe, creating a Ghon complex
Isoniazid SE
Peripheral neruopathy as isoniazid is structurally similar to pyridoxine (B6). This arises from increased urinary excretion and defective synthesis of GABA neuroransmitters
Cheyne-Stokes respiration
Cyclic breathing that periods of apnea are followed by gradually increasing tidal volumes and then gradually decreasing tidal volumes until the next apneic period; most commonly seen in CHF
SVC syndrome presentation, most common cause
Dyspnea, cough, facial swelling, upper extremnities; HA, dizziness, confusoin 2/2 cerebral edema and elevated ICP, dilated collateral veins; Mediastinal mass (lung cancer, then non-Hodgkin lymphoma)
Streptomycin MOA
Inactivates 30S ribosomal subunit, inhibits protein synthesis
Elastase released from what cell?
PMN (inhibited by alpha-1 antitrypsin) and macrophages (inhibited by tissue inhibitors of metalloproteinases)
Difference between arterial resistance in systemic and pulmonary circulation
Systemic: high; pulmonary: low
Medullary respiratory has 3 inputs
Central chemoreceptors (detect hypercapnia), peripheral chemoreceptors at carotid and aortic bodies (detect hypoxemia), and pulmonary stretch receptors (regulate inspiration during lung distention)
Alpha-1-antitrypsin deficiency
Chronic panacinar emphysema, prferentially localized to lower pulmonary lobes
Small cell carcinoma
Tumor arises from primitive cells in the basal layer of the bronchial epithelium; round/oval cells with scant cytoplasm and large hyperchromatic nuclei, may resemble lymphocytes but smaller in size; IHC stains show neuroendocrine markers like neuron specific enolase, chromogranin, synaptophysin; strongly associated with smoking, centrally located
Abscess formation
PMN and macrophage srelease lysosomal enzymes taht damage tissue
Reid index
Measures mucous gland enlargement; thickness of mucous gland layer in the bronchial wall submucosa divided by thickness of the bronchial wall between the respiratory epithelium and bronchial cartilage (excluding cartilage); >40 percent indicates diseases, reflects severity as well
Difference between minute ventilation and alveolar ventilation?
Alveolar ventilation does not take into account dead space
Ethambutol MOA, SE
Inhibits carbohydrate polymerization and prevents peptidoglycan cell wall synthesis; optic neuritis, decreased visual acuity, central scotoma, color blindness
Differentiate between absolute and relative (plasma contraction) erythrocytosis with
RCB mass (increased mass means absolute, normal means relative)
Differentiate between primary and secondary erythrocytosis with
Serum epo levels (low means primary, high means secondary)
Differentiate between hypoxic and other causes of secondary erythrocytosis with
SaO2 < 92, PaO2 < 65
Most common benigh lung tumor
Hamartomas, pw asymptomatic peripherally located “coin lesion” in patients 50-60 years old, composed of disorganized cartilage, fibrous, and adipose tissue
Supine pts aspirate into:
Posterior segments of the upper lobes and the superior segment of the lower lobs; R>L
Basophil
Dark blue granules, irregular size, obscured nucleus; granules contain heparin, histamine, SRS-A
Eosinophil
bilobed nuclei with large eosinophilic granules; release major basic protein, a potent anti-helminth toxin capable of causing dmg to epithelial and endothelial cells (moa of atopic/extrinsic allergic asthma)
Chronic rejection of lung transplant MOA
Bronchiolitis obliterans syndrome: inflammation and fibrosis of the small bronchioles leads to obstruction, presenting with dyspnea, nonproductive cough, and wheezing
Retinopathy of prematurity or retrolental fibroplasia MOA
Temporary local hyperoxia in the retina causes upregulation of proangiogenic factors like VEGF upon return to room air ventilation; this neovascularization may lead to retinal detachment and blindness
Fat emboli stains black with
Osmium tetroxide
chronic bronchitis histology
Thickened bronchial walls, PMN infiltratoin, mucous gland enlargement, patchy squamous metaplasia
Verenicline MOA
partial agonist of nicotinic acetylcholine receptors; reduces withdrawal cravings and attenuates reward of nicotine
Caspofungin MOA
Block polysaccharide glucan synthesis, suppress synthesis of cell wall
Physiologic dead space refers to:
Regions of alveolar ventilation that do not engage in gas exchange due to relatively low alveolar perfusion and or alveolar hyperareation
Nonselective BB SE
Bronchoconstriction, peripheral vasospasm, predispose DM pt to hypoglycemia
Pancoast tumor presentation
Ipsi Horner’s, rib destruction, atrophy of hand muscles, and C8-T1 pain
LaPlace law and the relationsihp between sphere radius and distending pressure
P = 2T/r; As radius with constant surface tension decreases, the distending pressure increases: thus, smaller spheres collapse before larger ones; surfactant counteracts alveolar collapse by decreasing surface tension as the alveolar radius decreases and surfactant concentration increases
Pulmonary vascular resistance components, point of minimum resistance
Alveolar vessels, where increased lung volumes increases resistance by increasing length and reducing diameter; and extra-alveolar, where decreased lung volumes increase resistance by decrease radial traction and compression by positive intrathoracic pressure; FRC
Vagal stimulation of lung leads to:
Bronchoconstriction and increased bronchial mucus secretion, which lead to increased airway resistance and WOB
Trachael deviation in an opacified lung
Toward lung opacified lung with atelectasis; away from opacificied lung with large pleural effusion
Obstructive lesion of mainstem bronchus
Unilateral pulmonary opacification and deviation of trachea toward the opacified lung
Vitamin D toxocity can occur with:
Sarcoidosis or other granulomatous dz (TB, Hodgkin’s, non-Hodgkin’s)
Smoking causes hypoxia via what mechanisms?
- chronic bronchitis decreases diameter of conducting airways; 2. emphysema dilates alveolar air spaces and reduce contact between airspaces and deoxygenated blood; 3. increasing concentration of carboxyhemoglobin
Inflammatory cytokines and effect
IL-1, IL-6, TNF-alpha; stimulate hepatic production of acute phase reactants to bind on microbes and fix complement
PGD2, PGE2, PGF2
Vasodilation, edema
PGI2
Vasodilation, inhibition of platelet aggregation
TxA2
Vasoconstriction, promotion of platelet aggregation
Leukotriene B4
Chemotaxis
Leukotriene C4, D4, E4
Vasoconstriction, bronchospasm, increased vascular permeability; important role in bronchial asthma
Lipoxin A4, B4
Vasodilation, inhibition of PMN chemotaxis, monocyte adhesion
Bradykinin
Vasodilation, increased vascular permeability, stimulates SMC contraction
Interferon gamma
Produced by activated T cells, recruits leukocytes and activates phagocytosis
IL-4
Produced by Th2 cells, stimulates growth of B cells and increases number of Th2 cells at inflammation site
Asbestos exposure clinical manifestations
Pleural plaques, asbetosis (progressive, diffuse pulmonary fibrosis and asbestoes bodies (golden-brown beaded rodes), bronchogenic carcinoma, malignant mesothelioma
CF GU manifestations
Bilateral absence of vas deferns and azoospermia
Malignant mesothelioma
Hemorrhagic pleural effusions and pleural thickening; electron microscopy shows tumor cells with numerous long sleder microvilli and abundant tonofilaments
