scholarly journals Reduction in femoral neck and total hip bone mineral density following hospitalisation for diabetes-related foot ulceration

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Marcel M. Nejatian ◽  
Salar Sobhi ◽  
Blake N. Sanchez ◽  
Kathryn Linn ◽  
Laurens Manning ◽  
...  
Keyword(s):  
Bone Mineral Density ◽  
Lumbar Spine ◽  
Femoral Neck ◽  
Bone Mineral ◽  
Fat Mass ◽  
Mineral Density ◽  
Contralateral Limb ◽  
Foot Ulceration ◽  
Total Hip ◽  
Hip Bmd

AbstractManagement of diabetes-related foot ulceration (DFU) includes pressure offloading resulting in a period of reduced activity. The metabolic effects of this are unknown. This study aims to investigate changes in bone mineral density (BMD) and body composition 12 weeks after hospitalisation for DFU. A longitudinal, prospective, observational study of 22 people hospitalised for DFU was conducted. Total body, lumbar spine, hip and forearm BMD, and total lean and fat mass were measured by dual-energy X-ray absorptiometry (DXA) during and 12 weeks after hospitalisation for DFU. Significant losses in total hip BMD of the ipsilateral limb (− 1.7%, p < 0.001), total hip BMD of the contralateral limb (− 1.4%, p = 0.005), femoral neck BMD of the ipsilateral limb (− 2.8%, p < 0.001) and femoral neck BMD of the contralateral limb (− 2.2%, p = 0.008) were observed after 12 weeks. Lumbar spine and forearm BMD were unchanged. HbA1c improved from 75 mmol/mol (9.2%) to 64 mmol/mol (8.0%) (p = 0.002). No significant changes to lean and fat mass were demonstrated. Total hip and femoral neck BMD decreased bilaterally 12 weeks after hospitalisation for DFU. Future research is required to confirm the persistence and clinical implications of these losses.

scholarly journals Dose-dependent effects of inhaled corticosteroids on bone mineral density in postmenopausal women with asthma or COPD: A registry-based cohort study

2017 ◽  
Author(s):  
Wenjia Chen ◽  
Kate M. Johnson ◽  
J. Mark FitzGerald ◽  
Mohsen Sadatsafavi ◽  
William D. Leslie
Keyword(s):  
Bone Mineral Density ◽  
Lumbar Spine ◽  
Femoral Neck ◽  
Postmenopausal Women ◽  
Bone Mineral ◽  
Mineral Density ◽  
Cross Sectional ◽  
Total Hip ◽  
Hip Bmd ◽  
Sectional Analysis

ABSTRACTBackgroundThe effect of long-term inhaled corticosteroid (ICS) therapy on the bone health of older adults remains unclear due to its possible impact on bone mineral density (BMD).ObjectiveTo evaluate, cross-sectionally and longitudinally, the impact of ICS use on BMD in postmenopausal women with asthma or chronic obstructive pulmonary disease (COPD).MethodsWe used a population-based bone densitometry registry linked with administrative health data of the province of Manitoba, Canada (1999–2013), to identify women with diagnosed asthma or COPD. ICS use was defined as cumulative dispensed days prior to baseline BMD (cross-sectional analysis), and medication possession ratio (MPR) between two BMD measurements (longitudinal analysis). Results were adjusted for multiple covariates including the underlying respiratory diagnosis and its severity.ResultsIn the cross sectional analysis, compared with non-users, women with the highest tertile of prior ICS exposure had lower baseline BMD at the femoral neck (-0.09 standard deviations [SD] below a healthy young adult, 95% CI: −0.16, −0.02) and total hip (-0.14 SD, 95% CI: −0.22, −0.05), but not at the lumbar spine. Longitudinally, the highest tertile of ICS exposure was associated with a slight decline in total hip BMD relative to non-users (-0.02 SD/year, 95% CI: −0.04, −0.01), with no significant effect at the femoral neck and lumbar spine. Middle and lower tertiles of ICS use had no significant effects.ConclusionHigh exposure to ICS was associated with a small adverse effect on baseline hip BMD and total hip BMD loss in post-menopausal women with asthma or COPD.

scholarly journals Effects of Teriparatide in Postmenopausal Women with Osteoporosis on Prior Alendronate or Raloxifene: Differences between Stopping and Continuing the Antiresorptive Agent

