P15 Resuming antiplatelet and anticoagulant therapy following isolated traumatic brain injury in adults: a national survey and review of literature

2019 ◽  
Vol 90 (3) ◽  
pp. e29.3-e30
Author(s):  
T Valenzuela ◽  
D Fellows ◽  
M Zaben ◽  
D Shastin ◽  
P Leach
Keyword(s):  
Traumatic Brain Injury ◽  
Decision Making ◽  
Risk Factor ◽  
Online Survey ◽  
Clinical Problem ◽  
The Elderly ◽  
Review Of Literature ◽  
Intracranial Bleed ◽  
Intracranial Complications

ObjectivesAntithrombotics use in the elderly is widespread and is seen as a risk factor for intracranial complications following TBI. Antithrombotics are commonly discontinued on admission, with little guidance on when or how to restart them. This study aims to establish current national practices with restarting antithrombotic medications following TBI and review available evidence identifying areas for further research.DesignAn online survey and a literature review.SubjectsSBNS members.MethodsA SBNS Academic Committee approved survey with five TBI scenarios dealing with different antithrombotics. Respondents were asked to indicate when they would restart the medications for each scenario and what drives their decision.ResultsPreliminary results included responses from 22 consultants. The most common practice was to restart antithrombotics after two weeks; however, less than 50% agreed on each individual option. About 50% had the same approach to everything and 1/3 believed single antiplatelet can be resumed earlier than dual antiplatelets. Other deciding factors included size of intracranial bleed, patient’s neurological recovery, and follow up imaging. Some advocated involving the physicians. Final results following a repeat dissemination of the survey will be presented at the meeting.ConclusionsThere is obvious discrepancy in how the problem of restarting antithombotics following TBI is approached nationally. Further research is needed to help decision making with this everyday clinical problem.

scholarly journals A longitudinal study over 40 years to study the metabolic syndrome as a risk factor for cardiovascular diseases

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Lars Lind ◽  
Johan Sundström ◽  
Johan Ärnlöv ◽  
Ulf Risérus ◽  
Erik Lampa
Keyword(s):  
Metabolic Syndrome ◽  
Risk Factor ◽  
Longitudinal Study ◽  
Clinical Intervention ◽  
The Elderly ◽  
Adult Men ◽  
The Metabolic Syndrome ◽  
The Impact ◽  
Over 40 Years

AbstractThe impact of most, but not all, cardiovascular risk factors decline by age. We investigated how the metabolic syndrome (MetS) was related to cardiovascular disease (CVD) during 40 years follow-up in the Uppsala Longitudinal Study of Adult Men (ULSAM, 2,123 men all aged 50 at baseline with reinvestigations at age 60, 70, 77 and 82). The strength of MetS as a risk factor of incident combined end-point of three outcomes (CVD) declined with ageing, as well as for myocardial infarction, ischemic stroke and heart failure when analysed separately. For CVD, the risk ratio declined from 2.77 (95% CI 1.90–4.05) at age 50 to 1.30 (95% CI 1.05–1.60) at age 82. In conclusion, the strength of MetS as a risk factor of incident CVD declined with age. Since MetS was significantly related to incident CVD also at old age, our findings suggest that the occurrence of MetS in the elderly should not be regarded as innocent. However, since our data were derived in an observational study, any impact of MetS in the elderly needs to be verified in a randomized clinical intervention trial.

scholarly journals 315 Cardiac surgery in the elderly: the underestimate role of frailty in the decision making

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Pasquale Campana ◽  
Maddalena Conte ◽  
Maria Emiliana Palaia ◽  
Laura Petraglia ◽  
Adele Ferro ◽  
...  
Keyword(s):  
Decision Making ◽  
Cardiac Surgery ◽  
Nutritional Status ◽  
Elderly Patients ◽  
Frailty Index ◽  
The Elderly ◽  
Risk Scores ◽  
Surgical Risk ◽  
The Impact

