scholarly journals The efficacy of acupressure in managing opioid-induced constipation: Single-blind a randomized controlled study

2021 ◽  
Author(s):  
DİLEK YILDIRIM ◽  
Vildan KOCATEPE ◽  
Gül KÖKNEL TALU
Keyword(s):  
Quality Of Life ◽  
Negative Impact ◽  
Controlled Trial ◽  
Routine Care ◽  
Controlled Study ◽  
Life Questionnaire ◽  
Control Groups ◽  
Randomized Controlled ◽  
Significant Difference

Abstract Purpose Opioid-induced constipation is one of the heath problems with a negative impact on the quality of life. This randomized-controlled trial aimed to investigate the effects of acupressure therapy on the management of opioid-induced constipation. Methods The trial was conducted on 140 patients, who were assigned to the acupressure (n = 70) and the control groups (n = 70). In addition to routine care, patients in the acupressure group received 8-min acupressure from the Zhongwan (CV12), Guanyuan (CV4) and Tianshu (ST25) acupoints once a day for 4 weeks. The outcomes included Defacationa Diary (DD), Visual Analog Scale Questionnaire (VASQ) and Patient assessment of constipation quality of life questionnaire (PAC-QOL). Results DD scores obtained by the acupressure and the control groups. There was a statistically significant difference between the acupressure and control groups in terms of stool consistency (2.22 ± .49 vs 1.80 ± .55) (p = 0.001), straining (1.98 ± .71 vs 2.91 ± .37) (p = 0.001), incomplete evacuation (0.37 ± .29 vs 0.61 ± .43) (p = 0.001), stool amount (0.93 ± .14 vs .95 ± .20) (p = 0.001) and the number of defecations (0.70 ± .22 vs 0.46 ± .29), (p = 0.001) measured at the fifth week. Besides, with the exception of stool amount, there was a statistically significant increase in the DD scores obtained by the acupressure group between the first and the fifth weeks. Inter-group comparison of the pre-test and post-test scores showed that acupressure group obtained statistically significantly higher scores from the PAC-QOL (p = .0001). Conclusions Findings of this trial suggested that 4-week acupressure was an effective way to improve the quality of life and reduce both subjective and objective constipation symptoms in patients with opioid-induced constipations.

Comparison of the effects of Buteyko and pranayama breathing techniques on quality of life in patients with asthma – a randomized controlled trial

2012 ◽  
Vol 27 (2) ◽  
pp. 133-141 ◽  
Author(s):  
Venkatesan Prem ◽  
Ramesh Chandra Sahoo ◽  
Prabha Adhikari
Keyword(s):  
Quality Of Life ◽  
Controlled Trial ◽  
Control Group ◽  
Life Questionnaire ◽  
Control Groups ◽  
Quality Of Life Questionnaire ◽  
Randomized Controlled ◽  
Questionnaire Score ◽  
And Control

Objective: To compare two breathing exercises (Buteyko and pranayama) with a control group in patients with asthma. Design: Randomized controlled trial. Subjects: One hundred and twenty subjects were randomized to three groups through block randomization. Subjects with an Asthma Quality of Life Questionnaire score <5.5 participated in the study. Setting: Outpatient pulmonary medicine department. Interventions: Subjects in the Buteyko and pranayama groups were trained for 3–5 days and instructed to practise the exercises for 15 minutes twice daily, and for three months duration. The control group underwent routine pharmacological management during the study period. Outcome measures: Asthma Quality of Life Questionnaire, Asthma Control Questionnaire and pulmonary function test. Results: The baseline characteristics were similar in all three groups. Post intervention, the Buteyko group showed better trends of improvement (mean (95% confidence interval), P-value) in total Asthma Quality of Life Questionnaire score than the pranayama (0.47 (–0.008–0.95), P = 0.056) and control groups (0.97 (0.48–1.46), P = 0.0001). In comparison between the pranayama and control groups, pranayama showed significant improvement (0.50 (0.01–0.98), P = 0.042) in total Asthma Quality of Life Questionnaire score. Conclusion: The Buteyko group showed better trends of improvement in quality of life and asthma control than the group performing the pranayama breathing exercise.

