scholarly journals The association between benzodiazepine use and falls, and the impact of sleep quality on this association: data from the TILDA study

QJM ◽  
2019 ◽  
Vol 113 (1) ◽  
pp. 31-36
Author(s):  
L Marron ◽  
R Segurado ◽  
R A Kenny ◽  
T McNicholas
Keyword(s):  
Older Adults ◽  
Sleep Quality ◽  
Community Dwelling ◽  
Public Health Issue ◽  
P Value ◽  
Poor Sleep ◽  
Daytime Somnolence ◽  
Cross Sectional ◽  
Falling Asleep ◽  
The Impact

Summary Background Benzodiazepines (BZD) are associated with adverse effects, particularly in older adults. Aim This study assesses the association between BZD use and falls, and the impact of sleep quality on this association, in community dwelling adults aged over 50. Design Cross-sectional analysis of data from wave 1 of The Irish Longitudinal Study on Ageing. Methods Participants were classed as BZD users or non-users and asked if they had fallen in the last year, and whether any falls were unexplained. Sleep quality was assessed via self-reported trouble falling asleep, daytime somnolence and early-rising. Logistic regression assessed for an association between BZD use and falls, and the impact of sleep quality on this association was assessed by categorizing based on BZD use and sleep quality variables. Results Of 8175 individuals, 302 (3.69%) reported taking BZDs. BZD use was associated with falls, controlling for confounders [Odds Ratio (OR) 1.40; 1.08, 1.82; P-value 0.012]. There was no significant association between BZDs and unexplained falls, controlling for confounders [OR 1.41; 95% Confidence Interval (CI) 0.95, 2.10; P-value 0.09]. Participants who use BZDs and report daytime somnolence (OR 1.93; 95% CI 1.12, 3.31; P-value 0.017), early-rising (OR 1.93; 95% CI 1.20, 3.11; P-value 0.007) or trouble falling asleep (OR 1.83; 95% CI 1.12, 2.97; P-value 0.015), have an increased odds of unexplained falls. Conclusion BZD use is associated with falls, with larger effect size in those reporting poor sleep quality in community dwelling older adults. Appropriate prescription of medications such as BZDs is an important public health issue.

scholarly journals 342 The Association Between Benzodiazepine Use and Falls, and the Impact of Sleep Quality on this Association: Data from TILDA

2019 ◽  
Vol 48 (Supplement_3) ◽  
pp. iii17-iii65
Author(s):  
Louise Marron ◽  
Ricardo Segurado ◽  
Paul Claffey ◽  
Rose Anne Kenny ◽  
Triona McNicholas
Keyword(s):  
Older Adults ◽  
Sleep Quality ◽  
Effect Size ◽  
Community Dwelling ◽  
Public Health Issue ◽  
P Value ◽  
Poor Sleep ◽  
Daytime Somnolence ◽  
Falling Asleep ◽  
The Impact

Abstract Background Benzodiazepines (BZD) are associated with adverse effects, particularly in older adults. Previous research has shown an association between BZDs and falls and BZDs have been shown to impact sleep quality. The aim of this study is to assess the association between BZD use and falls, and the impact of sleep quality on this association, in community dwelling adults aged over 50. Methods Data from the first wave of The Irish Longitudinal Study on Ageing were used. Participants were classed as BZD users or non-users and asked if they had fallen in the last year, and whether any of these falls were unexplained. Sleep quality was assessed via self-reported trouble falling asleep, daytime somnolence, and early-rising. Logistic regression assessed for an association between BZD use and falls, and the impact of sleep quality on this association was assessed by categorising based on BZD use and each sleep quality variable. Results Of 8,175 individuals, 302 (3.69%) reported taking BZDs. BZD use was associated with falls, controlling for con-founders (OR 1.40; 1.08, 1.82; p-value 0.012). There was no significant association between BZDs and unexplained falls, controlling for con-founders (OR 1.41; 95% CI 0.95, 2.10; p-value 0.09), however a similar effect size to all falls was evident. Participants who take BZDs and report daytime somnolence (OR 1.93; 95% CI 1.12, 3.31; p-value 0.017), early-rising (OR 1.93; 95% CI 1.20, 3.11; p-value 0.007) or trouble falling asleep (OR 1.83; 95% CI 1.12, 2.97; p-value 0.015), have an increased odds of unexplained falls. Conclusion BZD use is associated with falls, with larger effect size in BZD users reporting poor sleep quality in community dwelling older adults. Appropriate prescription of and regular review of medications such as BZDs is an important public health issue.