Abstract Aims Elders represent the most common population with indication to cardiac surgery, also presenting the highest mortality/disability after interventions. Both for valve and coronary artery surgery the estimation of the surgical risk, including the frailty assessment, is recommended to guide the decision making. However, frailty results not exhaustively assessed by the commonly used surgical risk scores such as EuroSCORE I-II and score of the Society of Thoracic Surgeons and is mostly used the Kat’s Index (included in the latest European guidelines). This study aims at establishing the feasibility and the value of a Comprehensive Geriatric Assessment (CGA) in elderly undergoing cardiac surgery. Methods From June 2021we consecutively enrolled 50 elderly patients undergoing cardiac surgery (age > 65 years old). All patients underwent CGA with an expert geriatrician and the demographic, biometrics, clinical and echocardiographic data were collected. We evaluated frailty and disability (Kats index, Barthel Index and Frailty Index FI), cognitive status (Montreal Cognitive Assessment MOCA, Mini Mental State Examination MMSE and Geriatric Depression Scale), physical status (Tinetti test, Short Performance Physical Battery SPPB, Physical Activity Scale for the Elderly PASE and 6-min Walking test), delirium condition, sarcopenia and nutritional status (Mini-Nutritional Assessment MNA). A clinical, echocardiographic, and geriatric 3-month follow-up is planned. In particular, we are evaluating the impact of frailty, assessed by CGA, on peri-surgical outcome and the potential additive value of a CGA on the commonly used surgical risk-scores and Kat’s Index. Furthermore, we are assessing the impact of cardiac surgery of frail elderly at GCA. Results The CGA was feasible in all patients and lasted 1 h/patient. In our baseline data, only 23% of the enrolled patients resulted ‘frail’ according to Kat’s Index. However, in the remaining 77% of the study population, the CGA have identified 30% of patients with increased frailty index and 30% with disability, assessed by Barthel Index and physical function indexes (PASE and SPPB). In these patient, frailty and disability were associated to impaired nutritional status, assessed at MNA. Furthermore, 40% of the patients of this group resulted sarcopenic at the hand grip test. The cognitive valuation has shown a cognitive impairment in the 20% of patients at the MMSE and the 70 % at the MOCA. Of note, the 40% of the patients resulted to suffer of depression, not diagnosed before the GCA. At mid-November 2021 the follow-up will be completed. Conclusions The preliminary results of the presents study suggest that in patients undergoing cardiac surgery frailty is currently underdiagnosed. The follow-up analysis will establish if a CGA has an additive value on common surgical risk estimators. This study has a potential impact on the risk stratification of elderly patients undergoing invasive procedures and defines the need of a geriatrician in the heart team.

Antithrombotic agents and traumatic brain injury in the elderly population: hemorrhage patterns and outcomes

2020 ◽  
Vol 133 (2) ◽  
pp. 486-495 ◽  
Author(s):  
Pasquale Scotti ◽  
Chantal Séguin ◽  
Benjamin W. Y. Lo ◽  
Elaine de Guise ◽  
Jean-Marc Troquet ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Head Trauma ◽  
Ct Scanning ◽  
The Elderly ◽  
International Normalized Ratio ◽  
Trauma Patients ◽  
Risk Of Falls ◽  
Gcs Score