2009 ◽  
Vol 94 (10) ◽  
pp. 3772-3780 ◽  
Author(s):  
Felicia Cosman ◽  
Robert A. Wermers ◽  
Christopher Recknor ◽  
Karen F. Mauck ◽  
Li Xie ◽  
...  
Keyword(s):  
Bone Mineral Density ◽  
Lumbar Spine ◽  
Femoral Neck ◽  
Bone Turnover ◽  
Postmenopausal Women ◽  
Bone Mineral ◽  
Mineral Density ◽  
Total Hip ◽  
Hip Bmd ◽  
Switch Group

Objective: The aim of the study was to assess adding vs. switching to teriparatide 20μg/d in patients on alendronate or raloxifene. Design: We conducted a randomized, open-label trial. Patients and Interventions: Postmenopausal women with osteoporosis on alendronate or raloxifene for at least 18 months added teriparatide (Add groups) or switched to teriparatide (Switch groups) for 18 months. Main Outcome Measures: We measured bone turnover markers (BTM) and bone mineral density (BMD). Results: In the alendronate stratum, increases in BTM were smaller in the Add vs. Switch group [6-month PINP (64 vs. 401%); bone ALP (15 vs. 71%); βCTX (27 vs. 250%); all P &lt; 0.001]. However, at 6 months, total hip BMD increased more in the Add vs. Switch group (1.4 vs. −0.8%; P = 0.002). In the Add vs. Switch group, 18-month BMD increments were higher in lumbar spine (8.4 vs. 4.8%; P = 0.003) and total hip (3.2 vs. 0.9%; P = 0.02), but not in femoral neck (2.7 vs. 2.3%; P = 0.75). In the raloxifene stratum, increases in BTM were also smaller in the Add vs. Switch group [6-month PINP (131 vs. 259%; P &lt; 0.001), bone ALP (31 vs. 44%; P = 0.035), and βCTX (67 vs. 144%; P = 0.001)]. At 6 months, total hip BMD increase was greater in the Add vs. Switch group (1.8 vs. 0.5%; P = 0.028). At 18 months, increases in lumbar spine (9.2 vs. 8.1%), total hip (2.8 vs. 1.8%), and femoral neck (3.8 vs. 2.2%) were not significantly different between groups. Conclusions: In women with osteoporosis treated with antiresorptives, greater bone turnover increases were achieved by switching to teriparatide, whereas greater BMD increases were achieved by adding teriparatide. In patients treated with alendronate or raloxifene, adding teriparatide results in a greater bone mineral density response, and appears to be at least as safe as switching to teriparatide.

scholarly journals Effect of once-daily fluticasone furoate/vilanterol versus vilanterol alone on bone mineral density in patients with COPD: a randomized, controlled trial

2020 ◽  
Vol 14 ◽  
pp. 175346662096514
Author(s):  
Francois Maltais ◽  
Isabelle Schenkenberger ◽  
Pascal L. M. L. Wielders ◽  
Juan Ortiz de Saracho ◽  
Kenneth Chinsky ◽  
...  
Keyword(s):  
Bone Mineral Density ◽  
Lumbar Spine ◽  
Bone Mineral ◽  
Smoking History ◽  
Mineral Density ◽  
Fluticasone Furoate ◽  
Treatment Difference ◽  
Total Hip ◽  
Copd Exacerbations ◽  
Hip Bmd

Background: The relationship between inhaled corticosteroids and bone mineral density (BMD) remains uncertain despite extensive research. Methods: This was an international, multicenter, randomized, double-blind, parallel-group, 3-year noninferiority study. Patients with chronic obstructive pulmonary disease (COPD) (⩾40 years of age; smoking history ⩾10 pack years) and at least one native hip evaluable for BMD were enrolled and randomized 1:1, stratified by sex, to treatment with vilanterol (VI) 25 µg or fluticasone furoate/vilanterol (FF/VI) 100 µg/25 µg. BMD measurements were taken via dual-energy X-ray absorptiometry every 6 months. The primary endpoint was assessment of the noninferiority of change from baseline in total hip BMD per year at the −1% noninferiority level. Change from baseline in BMD at the lumbar spine and BMD measurements by sex were secondary endpoints. Incidences of COPD exacerbations and bone fractures throughout the study were also recorded. Results: Of 283 randomized patients, 170 (60%) completed the study. Noninferiority was demonstrated for FF/VI versus VI with regards to change from baseline in total hip BMD per year, with changes of −0.27% and 0.18%, respectively, and a treatment difference of −0.46% per year [95% confidence interval (CI) −0.97 to 0.06]. The treatment difference for FF/VI versus VI regarding lumbar spine BMD was −0.51% per year (95% CI −1.11 to 0.10). COPD exacerbations and bone fracture rates were similar between treatment groups. Conclusion: FF/VI showed noninferiority to VI for change from baseline in total hip BMD per year, when assessed at the −1% noninferiority margin in a combined sample of men and women with COPD. The reviews of this paper are available via the supplemental material section.