scholarly journals Sleep quality and chronic pain in community dwelling older adults: preliminary results

2020 ◽  
Vol 18 ◽  
pp. 1-7
Author(s):  
Celuane Oliveira Silva ◽  
Glaudson Sá Brandão ◽  
Maria Eduarda Moreira Lino ◽  
Adriano L. Fonseca ◽  
Marcos Mota Silva ◽  
...  
Keyword(s):  
Older Adults ◽  
Chronic Pain ◽  
Sleep Quality ◽  
Older People ◽  
Cross Sectional Study ◽  
Pain Scale ◽  
Community Dwelling ◽  
Poor Sleep ◽  
Cross Sectional ◽  
Student’S T

Background: The natural process of human aging causes biopsychosocial alterations, which can trigger chronic pain and poor sleep quality in older adults. Considering the high prevalence and possible association between these two clinical conditions, special attention from public health policies is necessary to provide quality aging. Objective: To verify if there is an association between chronic pain and sleep quality among older adults in the community. Methods: A quantitative, cross-sectional study on the association of chronic pain with the sleep quality among older people in the community. Participants were evaluated using the Pittsburgh Sleep Quality Index (PSQI); Visual Analog Pain scale; questionnaires of sociodemographic and clinical data, assessment of cognitive impairment through the Mini Mental State Examination, and anthropometric assessments. The data were submitted to descriptive statistics. The means between the groups of older people with and without chronic pain were compared using the Student's t test for independent samples and Pearson's correlation coefficient (r) was used to analyze the association of PSQI with pain intensity. Results: In total, 51 older women were included, with a mean age of 70 ± 8 years. The majority had a low level of education (52.9%), low financial income (64.7%), and chronic pain (56.9%). It was found that the older adults with chronic pain presented worse sleep quality when compared those without chronic pain and a moderate (r=0.595) and significant (p<0.01) correlation between sleep quality and the intensity of chronic pain was observed. Conclusion: Older adults in the community with chronic pain present worse sleep quality when compared to the older adults without pain. There is a strong correlation between the intensity of chronic pain and sleep quality in older adults; the greater the intensity of pain, the worse the sleep quality. Trial Registration: Registro Brasileiro de Ensaios Clínicos (REBEC) Identifier: RBR-3cqzfy  

scholarly journals POS1465-HPR THE RELATIONSHIP BETWEEN SEDENTARY BEHAVIOR AND SLEEP IN RHEUMATOID ARTHRITIS: A CROSS-SECTIONAL STUDY

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 1017.2-1018
Author(s):  
N. Kelly ◽  
E. Hawkins ◽  
H. O’leary ◽  
K. Quinn ◽  
G. Murphy ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Physical Activity ◽  
Sleep Quality ◽  
Sedentary Behavior ◽  
Disease Duration ◽  
Cross Sectional Study ◽  
P Value ◽  
Poor Sleep ◽  
Cross Sectional ◽  
The Relationship