OBJECTIVEAmong the elderly, use of antithrombotics (ATs), antiplatelets (APs; aspirin, clopidogrel), and/or anticoagulants (ACs; warfarin, direct oral ACs [DOACs; dabigatran, rivaroxaban, apixaban]) to prevent thromboembolic events must be carefully weighed against the risk of intracranial hemorrhage (ICH) with trauma. The goal of this study was to assess the risk of sustaining a traumatic brain injury (TBI), ICH, and poorer outcomes in relation to AT use among all patients 65 years or older presenting to a single institution with head trauma.METHODSData were collected from all head trauma patients 65 years or older presenting to the authors’ supraregional tertiary trauma center over a 24-month period and included age, sex, injury mechanism, medical history, international normalized ratio, Glasgow Coma Scale (GCS) score, ICH presence and type, hospital admission, reversal therapy, surgery, discharge destination, Extended Glasgow Outcome Scale (GOSE) score at discharge, and mortality.RESULTSA total of 1365 head trauma patients 65 years or older were included; 724 were on AT therapy (413 on APs, 151 on ACs, 59 on DOACs, 48 on 2 APs, 38 on AP+AC, and 15 on AP+DOAC) and 641 were not. Among all head trauma patients, the risk of sustaining a TBI was associated with AP use after adjusting for covariates. Of the 731 TBI patients, those using ATs had higher rates of ICH (p <0.0001), functional dependency at discharge (GOSE score ≤ 4; p < 0.0001), and mortality (p < 0.0001). Elevated rates of ICH progression on follow-up CT scanning were observed in patients in the warfarin monotherapy (OR 5.30, p < 0.0001) and warfarin + AP (OR 6.15, p = 0.0011). Risk of mortality was not associated with single antiplatelet use but was notably high with 2 APs (OR 4.66, p = 0.0056), warfarin (OR 5.18, p = 0.0003), and DOAC use (OR 5.09, p = 0.0149).CONCLUSIONSElderly trauma patients on ATs, especially combination therapy, are at elevated risk of ICH and poor outcomes compared with those not on AT therapy. While both AP and warfarin use alone and in combination were associated with significantly elevated odds of sustaining an ICH among TBI patients, only warfarin use was a predictor of hemorrhage progression on follow-up scans. The use of a single AP was not associated with mortality; however, the combination of both aspirin and clopidogrel was. Warfarin and DOAC users had comparable mortality rates; however, DOAC users had lower rates of ICH progression, and fewer survivors were functionally dependent at discharge than were warfarin users. DOACs are an overall safer alternative to warfarin for patients at high risk of falls.

Patient involvement in multidisciplinary treatment planning (MTP).

2013 ◽  
Vol 31 (31_suppl) ◽  
pp. 145-145
Author(s):  
Irene Prabhu Das ◽  
Heather Rozjabek ◽  
Mary L. Fennell ◽  
Katherine Mallin ◽  
E. Greer Gay ◽  
...  
Keyword(s):  
Decision Making ◽  
Online Survey ◽  
Patient Involvement ◽  
Treatment Plan ◽  
Multidisciplinary Treatment ◽  
Treatment Decision ◽  
Case Presentation ◽  
Patient Navigators ◽  
Treatment Decision Making

145 Background: Patient involvement in treatment decision-making has been well-studied. However, little is known about how patients are involved in the MTP process prior to their consideration of treatment options. Methods: An online survey was administered to 1,261 Commission on Cancer (CoC)-accredited programs to describe current MTP practice. Survey items addressed team structure and process, case presentation, and patient involvement. A total of 797 (63%) facilities responded. Multiple aspects of patient involvement focusing on the initial case presentation and post-meeting follow-up regarding information provision and communication are examined. Initial descriptive analyses are presented. Results: 97% of facilities reported patients are not invited to attend MTP meetings. Reasons for not inviting patients included: patients may find it overwhelming (62%), physicians not able to speak freely (58%), liability (43%) and privacy (42%) concerns. Of the facilities that do invite patients, 1/3 reported that patients often or always attend. Treatment recommendations from MTP meetings are shared with patients at 75% of facilities, 42% share treatment plans, and 28% give a meeting summary to patients. Nine percent of facilities do not give patients any information from the meeting. Prior to treatment, a written treatment plan is developed at 43% of facilities, and among these, 15% give the plan to patients. Regarding communication about MTP meetings, facilities reported pre-meeting discussions with attending physicians (95%) and patient navigators (21%). Post-meeting follow-up by 93% of facilities is usually done by physicians, 26% by patient navigators and 16% by PA/NPs, and 66% follow-up within 1 week. Conclusions: Initial findings suggest that even if facilities do not invite patients to MTP meetings, they engage patients in various ways at pre- and post-MTP meetings, providing information and having discussions. Physicians are integral in communicating with patients throughout the MTP process. Further study on the multiple facets of patient involvement in MTP is needed to better understand its influence on treatment decision-making.

scholarly journals Asymptomatic COVID-19 in the elderly: dementia and viral clearance as risk factors for disease progression.