scholarly journals POS0519 BONE MINERAL DENSITY, LEAN AND FAT MASS IN POSTMENOPAUSAL WOMEN WITH RHEUMATOID ARTHRITIS

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 493.2-493
Author(s):  
N. Toroptsova ◽  
O. Dobrovolskaya ◽  
A. Feklistov ◽  
O. Nikitinskaya ◽  
A. Efremova ◽  
...  
Keyword(s):  
Bone Mineral Density ◽  
Body Composition ◽  
Femoral Neck ◽  
Postmenopausal Women ◽  
Bone Mineral ◽  
Fat Mass ◽  
Multivariate Linear Regression Analysis ◽  
Mineral Density ◽  
Total Hip ◽  
The Relationship

Background:The relationship between lean mass (LM), fat mass (FM) and bone mineral density (BMD) remains controversial. Some population studies have emphasized the positive association between them, while others have found an inverse relationship. RA patients are characterized by a decrease in muscle mass and an increase in fat mass. Such changes in body composition may be associated with low BMD.Objectives:To study the relationship between BMD, LM and FM in postmenopausal women with RA.Methods:68 postmenopausal women with RA (median age 59 [54; 63] years) were included in the study. BMD and body composition were evaluated using two-energy X-ray absorptiometry. Correlation analysis between body composition parameters and BMD was performed with the Spearman method, correlation coefficients R for p<0.05 are presented.Results:The average L1-L4 BMD was 0,92±0,16 g/cm2, total hip BMD - 0,84±0,15 g/cm2 and femoral neck - 0,73±0,13 g/cm2. 33 (48.5%) women had osteopenia, and 17 (25.0%) - osteoporosis (OP). Low appendicular LM was found in 5 (7.4%) and low appendicular muscle index (appendicular LM/height2, AMI) – in 10 (14.7%) patients. Overfat was revealed in 47 (69.1%) women, but only 20 (29.4%) women had BMI corresponding to obesity. The positive correlations between BMD in L1-L4, total hip and femoral neck regions and body weight (R=0.46, R=0.56 and R=0.50, respectively), trunk fat (R=0.4, R=0.51 and R=0.37, respectively), total FM (R=0.27, R=0.43 and R=0.34, respectively), trunk LM (R=0.55, R=0.54 and R=0.51, respectively), total LM (R=0.51, R=0.50 and R=0.52, respectively), appendicular LM (R=0.31, R=0.29 and R=0.37, respectively) and AMI (R=0.26, R=0.33 and R=0.51, respectively) were found out. In the multivariate linear regression analysis total LM was associated with BMD of lumbar spine (β=0.638, p=0.001) and total hip (β=0.473, p=0.008), and AMI - with femoral neck BMD (β=0.360; p=0.014). We found that FM hadn’t a significant effect on BMD in any region.Conclusion:73.5% of patients with RA had a reduced BMD, and 14.7% women – low AMI. LM was positively associated with BMDs in different regions of interest, but FM had no effect on BMD. Further researches are needed to identify associations between body composition, inflammatory activity and bone health in patients with RA.Disclosure of Interests:None declared

scholarly journals Bone mineral density and hip structural analysis in type 1 diabetic men