Background:Rheumatoid arthritis (RA) is a chronic, autoimmune inflammatory condition that affects 0.5% of the adult population worldwide (1). Sedentary behavior (SB) is any waking behavior characterized by an energy expenditure of ≤1.5 METs (metabolic equivalent) and a sitting or reclining posture, e.g. computer use (2) and has a negative impact on health in the RA population (3). Sleep is an important health behavior, but sleep quality is an issue for people living with RA (4, 5). Poor sleep quality is associated with low levels of physical activity in RA (4) however the association between SB and sleep in people who have RA has not been examined previously.Objectives:The aim of this study was to investigate the relationship between SB and sleep in people who have RA.Methods:A cross-sectional study was conducted. Patients were recruited from rheumatology clinics in a large acute public hospital serving a mix of urban and rural populations. Inclusion criteria were diagnosis of RA by a rheumatologist according to the American College of Rheumatology criteria age ≥ 18 and ≤ 80 years; ability to mobilize independently or aided by a stick; and to understand written and spoken English. Demographic data on age, gender, disease duration and medication were recorded. Pain and fatigue were measured by the Visual Analogue Scale (VAS), anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS), and sleep quality was assessed using the Pittsburgh Sleep Quality Index. SB was measured using the ActivPAL4™ activity monitor, over a 7-day wear period. Descriptive statistics were calculated to describe participant characteristics. Relationships between clinical characteristics and SB were examined using Pearson’s correlation coefficients and regression analyses.Results:N=76 participants enrolled in the study with valid data provided by N=72 participants. Mean age of participants was 61.5years (SD10.6) and the majority 63% (n = 47) were female. Participant mean disease duration was 17.8years (SD10.9). Mean SB time was 533.7 (SD100.1) minutes (8.9 hours per day/59.9% of waking hours). Mean sleep quality score was 7.2 (SD5.0) (Table 1). Correlation analysis and regression analysis found no significant correlation between sleep quality and SB variables. Regression analysis demonstrated positive statistical associations for SB time and body mass index (p-value=0.03846, R2 = 0.05143), SB time and pain VAS (p-value=0.009261, R2 = 0.07987), SB time and HADS (p-value = 0.009721, R2 = 0.08097) and SB time and HADSD (p-value = 0.01932, R2 = 0.0643).Conclusion:We found high levels of sedentary behavior and poor sleep quality in people who have RA, however no statistically significant relationship was found in this study. Future research should further explore the complex associations between sedentary behavior and sleep quality in people who have RA.References:[1]Carmona L, et al. Rheumatoid arthritis. Best Pract Res Clin Rheumatol 2010;24:733–745.[2]Anon. Letter to the editor: standardized use of the terms “sedentary” and “sedentary behaviours”. Appl Physiol Nutr Metab = Physiol Appl Nutr Metab 2012;37:540–542.[3]Fenton, S.A.M. et al. Sedentary behaviour is associated with increased long-term cardiovascular risk in patients with rheumatoid arthritis independently of moderate-to-vigorous physical activity. BMC Musculoskelet Disord 18, 131 (2017).[4]McKenna S, et al. Sleep and physical activity: a cross-sectional objective profile of people with rheumatoid arthritis. Rheumatol Int. 2018 May;38(5):845-853.[5]Grabovac, I., et al. 2018. Sleep quality in patients with rheumatoid arthritis and associations with pain, disability, disease duration, and activity. Journal of clinical medicine, 7(10)336.Table 1.Sleep quality in people who have RASleep variableBed Time N(%) before 10pm13(18%) 10pm-12pm43 (60%) after 12pm16 (22%)Hours Sleep mean(SD)6.56 (1.54)Fall Asleep minutes mean(SD)33.3(27.7)Night Waking N(%)45(63%)Self-Rate Sleep mean(SD)2.74 (0.90)Hours Sleep mean(SD)6.56 (1.54)Disclosure of Interests:None declared

scholarly journals Assessing the Impact of a Hilly Environment on Depressive Symptoms among Community-Dwelling Older Adults in Japan: A Cross-Sectional Study

2021 ◽  
Vol 18 (9) ◽  
pp. 4520
Author(s):  
Takafumi Abe ◽  
Kenta Okuyama ◽  
Tsuyoshi Hamano ◽  
Miwako Takeda ◽  
Masayuki Yamasaki ◽  
...  
Keyword(s):  
Older Adults ◽  
Depressive Symptoms ◽  
Depression Scale ◽  
Cross Sectional Study ◽  
Community Dwelling ◽  
Rural Setting ◽  
Sectional Study ◽  
Cross Sectional ◽  
The Impact ◽  
Community Dwelling Older Adults

Although some neighborhood environmental factors have been found to affect depressive symptoms, few studies have focused on the impact of living in a hilly environment, i.e., land slope, on depressive symptoms among rural older adults. This cross-sectional study aimed to investigate whether a land slope is associated with depressive symptoms among older adults living in rural areas. Data were collected from 935 participants, aged 65 years and older, who lived in Shimane prefecture, Japan. Depressive symptoms were assessed using the Zung Self-Rating Depression Scale (SDS) and defined on the basis of an SDS score ≥ 40. Land slopes within a 400 m network buffer were assessed using geographic information systems. Odds ratios (ORs) with 95% confidence intervals (CIs) of depressive symptoms were estimated using logistic regression. A total of 215 (23.0%) participants reported depressive symptoms. The land slope was positively associated with depressive symptoms (OR = 1.04; 95% CI = 1.01–1.08) after adjusting for all confounders. In a rural setting, living in a hillier environment was associated with depressive symptoms among community-dwelling older adults in Japan.