2021 ◽  
Vol 5 ◽  
pp. 143
Author(s):  
Ignacio Esteban ◽  
Georgina Bergero ◽  
Camila Alves ◽  
Micaela Bronstein ◽  
Valeria Ziegler ◽  
...  
Keyword(s):  
Risk Factor ◽  
Severe Disease ◽  
The Elderly ◽  
Clinical Risk Factor ◽  
Cumulative Probability ◽  
Medical Surveillance ◽  
Multivariable Logistic Regression Model ◽  
Asymptomatic Group ◽  
Symptomatic Infection

Background: SARS-CoV-2 infected individuals ≥60 years old have the highest hospitalization rates and represent >80% fatalities. Within this population, those in long-term facilities represent >50% of the total COVID-19 related deaths per country. Among those without symptoms, the rate of pre-symptomatic illness is unclear, and potential predictors of progression for symptom development are unknown. Our objective was to delineate the natural evolution of asymptomatic SARS-CoV-2 infection in elders and identify determinants of progression. Methods: We established a medical surveillance team monitoring 63 geriatric institutions. When an index COVID-19 case emerged, we tested all other eligible asymptomatic elders ≥75 or >60 years old with at least 1 comorbidity. SARS-CoV-2 infected elders were followed for 28 days. Disease was diagnosed when any COVID-19 manifestation occurred. SARS-CoV-2 load at enrollment, shedding on day 15, and antibody responses were also studied. Results: After 28 days of follow-up, 74/113(65%) SARS-CoV-2-infected elders remained asymptomatic. 21/39(54%) pre-symptomatic patients developed hypoxemia and ten pre-symptomatic patients died(median day 13.5,IQR 12). Dementia was the only clinical risk factor associated with disease(OR 2.41(95%CI=1.08, 5.39). In a multivariable logistic regression model, dementia remained as a risk factor for COVID-19 severe disease. Furthermore, dementia status showed a statistically significant different trend when assessing the cumulative probability of developing COVID-19 symptoms(log-rank p=0.027). On day 15, SARS-CoV-2 was detectable in 30% of the asymptomatic group while in 61% of the pre-symptomatic(p=0.012). No differences were observed among groups in RT-PCR mean cycle threshold at enrollment(p=0.391) and in the rates of antibody seropositivity(IgM and IgG against SARS-CoV-2 nucleocapsid protein). Conclusions: In summary, 2/3 of our cohort of SARS-CoV-2 infected elders from vulnerable communities in Argentina remained asymptomatic after 28 days of follow-up with high mortality among those developing symptoms. Dementia and persistent SARS-CoV-2 shedding were associated with progression from asymptomatic to symptomatic infection.

Abstract 12127: Integrated Flow-Mediated Vasodilation Response Predicts Cardiovascular Events in Elderly Patients at Cardiovascular Risk Factor

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Tomoyuki Kabutoya ◽  
Satoshi Hoshide ◽  
Yukiyo Ogata ◽  
Kazuo Eguchi ◽  
Kazuomi Kario
Keyword(s):  
Risk Factor ◽  
Cardiovascular Risk ◽  
Elderly Patients ◽  
Cardiovascular Risk Factor ◽  
Cardiovascular Events ◽  
The Elderly ◽  
Detection Algorithm ◽  
Younger Patients ◽  
Flow Mediated Vasodilation

Introduction: The integrated flow-mediated vasodilation (FMD) response was shown to be associated with cardiovascular risk factors, but the association between the integrated FMD response and consequent cardiovascular events has been unclear. Hypothesis: We assessed the hypothesis that the integrated FMD response predicts consequent cardiovascular events. Methods: We enrolled 575 patients who had at least one cardiovascular risk factor (hypertension, dyslipidemia, diabetes, or smoking). We measured the FMD magnitude of the percentage change in peak diameter (ΔFMD), and we measured the integrated FMD response calculated as the area under the dilation curve during a 120-sec dilation period (FMD-AUC 120 ) using a semiautomatic edge-detection algorithm. The primary outcome was defined as any cardiovascular event (a composite of cardiovascular death, and hospitalization for myocardial infarction, stroke, or heart failure). Results: The mean duration of follow-up was 35±22 months (range: 1-74 months). During the follow-up period, 34 cardiovascular events were recorded. Among the elderly patients (age[[Unable to Display Character: &#8201;]]≥[[Unable to Display Character: &#8201;]]65 yrs, n[[Unable to Display Character: &#8201;]]=[[Unable to Display Character: &#8201;]]281), the patients with the lowest tertile of FMD-AUC 120 (FMD-AUC 120 <[[Unable to Display Character: &#8201;]]5.6) suffered a higher incidence of cardiovascular events compared with the patients with the higher two tertiles (FMD-AUC 120 ≥[[Unable to Display Character: &#8201;]]5.6) (log rank 4.16, p=0.041). The association remained significant after adjusting for age, gender and office systolic blood pressure (hazard ratio 1.25, p=0.039). In the younger patients (age[[Unable to Display Character: &#8201;]]<[[Unable to Display Character: &#8201;]]65 yrs, n[[Unable to Display Character: &#8201;]]=[[Unable to Display Character: &#8201;]]294), cardiovascular events were similar among the patients with the lowest tertile and those with the higher two tertiles of FMD-AUC 120 . Cardiovascular events were also similar in the patients with the lowest tertile and the higher two tertiles of ΔFMD in both the elderly and younger patients. Conclusions: The integrated FMD response, but not ΔFMD, predicted cardiovascular events in elderly patients with a cardiovascular risk factor.