Daflon 500 mg: Symptoms and Edema

Angiology ◽  
2005 ◽  
Vol 56 (6_suppl) ◽  
pp. S25-S32 ◽  
Author(s):  
Albert-Adrien Ramelet
Keyword(s):  
Quality Of Life ◽  
Controlled Study ◽  
Venous Disease ◽  
Double Blind Study ◽  
Life Questionnaire ◽  
Double Blind ◽  
Randomized Controlled ◽  
Randomized Controlled Studies ◽  
Significant Difference

Patients suffering from any class of the Clinical, Etiological, Anatomical, Pathophysiological (CEAP) classification of chronic venous disease (CVD) may be symptomatic (C0s-C6s). Leg heaviness, discomfort, itching, cramps, pain, paresthesia, and edema (C3) are the most frequent manifestations of CVD and a major reason for medical consultation. Daflon 500 mg (micronized purified flavonoid fraction [MPFF]) is an effective treatment for symptoms and edema in CVD as demonstrated in several randomized controlled studies. A 2-month, double-blind study in 40 patients established the superiority of Daflon 500 mg over placebo with regard to symptoms and objective signs. This was confirmed in another double-blind, placebo-controlled trial (2 months’ treatment, 160 patients), and in the Reflux assEssment and quaLity of lIfe improvEment with micronized Flavonoids (RELIEF) study. The latter included 5,052 patients in 23 countries, using a visual analog scale for evaluating pain, leg heaviness, cramps, and a sensation of swelling. All symptoms showed significant and progressive improvement. The quality-of-life results (scores on the ChronIc Venous Insufficiency quality of life Questionnaire [CIVIQ]) paralleled those of symptoms. The decrease in the ankle and calf circumferences was significantly greater (p<0.001) in the group of patients treated with Daflon 500 mg in two studies, and correlated well with the improvement in the sensation of swelling (p<0.001). This was confirmed with more sophisticated measurement techniques as in the RELIEF study or in a trial assessing edema with an optoelectronic volumeter in 20 patients. A further double-blind, randomized, controlled study established a statistically significant difference in favor of Daflon 500 mg in comparison with diosmin, both on symptoms and edema. The therapeutic efficacy of Daflon 500 mg on CVD symptoms and edema has been demonstrated in double-blind, randomized, controlled studies. Further studies using a new approach may define the most precise and validated methodology for application in future research in phlebology.

scholarly journals Modulation of the human immune status by spinal thermal massage: a non-randomized controlled study

2021 ◽  
Keyword(s):  
Quality Of Life ◽  
Nk Cells ◽  
Nk Cell ◽  
Controlled Trial ◽  
Controlled Study ◽  
Control Group ◽  
Randomized Controlled ◽  
Significant Difference ◽  
Experimental Group

Thermal and massage therapies have long been used to control pain. Although spinal thermal massage (STM) has been used worldwide, its effectiveness has not been proven in a controlled clinical study. We here conducted a non-randomized controlled trial to assess the pain-relieving and immunomodulatory effects of STM in old-aged patients experiencing pain or disability. The experimental group was treated with STM five times a week for 8 weeks and rehabilitative regular care (RRC). The control group was treated with only RRC. Pain and immunological parameters were tested before treatment and after 4 and 8 weeks of treatment. The scores of three pain parameters were lowered by STM, and the differences between the groups were statistically significant at the two time points (p < 0.01). Quality of life determined using the 3-level EuroQol five-dimensional questionnaire scores was significantly higher in patients in the experimental group than those in the control group. Effect sizes (ES) were in the range of medium to large in the pain-related measures (0.54–1.22). The total leukocyte counts and the proportions of lymphocytes and subsets were not significantly different between the groups, whereas the proportions of monocytes and natural killer (NK) cells were higher in the experimental group than in the control group after 8 weeks (p < 0.05). The production of interleukin (IL)-4 and interferon γ in T cells was not significantly different between the groups, whereas the production of IL-2 was high in the control group. However, there was a significant increase in IFN-γ production by NK cells in the experimental group (at 4 weeks, p < 0.05). ES were medium in the immunological measures (0.53–0.68). No significant difference was observed in the production of proinflammatory cytokines, IL-1β, tumor necrosis factor α, or IL-6 between the groups. In conclusion, STM treatment has a positive effect on subjective pain and quality of life. It also enhanced NK cell proportion and activity, suggesting that STM may be beneficial in the prevention of viral diseases and cancer in old-aged people.

scholarly journals Effectiveness of acupuncture, ozonio therapy and low-intensity laser in the treatment of temporomandibular dysfunction of muscle origin: a randomized controlled trial

2019 ◽  
Vol 48 ◽  
Author(s):  
Síglia Adriana Campos TORTELLI ◽  
Leonardo SARAIVA ◽  
Daniela Cristina MIYAGAKI
Keyword(s):  
Quality Of Life ◽  
Randomized Controlled Trial ◽  
Laser Therapy ◽  
Controlled Trial ◽  
Mouth Opening ◽  
Life Questionnaire ◽  
Ozone Therapy ◽  
Randomized Controlled ◽  
Significant Difference