The Effect of Shift Fluctuations on Sleep Quality among Nurses Working in the Emergency Room in Amman, Jordan

2020 ◽  
Vol 10 (1) ◽  
pp. 11-17
Author(s):  
Khaled Suleiman ◽  
Tarek Al-Khaleeb ◽  
Mahmoud Al-Kaladeh ◽  
Loai Abu Sharour
Keyword(s):  
Sleep Quality ◽  
Emergency Room ◽  
Work Performance ◽  
Poor Sleep ◽  
Emergency Rooms ◽  
Poor Sleep Quality ◽  
Cross Sectional ◽  
Public And Private ◽  
Work Related ◽  
The Impact

Introduction: Sleep Quality disturbances are common among nurses especially those working in stressful situations such as emergency room. Additionally, sleep quality disturbances were found to interfere with nurses’ quality of life and work performance. No studies have found the effect of fluctuated shifts on sleep quality among nurses. Objectives: To examine the impact of shift fluctuations on sleep quality among nurses working in the emergency room. Methods: A cross-sectional, descriptive design was employed. Five emergency rooms were selected from public and private hospitals located in Amman, Jordan. The selected hospitals were also referral sites with capacity of more than 200 beds. A convenient sample of nurses who had a minimum of six months experience in the emergency room and working on rotating shifts were eligible for participation. Nurses with known chronic respiratory problems and sleep apnea were excluded. A self-administered questionnaire including a demographic and work-related questions, and the Arabic version of the Pittsburgh Sleep Quality Index were provided. Shift fluctuations were clustered based on interchanging between morning, evening and night shifts. Results: A total of 179 emergency nurses working in rotating shifts participated in the study. The majority of the nurses were poor sleepers. The study found no significant differences between different shifts interchange and sleep quality. However, interchange between morning and evening shift reported the highest sleep disturbance. Sleep quality was positively correlated with the length of experience, while negatively correlated with the age and the number of monthly shifts. Nurses who declared higher satisfaction and ability to work under pressure revealed better sleep quality. Conclusion: Emergency room nurses showed poor sleep quality. While there was no specific shift interchange cluster inducing poor sleep quality, some demographical and work-related characteristics indicated their influence on sleep quality.

scholarly journals Sleep and Olfaction among Older Adults

2017 ◽  
Vol 48 (3-4) ◽  
pp. 147-154 ◽  
Author(s):  
V. Eloesa McSorley ◽  
Jayant Pinto ◽  
L. Philip Schumm ◽  
Kristen Wroblewski ◽  
David Kern ◽  
...  
Keyword(s):  
Older Adults ◽  
Sleep Quality ◽  
Structural Equation Models ◽  
Sleep Problems ◽  
Community Dwelling ◽  
Odor Identification ◽  
Self Report ◽  
Poor Sleep ◽  
Wrist Actigraphy ◽  
Odor Sensitivity

Background: Sleep and olfaction are both critical physiological processes that tend to worsen with age. Decline in olfaction can be an early indicator of neurodegenerative diseases, whereas poor sleep quality is associated with reduced physical and mental health. Given associations with aging-related health declines, we explored whether variations in sleep were associated with olfactory function among older adults. Methods: We assessed the relationship between sleep characteristics and olfaction among 354 community-dwelling older adults. Olfaction was measured using a validated field and survey research tool. Sleep characteristics were measured using wrist actigraphy and with self-report of sleep problems. We fit structural equation models of latent constructs of olfaction based on olfactory task items and let this be a function of each sleep characteristic. Results: Actigraph sleep quality measures were associated with odor identification, but not with odor sensitivity. Longer duration sleepers had worse odor sensitivity compared to medium (58 h) sleepers, but sleep duration was not associated with odor identification. Reported sleep problems and reported usual duration were not associated with olfaction. Conclusions: Diminished sleep quality was associated with reduced capacity to identify odors. Determining whether this is a causal association will require further study and longitudinal data.

scholarly journals Impact of covid19 lockdown on sleep quality and acute psychiatric morbidity in medical students in Sudan. 