scholarly journals Traumatic brain injury as a risk factor for dementia

2019 ◽  
Vol 29 (Supplement_4) ◽  
Author(s):  
E Mezzalira ◽  
B Stopa ◽  
A Khawaja ◽  
S Izzy ◽  
W Gormley
Keyword(s):  
Public Health ◽  
Traumatic Brain Injury ◽  
Risk Factor ◽  
Brain Injury ◽  
The United States ◽  
Age Group ◽  
Global Public Health ◽  
Public Health Burden ◽  
Increased Risk

Abstract Introduction The Centers for Disease Control and Prevention (CDC) reports that there were 2.87 million cases of traumatic brain injury (TBI) in the United States in 2014, 69 million worldwide. Some studies suggest a connection between TBI and increased risk of dementia, but it remains unclear whether the risk increases with age and TBI severity. Given our aging population, it is essential to better characterize the link between TBI and dementia. Methods We conducted a retrospective cohort study of two major academic medical centers for years 2000-2015. We identified all patients with TBI, aged 45 and older. Variables included age, TBI severity, pre-existing dementia, dementia diagnosed after TBI, years to dementia, and follow-up time. TBI severity was determined by head/neck AIS score, using ICD-PIC software. Mild TBI was defined as AIS 0-2, and Moderate/Severe as AIS 3-6. Analysis was done in R.v.3.0.1 software. Results Overall, there were 14,199 patients with TBI, of which 9,938 (70%) were mild and 4,261 (30%) were moderate/severe. Mean age was 70.5 (±14.0). There were 1,422 cases (10%) of pre-existing dementia, and 850 (6%) cases of dementia diagnosed after TBI. The mean follow-up time was 1,129 (±1,474) days. The 75-84 age group had the highest incidence of TBI (28%). When compared by age group and TBI severity, the proportion of moderate/severe TBI increased with increasing age. The proportion of pre-existing dementia increased with age, as expected. Notably, there is increased incidence of dementia after TBI in patients aged 65 and older (7-10%, p &lt; 0.001). There was no observed effect of TBI severity on the risk of dementia after TBI. Conclusions Our results indicate that TBI is a risk factor for the development of dementia, especially in patients aged 65 and older. Given the global public health burden of these two diseases it is critical to develop effective TBI primary prevention strategies. Key messages TBI is a risk factor for the development of dementia. Need for public health measures to mitigate the risk of TBI in the patient population 65 and older.

scholarly journals Traumatic Brain Injury as a Risk Factor for Dementia: An Eighteen-Year Two Institution Clinical Experience

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Brittany M Stopa ◽  
Elisabetta Mezzalira ◽  
Ajaz Khawaja ◽  
Saef Izzy ◽  
William B Gormley
Keyword(s):  
Traumatic Brain Injury ◽  
Risk Factor ◽  
Brain Injury ◽  
The United States ◽  
Age Group ◽  
Academic Medical ◽  
Increased Risk ◽  
Control And Prevention ◽  
Severe Tbi