Abstract Introduction One of the most common causes of orofacial pain is temporomandibular disorder (TMD). Objective The aim of this study was to compare the effectiveness of acupuncture, ozone therapy and laser therapy in the treatment of muscle TMD patients through a randomized controlled trial. Material and method Twelve professors and postgraduate students from the University of Passo Fundo, diagnosed with TMD, aged between 23 and 50 years old, of both sexes, were evaluated. Individuals were randomly divided into 3 groups: G1: laser therapy, G2: acupuncture, and G3: ozone therapy. TMD diagnostic questionnaires (RDC / TMD), Quality of Life Questionnaire (OHIP-14), Pain Scale (VAS) and maximum mouth opening were applied. Descriptive statistics and percentage were used for sample characterization, which were presented using absolute and relative frequency distributions. Qualitative variables were analyzed with Wilcoxon tests p≤0.05. Result There was no statistically significant difference between treatments. Regarding pain and maximum mouth opening, the groups showed no statistical difference when individually analyzed, but when compared in general, they did (p=0.002 and p=0.003). Conclusion It can be considered that all treatments were able to decrease pain and improve maximal opening capacity related to muscle TMD. It can also be concluded that the TMD-related quality of life, in relation to the pain variable, was generally effective when compared before and after the interventions.

scholarly journals Effects of daily mindfulness practice on fatigue, kinesiophobia, and quality of life in patients with acute myocardial infarction: a randomized controlled trial

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
C Karadas ◽  
M Oksul ◽  
N Ozer ◽  
L Ozdemir
Keyword(s):  
Quality Of Life ◽  
Controlled Trial ◽  
Mindfulness Practice ◽  
Controlled Study ◽  
Control Group ◽  
Randomized Controlled ◽  
Significant Difference ◽  
Quality Of Life Scale ◽  
Tampa Scale For Kinesiophobia

Abstract Funding Acknowledgements Type of funding sources: None. Background and Aim Mindfulness meditation (MM) leads to controlled blood pressure and positive improvements in other symptoms which may trigger acute coronary diseases. The present randomized controlled study was aimed to investigate the effect of the MM on fatigue, kinesiophobia, and the quality of life (QoL) in patients with acute MI. Method The study was carried out with 56 MI patients. Participants were randomly assigned to meditation group (MG; n = 28) or control group (CG; n = 28).  The MG patients received a 15 min MM session comprising sitting and breathing for a total of eight weeks, while the CG patients received only a single-time attention-matched education. Piper Fatigue Intervention, Tampa Scale for Kinesiophobia-Heart and MacNew Quality of Life scales were utilized for data collection. Results After completion of the 8-week MM, any significant difference was not found in the fatigue scores of the patients (p &gt; 0.05). On the other hand, kinesiophobia scores in the MG were significantly lower in the 4th, 8th and 12th weeks (p &lt; 0.05). Similarly, the QoL scores were significantly higher in the MG in 8th week (p &lt; 0.05). Significant change in the emotional function sub-dimension of QoL continued in the follow-up assessment at 12th week (p &lt; 0.05). Conclusion The MM can significantly improve the QoL and decrease kinesiophobia in patients with MI. Beneficial effect of MM is maintained particularly in the emotional aspect. Based on the results of the study, MM may be recommended as a mind-body based complementary approaches within the scope of secondary protection after MI. Comparison of the study groupsGroupBaseline(Mean ± SD)4th week(Mean ± SD)8th week(Mean ± SD)12th week(Mean ± SD)PFSMM2.08 ± 1.870.90 ± 0.990.47 ± 0.780.44 ± 0.76CG1.56 ± 2.011.12 ± 1.590.98 ± 1.520.76 ± 1.33tp1.004 0.32-0.6210.54-1.5840.12-1.0850.28TSK-HMM40.25 ± 5.0436.18 ± 4.4934.39 ± 4.6134.96 ± 4.71CG41.71 ± 7.2841.89 ± 6.7441.82 ± 5.8441.00 ± 5.54tp-0.8750.39-3.7340.001-5.279 0.000-4.3900.00MacNewMM5.04 ± 0.715.53 ± 0.455.76 ± 0.475.77 ± 0.47CG5.17 ± 0.855.32 ± 0.605.37 ± 0.525.53 ± 0.46t; p-0.640; 0.531.436; 0.162.933; 0.0051.964; 0.06(Mean ± SD): Mean ± Standard Deviation; PFS: Piper Fatigue Scores; TSK-H: Tampa Scale for Kinesiophobia-Heart; MacNew: MacNew Quality of life Scale; EFS: emotional functioning sub-dimension; PFS: physical functioning sub-dimension; SFS: social functioning sub-dimension; t= Student T Test value; p&lt; 0.05

scholarly journals Effects of variable frequencies of kinesthesia, balance and agility exercise program in adults with knee osteoarthritis: study protocol for a randomized controlled trial