2021 ◽  
Author(s):  
Albashir A. Altayeb ◽  
Batool A. altayeb ◽  
Mohammed E. Ibrahim ◽  
Amira Siddig Abdalgalil
Keyword(s):  
Medical Students ◽  
Sleep Quality ◽  
Negative Impact ◽  
Psychiatric Morbidity ◽  
Systematic Sampling ◽  
Poor Sleep ◽  
Cross Sectional ◽  
The Impact ◽  
Junior Students ◽  
Severe Anxiety

Abstract Introduction: The severe acute respiratory syndrome coronavirus-2 (SARS-COV-2) is an emerging infection causing a widely spread pandemic of Coronavirus disease 2019 (COVID-19). The current COVID-19 pandemic is promoting fear of falling sick, dying, helplessness, and stigma. Urgent and timely understanding of sleep quality and mental health status is needed to help the community. Our investigation designed to assess the degree of sleep disturbance and psychological impact of the lockdown among medical students at university of Khartoum.Objectives: this study conducted to assess the impact of covid-19 lockdown on sleep quality and acute psychiatric morbidities among medical students at university of Khartoum.Method: Institutional based cross sectional study was conducted among 326 participants from Khartoum university, faculty of medicine. Study participants were determined by two steps, stratified sampling followed by systematic sampling techniques. Data was collected using standardized questionnaire, entered and analyzed using Statistical Package for Social Science (SPSS) software version 25.Results: out of the total 326 participants 211(64.7%0 were females, and 115(35.35) were males. 92 (28.2%) form the participants were good sleepers and 234 (71.8%) were poor sleepers, the prevalence of moderate to severe anxiety and depression in the participants was found 19.4%, 35.9% respectively. There was correlation between having poor sleep quality and depression among the participants.Conclusion: This study found that there is negative impact of the covid-19 lockdown on medical students, which we found that two thirds of the participants are poor sleepers with a predominance of the female gender among them, One third of the participants had moderate to severe depression which also affects the female more than the males and the junior students more than the seniors, Fifth of the participants had moderate to severe anxiety which affect both gender equally but it did affect the junior students more than the seniors.

scholarly journals SARCOPENIA AND SARCOPENIC OBESITY IN OLDER COMMUNITY-DWELLING ADULTS WITH FAVORABLE HEALTH CONDITIONS

2017 ◽  
pp. 1-6
Author(s):  
E. Ramírez-García ◽  
K. Moreno-Tamayo ◽  
S.C. Briseño-Fabian ◽  
S. Sánchez-García
Keyword(s):  
Older Adults ◽  
Muscle Mass ◽  
Community Dwelling ◽  
Health Conditions ◽  
Sarcopenic Obesity ◽  
P Value ◽  
Fat Percentage ◽  
Bioelectric Impedance Analysis ◽  
Cross Sectional ◽  
European Working

Objective: Determine the prevalence of sarcopenia and sarcopenic obesity in community-dwelling older adults with favorable health conditions using the diagnostic criteria from the European Working Group on Sarcopenia in Older People (EWGSOP). Design: Cross-sectional study. Setting/Participants: Including 197 older adults representing a population-based sample (n = 1,252) from baseline (year 2014) of the Cohort of Obesity, Sarcopenia and Frailty of Older Mexican Adults (COSFOMA). Measurements: Anthropometric and body composition measurements were performed using bioelectric impedance analysis (BIA). Walking speed was determined with walking time of 4.5 m (<0.8 m/s), grip strength with dynamometer (women <20 kg and men <30 kg) and muscle mass using BIA (muscle mass index: women <6.1 kg/m2 and men <8.5 kg/m2). The cutoff point for low muscle mass was set at 2 SD below average for a group of young adults. For obesity, body fat percentage >60th percentile was considered (38.4% female and 26.7% male). A p value <0.050 was considered statistically significant. Results: Mean age of the 197 older adults (44.2% female and 55.8% male) was 66.4 years (5.6): women 66.6 years (5.6) and men 66.4 years (5.8). The prevalence of sarcopenia was 7.1% (women 6.9% and men 7.2%). The presence of sarcopenic obesity was 2.5% (women 1.1% and men 3.6%). Conclusion: The magnitude of sarcopenia in older adults is important despite the absence of adverse health effects. This finding provides a reference point for future studies.