Abstract INTRODUCTION The Centers for Disease Control and Prevention (CDC) reports that there were 2.87 million cases of traumatic brain injury (TBI) in the United States in 2014. Some studies suggest a connection between TBI and increased risk of dementia, but it remains unclear whether the risk increases with age and TBI severity. Given our aging population, it is essential to better characterize the link between TBI and dementia. METHODS We conducted a retrospective cohort study of 2 major academic medical centers for years 2000 to 2015. We identified all patients with TBI, aged 45 and older. Variables included age, TBI severity, pre-existing dementia, dementia diagnosed after TBI, years to dementia, and follow-up time. TBI severity was determined by head/neck AIS score, using ICD-PIC software. Mild TBI was defined as AIS 0 to 2, and moderate/severe as AIS 3 to 6. Analysis was done in R.v.3.0.1 software. RESULTS Overall, there were 14 199 patients with TBI, of which 9938 (70%) were mild and 4261 (30%) were moderate/severe. Mean age was 70.5 (± 14.0). There were 1422 cases (10%) of pre-existing dementia, and 850 (6%) cases of dementia diagnosed after TBI. The mean follow-up time was 1129 (± 1,474) d. The 75 to 84 age group had the highest incidence of TBI (28%). When compared by age group and TBI severity, the proportion of moderate/severe TBI increased with increasing age. The proportion of pre-existing dementia increased with age, as expected. Notably, there is increased incidence of dementia after TBI in patients aged 65 and older (7%-10%, P < .001). There was no observed effect of TBI severity on the risk of dementia after TBI. CONCLUSION Our results indicate that TBI is a risk factor for the development of dementia, especially in patients aged 65 and older. This points to the need for public health measures to mitigate the risk of TBI in this patient population.

scholarly journals Physician decision-making pattern and family presence: A randomized cross-sectional online vignette study in Japan (Preprint)

2018 ◽  
Author(s):  
Kenji Tsuda ◽  
Asaka Higuchi ◽  
Emi Yokoyama ◽  
Kazuhiro Kosugi ◽  
Tsunehiko Komatsu ◽  
...  
Keyword(s):  
Decision Making ◽  
Elderly People ◽  
Online Survey ◽  
Artificial Ventilation ◽  
Family Members ◽  
Treatment Decision ◽  
The Elderly ◽  
Cross Sectional ◽  
Treatment Decision Making ◽  
Consciousness Disturbance

BACKGROUND Japan faces increase of elderly people without children living in single households with the progress of low birthrate and aging population. The elderly without spouse and/or children result in lack of caregivers because most care for the elderly are not provided by private agencies but by family members in Japan. However, family caregivers are not only helpers of daily living but are key participants in the treatment decision-making. Effect of family absence on treatment decision-making has not been elucidated although more and more elderly people will not have family members who make surrogate decisions on behalf of incapacitated themselves. OBJECTIVE To understand the influence of family absence on treatment decision-making, we conducted a randomized, cross-sectional online survey with three hypothetical vignettes of patients. METHODS We conducted a randomised cross-sectional online survey among Japanese physicians using three hypothetical vignettes. The first vignette was about a 65-year-old man with alcoholic liver cirrhosis and the second about a 78-year-old woman with dementia, both of whom developed pneumonia with consciousness disturbance. The third vignette was about a 70-year-old woman with necrosis of her lower limb. Participants were randomly assigned either of the two versions of questionnaires—with family or without family—but otherwise identical. Participants chose yes or no responses to questions about whether they would perform the presented medical procedures. RESULTS Among 1112 physicians, 454 (40.8%) completed the survey and there were no significant differences in the baseline characteristics between groups. Significantly fewer physicians had a willingness to perform dialysis (odds ratio [OR], 0.55; P=0.002) and artificial ventilation (OR, 0.51; P<0.001) for a patient from vignette one, without family. Similarly, artificial ventilation was less intended in vignette two (OR, 0.59; P=0.02). In vignette three, significantly fewer physicians showed willingness to perform wound treatment (OR, 0.51; P=0.007), surgery (OR, 0.35; P<0.001), blood transfusion (OR, 0.45; P<0.001), vasopressor (OR, 0.49; P<0.001), dialysis (OR, 0.38; P<0.001), artificial ventilation (OR, 0.25; P<0.001) and chest compression (OR, 0.29; P<0.001) for a patient without family. CONCLUSIONS Elderly patients may sometimes be submitted to treatments withheld due to the absence of family, highlighting the potential importance of the advance care planning in the era of aging society with declining birthrate. CLINICALTRIAL None

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