2007 ◽  
Vol 156 (1) ◽  
pp. 123-127 ◽  
Author(s):  
Tomasz Miazgowski ◽  
Slawomir Pynka ◽  
Marzena Noworyta-Ziętara ◽  
Barbara Krzyzanowska-Świniarska ◽  
Robert Pikul
Keyword(s):  
Bone Mineral Density ◽  
Lumbar Spine ◽  
Metabolic Control ◽  
Bone Mineral ◽  
Microvascular Complications ◽  
Mineral Density ◽  
Hip Strength ◽  
Total Hip ◽  
Hip Bmd

Objective: The risk of non-vertebral fractures is increased in men with type 1 diabetes (DM1) but studies have shown only moderately decreased or normal bone mineral density (BMD) in these patients. No previous studies have evaluated hip strength and geometry indices in DM1 patients. This study was therefore designed to characterize associations between BMD, dual X-ray absorptiometry (DXA)-based hip strength indices, metabolic control, and DM1chronic complications. Design and methods: The study was performed on 36 males aged 43.6 ± 5.1 years with long-lasting DM1 and 36 healthy males matched for age, weight, and height. BMD in lumbar spine, total hip, upper and lower part of the femoral neck, hip axis length, cross-sectional area and moment of inertia (CSMI), and glycated hemoglobin (HbA1c) were measured. Results: DM1 men had decreased spine BMD (P < 0.05) and normal total hip BMD in comparison with controls. Hip geometry and strength indices were comparable in both groups. However, M1 men had decreased CSMI and upper femur BMD but these differences did not reach statistical significance (P = 0.06). BMD changes and hip strength parameters did not correlate with HbA1c. Conclusions: Middle-aged DM1 men have decreased lumbar spine BMD, normal hip BMD and normal hip strength indices. These changes are not influenced by metabolic control and presence of chronic microvascular complications.

scholarly journals Preoperative and Postoperative Bone Mineral Density Change and Risk Factor Analysis in Patients with a GH-Secreting Pituitary Adenoma

2019 ◽  
Vol 2019 ◽  
pp. 1-8
Author(s):  
Li’nan Qin ◽  
Xiaopeng Guo ◽  
Lu Gao ◽  
Zihao Wang ◽  
Chenzhe Feng ◽  
...  
Keyword(s):  
Bone Mineral Density ◽  
Risk Factor ◽  
Lumbar Spine ◽  
Femoral Neck ◽  
Bone Mineral ◽  
Pituitary Adenomas ◽  
Disease Duration ◽  
Femoral Shaft ◽  
Mineral Density ◽  
Total Hip

Purpose. This study analysed changes in bone mineral density (BMD) at different sites in patients with acromegaly and postoperative BMD changes and explored risk factors associated with BMD. Methods. Clinical data of 39 patients with growth hormone- (GH-) secreting pituitary adenomas and 29 patients with nonfunctioning pituitary adenomas who were newly diagnosed in neurosurgery from January 2016 to December 2018 were retrospectively analysed, including measurements of preoperative and postoperative BMD, serum GH glucose inhibition, random GH and IGF-1, and other anterior pituitary hormones. Results. The average patient age and disease duration were 43.74 (33.41–54.07) years and 72.15 (22.82–121.48) months, respectively. Compared with patients with nonfunctioning adenomas, patients with GH-secreting pituitary adenomas had significantly higher BMDs at L1, L2, femoral neck, Ward triangle, trochanter, femoral shaft, and total hip sites (p<0.05). The BMD Z score at L1 and femoral neck sites significantly increased (p<0.05). Thirteen patients underwent re-examination of BMD 1 year postsurgery, and the BMD Z score was reduced to normal levels at L1, L2, L3, L4, L1-L4, and L2-L4 compared with preoperative levels (p<0.05). Postoperative BMD Z scores in the femoral neck and total hip were significantly increased (p<0.05). Disease duration was negatively correlated with the lumbar-spine BMD Z score. IGF-1 burden was negatively correlated with the BMD Z score at L1 and L1–L4. Multiple regression analysis showed that IGF-1 burden was a risk factor for a BMD Z score decrease at L1 and L1–L4. Conclusion. BMD in patients with GH-secreting pituitary adenomas (compared with nonfunctional adenomas) increased at L1, L2, femoral neck, Ward triangle, trochanter, femoral shaft, and total hip sites. Lumbar-spine BMD Z score recovered to normal levels postsurgically when GH and IGF-1 levels were controlled. BMD Z score was negatively correlated with disease duration and IGF-1 burden in patients with GH-secreting pituitary adenomas, and IGF-1 burden was an independent risk factor for reduced lumbar-spine BMD Z score.