scholarly journals Sex differences in impact of sarcopenia on falls in community-dwelling Korean older adults

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Yunsoo Soh ◽  
Chang Won Won
Keyword(s):  
Older Adults ◽  
Sex Differences ◽  
Diagnostic Algorithm ◽  
Cross Sectional Study ◽  
Community Dwelling ◽  
Sectional Study ◽  
Cross Sectional ◽  
History Of ◽  
Adjusted Model ◽  
The Impact

Abstract Background Falls are one of the most serious health problems among older adults. Sarcopenia is characterized by a decrease in muscle mass, strength, and physical function. Due to potentially age-related conditions, both falls and sarcopenia have common risk factors. However, the association between sarcopenia and falls is controversial. Moreover, the sex differences in the impact of sarcopenia on falls is not yet clear. This study aimed to investigate the sex differences in the impact of sarcopenia, defined by the Asian Working Group for Sarcopenia (AWGS), on falls in Korean older adults. Methods In this cross-sectional study, we used data from the Korean Frailty and Aging Cohort Study; 2323 community-dwelling older adults (1111 males and 1212 females) aged 70–84 years were recruited in this cross-sectional study. To evaluate sarcopenia, the AWGS diagnostic algorithm was used. We compared the faller and non-faller groups. We performed unadjusted and fully adjusted logistic regression analyses to evaluate the relationship between sarcopenia, falls, and fall-related fractures. Results A total of 239 (24.1%) females in the faller group had a history of falls in the past year, which was statistically higher than that in males (176, 15.8%). In the fully adjusted model, handgrip strength (odds ratio [OR] = 1.508, 95% confidence interval [CI] = 1.028–2.211), and short physical performance battery (OR = 2.068, 95% CI = 1.308–3.271) were significantly lower in the male faller group. However, in the fully adjusted model, the female faller group only showed a significantly low appendicular skeletal muscle mass index (OR = 1.419, 95% CI = 1.058–1.903). Conclusions This large cohort study aimed to identify the sex differences in the incidence of sarcopenia in the older Korean population, using the AWGS diagnostic algorithm, and its correlation with falls and fall-related fractures. The incidence of falls did not increase in the sarcopenia group. Among the sarcopenia components, sex differences affect the history of falls. Therefore, when studying the risk of falls in old age, sex differences should be considered.

scholarly journals HUBUNGAN TINGKAT STRES DENGAN KUALITAS TIDUR PADA MAHASISWA AKHIR S1 KESEHATAN MASYARAKAT UNIVERSITAS PAHLAWAN TUANKU TAMBUSAI TAHUN 2021

2021 ◽  
Vol 5 (2) ◽  
pp. 963-968
Author(s):  
Zurrahmi Z.R ◽  
Sri Hardianti ◽  
Fitria Meiriza Syahasti
Keyword(s):  
Public Health ◽  
Sleep Quality ◽  
Undergraduate Students ◽  
Univariate Analysis ◽  
The Body ◽  
Bivariate Analysis ◽  
P Value ◽  
Cross Sectional ◽  
Stress Levels ◽  
The Impact

Sleep is a basic need for everyone. In conditions of rest and sleep, the body performs a recovery process to restore the body's stamina to be in optimal condition. The impact of lack of sleep causes a person to have difficulty concentrating, fatigue, headaches, feeling unwell, lazy, decreased memory, confusion, and has an impact on the ability to make decisions. The purpose of this study was to analyze the relationship between stress levels and sleep quality in the final undergraduate students of Public Health at Pahlawan Tuanku Tambusai University in 2021. This type of research was a descriptive correlation study with a Cross Sectional design. This research was conducted in July 2021.2020 with a sample of 60 final undergraduate students in Public Health, Tuanku Tambusai University, obtained using a total sampling technique. Data collection techniques using a questionnaire. Analysis of the data used is univariate analysis and bivariate analysis with Chi Square test. The results showed that there was a significant relationship between stress levels and sleep quality in final students with p value = 0.003. By conducting this research, researchers expect students to prevent stress that can affect sleep quality.

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