scholarly journals Bone Mineral Density in Adults With Cerebral Palsy

2021 ◽  
Vol 12 ◽  
Author(s):  
Jun Hee Won ◽  
Se Hee Jung
Keyword(s):  
Bone Mineral Density ◽  
Cerebral Palsy ◽  
Lumbar Spine ◽  
Femoral Neck ◽  
Motor Function ◽  
Bone Mineral ◽  
Fat Mass ◽  
Mineral Density ◽  
Male Sex ◽  
Total Fat

Low bone mineral density (BMD) is an emerging health issue in adults with cerebral palsy (CP). This cross-sectional study aimed to describe the characteristics of BMD in adults with CP, and to elucidate the risk factors for low BMD in this population. People aged ≥20 years and diagnosed with CP were recruited from February 2014 to November 2014. We assessed BMD using dual-energy X-ray absorptiometry (DXA) for the lumbar spine, femoral neck, and total femur. Moreover, the body composition was assessed using DXA. We included a total of 87 adults with CP (mean age 42.01 years; 52 men). The prevalence of low BMD was 25.3%. Male sex and age were associated with lower BMD. BMD was significantly lower in the non-ambulatory group than that in the ambulatory group for both lumbar spine and femoral neck. The total fat mass demonstrated a positive correlation with the Z-score and BMD for the femur neck and total femur. Body mass index (BMI) and total fat mass were positively correlated with BMD in the lumbar spine, femoral neck, and total femur. However, the Gross Motor Function Classification Scale levels were negatively correlated with BMD at the aforementioned three sites. In conclusion, adults with CP revealed decreased BMD, which was associated with male sex, age, decreased gross motor function, loss of ambulatory function, low BMI, decreased total fat mass, and decreased total fat-free mass.

scholarly journals Negative Association Between Serum Perfluorooctane Sulfate Concentration and Bone Mineral Density in US Premenopausal Women: NHANES, 2005–2008

2014 ◽  
Vol 99 (6) ◽  
pp. 2173-2180 ◽  
Author(s):  
Lian-Yu Lin ◽  
Li-Li Wen ◽  
Ta-Chen Su ◽  
Pau-Chung Chen ◽  
Chien-Yu Lin
Keyword(s):  
Bone Mineral Density ◽  
Lumbar Spine ◽  
Bone Mineral ◽  
Biological Significance ◽  
Chemical Exposure ◽  
Mineral Density ◽  
Pfos Concentration ◽  
Total Hip ◽  
Hip Bmd ◽  
The Relationship

Context: Perfluorooctanoic acid (PFOA) and perfluorooctane sulfate (PFOS) are used in a variety of products worldwide. However, the relationship among serum PFOA, PFOS concentration, bone mineral density (BMD), and the risk of fractures has never been addressed. Objectives: The study examined the association among serum PFOA, PFOS concentration, and lumbar spine and total hip BMD in the general US population. Design and Participants: We analyzed data on 2339 adults (aged ≧20 y) from the National Health and Nutrition Examination Survey conducted in 2005–2006 and 2007–2008 to determine the relationship among serum PFOA, PFOS concentration, and total lumbar spine and total hip BMD measured by dual-energy x-ray absorptiometry and history of fractures cross-sectionally. Results: After weighting for sampling strategy, a 1-U increase in the natural log-transformed serum PFOS level was associated with a decrease in total lumbar spine BMD by 0.022 g/cm2 (95% confidence interval −0.038, −0.007; P = .006) in women not in menopause. There was no association among PFOA, PFOS concentration, and self-reported fracture in adults. Conclusion: Serum PFOS concentration is associated with decreased total lumbar spine BMD in women not in menopause. However, the potential biological significance of this effect is marginal and subclinical in the general US population. Further studies are warranted to clarify the causal relationship between perfluorinated chemical exposure and BMD.

scholarly journals Positive Effect of Teriparatide on Areal Bone Mineral Density in Young Women with Anorexia Nervosa: A Pilot Study

2021 ◽  
Author(s):  
Gabriella Milos ◽  
Hanspeter Moergeli ◽  
Cynthia Sob ◽  
Doris Wisler ◽  
Mariusz Wasila ◽  
...  
Keyword(s):  
Bone Mineral Density ◽  
Anorexia Nervosa ◽  
Lumbar Spine ◽  
Pilot Study ◽  
Femoral Neck ◽  
Bone Mineral ◽  
Young Women ◽  
Fragility Fracture ◽  
Mineral Density ◽  
Total Hip

AbstractThe present pilot study investigated the effect of Teriparatide 1–34 rh-PTH (TPT) in young women diagnosed with anorexia nervosa (AN), and markedly compromised Bone Mineral Density (BMD). Patients were included who had (i) very low BMD (defined as Z-Score <  − 2.5 or T-Score <  − 2.5 if available) in at least one of the assessed localizations (lumbar spine L1–L4, total hip, femoral neck) without any previous fragility fracture; or (ii) low bone mineral density (defined as Z-Score <  − 1.5 or T-Score <  − 1.5 if available) in at least one of the assessed localizations (lumbar spine L1–L4, total hip, femoral neck) and at least one previous fragility fracture. Ten patients with an age range of 21–33 were recruited and their bone outcome was assessed after 12, 18, and 24 months. After 24 months of TPT treatment, BMD improved by 13.5% in the spine, 5.0% in the femoral neck, and 4.0% in the hip. Radius cortical bone density (− 2.6%) and radius cortical thickness (− 6.4%) decreased significantly, while in tibia there was no significant decrease. Neither in radius nor in tibia a significant change in trabecular bone parameters occurred. During the treatment, the patients’ body weight did not increase significantly. Patients did not experience severe adverse events; only mild side effects were observed. Although these results emerged from a single-arm prospective study, it seems that AN patients with a severely compromised bone situation can benefit from TPT. Larger studies are needed to ascertain the effect of this promising substance.

Effect of anastrozole on bone mineral density: 5-year results from the ’Arimidex’, Tamoxifen, Alone or in Combination (ATAC) trial

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 511-511 ◽  
Author(s):  
R. E. Coleman
Keyword(s):  
Bone Mineral Density ◽  
Lumbar Spine ◽  
Bone Loss ◽  
Bone Mineral ◽  
Treatment Effect ◽  
Mineral Density ◽  
Total Hip ◽  
Slowing Down ◽  
Significant Difference ◽  
Hip Bmd

511 Background: Since reporting the 1- and 2-year results from the ATAC trial bone sub-protocol, 68-month analysis results from the main ATAC trial have shown that, for postmenopausal women with invasive primary breast cancer, adjuvant treatment with anastrozole results in superior efficacy and tolerability compared with tamoxifen. Here we report 5-year bone mineral density (BMD) results from the monotherapy arms (anastrozole, n=81; tamoxifen, n=86) of the bone sub-protocol. Methods: Lumbar spine and total hip BMD were assessed by dual-energy X-ray absorptiometry at baseline and after 1, 2, and 5 years. Results: The median percentage changes in BMD at 1, 2, and 5 years, respectively, are shown in the table . Percentage changes in BMD from baseline to 5 years showed a statistically significant difference in favor of tamoxifen for both lumbar spine (treatment effect [percentage decrease of BMD on anastrozole relative to tamoxifen] −8.1; 95% confidence intervals [CI] −10.1, −6.1; p<0.0001) and total hip (treatment effect −7.4; 95% CI −9.6, −5.3; p<0.0001). For patients with data at baseline, 2, and 5 years, the rate of loss of lumbar spine BMD in the anastrozole group was significantly less from 2 to 5 years than from baseline to 2 years (mean difference in annual rate of change 0.0113, 95% CI 0.006, 0.017; p=0.0002), but there was no evidence of slowing down in the loss of total hip BMD. Five patients with osteopenia at baseline developed osteoporosis on treatment with anastrozole (4) or tamoxifen (1). No patients with normal BMD at baseline became osteoporotic at 5 years. Conclusions: Significant bone loss occurred throughout the 5 years in the anastrozole group, although there appeared to be a slowing down of the rate of bone loss in years 2–5. Although no patients with normal BMD at baseline had become osteoporotic at 5 years, regular monitoring of BMD and bone protection strategies are likely to be required in patients receiving anastrozole in the presence of pre-existing osteopenia. [Table: see text] [Table: see text]

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