2020 ◽  
Author(s):  
Aysha I. Adhama ◽  
Mukadas O. Akindele ◽  
Aminu A. Ibrahim
Keyword(s):  
Quality Of Life ◽  
Randomized Controlled Trial ◽  
Knee Osteoarthritis ◽  
Conventional Therapy ◽  
Controlled Trial ◽  
Hip Osteoarthritis ◽  
Life Questionnaire ◽  
Knee Oa ◽  
Randomized Controlled

Abstract Background: Knee osteoarthritis (OA) is a common painful and disabling condition that affects older individuals. Proprioceptive training programs in the form of kinesthesia, balance and agility (KBA) exercises have been reported to be beneficial for individuals with knee OA. However, the most optimal treatment dosage of KBA exercise is still unclear. The aim of this study is to determine the effects of different frequencies of KBA treatment (i.e. twice-weekly or thrice-weekly) in adults with knee OA.Methods: A single (assessor) blind, three-arm parallel, multi-center randomized controlled trial will be conducted. Eighty-four adults with knee OA will be recruited from four tertiary hospitals in Northwestern Nigeria and randomly assigned into one of three intervention groups; twice-weekly KBA (n = 28), thrice-weekly KBA (n = 28), and conventional physiotherapy or control (n = 28) in the ratio of 1:1:1. Participants in the conventional therapy group will receive two sessions of brief patient education, and 16 sessions of ultrasound therapy, stretching and strengthening exercises for 8 weeks. Participants in the two different KBA groups will receive KBA exercise according to the designed sessions for 8 weeks in addition to the conventional therapy. All groups will be assessed pre-intervention, immediately post-intervention and at 8 weeks, 3-month, 4-month, and 6-month post-randomization. The primary outcome will be physical function (Ibadan Knee and Hip Osteoarthritis Outcome Measure) while the secondary outcomes will be pain (Visual Analogue Scale for pain), knee stability (Knee Outcome Survey-Activities of Daily Living Scale), proprioception (electronic goniometer), and quality of life (Osteoarthritis Knee and Hip Quality of Life Questionnaire).Discussion: Findings of this study may provide evidence on the effectiveness of KBA exercise and the ideal number of sessions needed to achieve the highest effectiveness in adults with knee OA.Trial registration: Pan African Clinical Trials Registry, (PACTR201810713260138), Retrospectively registered on 28 November 2017.

Comparison of the effect of Myrtus communis herbal and anti-hemorrhoid ointments on the hemorrhoid symptoms and quality of life in postpartum women with grade I and II internal hemorrhoid: A triple-blinded randomized controlled clinical trial

2019 ◽  
Vol 16 (4) ◽  
Author(s):  
Jamileh Malekuti ◽  
Mojgan Mirghafourvand ◽  
Khadijeh Samadi ◽  
Fatemeh Abbasalizadeh ◽  
Laleh Khodaei
Keyword(s):  
Quality Of Life ◽  
Intervention Group ◽  
World Health ◽  
Control Group ◽  
Life Questionnaire ◽  
Myrtus Communis ◽  
World Health Organization Quality ◽  
Randomized Controlled ◽  
Significant Difference

Abstract Introduction Due to the effects of hemorrhoids on physical and mental health, this study aimed to compare the effect of Myrtus communis herbal and anti-hemorrhoid ointments on symptoms of hemorrhoid and quality of life (primary outcomes) and satisfaction of the treatment and side effects (secondary outcomes). Methods This triple-blind randomized controlled trial was performed on women with grade I and II hemorrhoid referring to health centers in Tehran, Iran, in 2017. Individuals were randomly assigned to two groups of 67 people through block randomization method. The intervention group received the Myrtus communis herbal ointment and the control group received anti-hemorrhoid ointment twice a day, every 12 ± 2 h, an applicator of the drug through the rectum for 4 weeks. The Colorectal Evaluation of a Clinical Therapeutics Scale (CORECTS) was used to assess the severity of symptoms of hemorrhoid. To assess the quality of life, the World Health Organization Quality of Life questionnaire (WHOQOL-BREF) was used to measure the general quality of life of participants. This questionnaire was completed once before the start of the study, then on the fourth and the eighth week after the start of the intervention. Repeated measure ANOVA, Chi-square, Mann–Whitney U and independent t-test were used for data analysis. Results The severity of all symptoms of hemorrhoid decreased in both two group and there was no statistically significant difference between the two groups (p>0.05). However, the mean of anal itching at 4 and 8 weeks after the intervention was significantly lower in the Myrtus communis ointment group (p<0.05). There was no significant difference between groups in terms of quality of life at 4 and 8 weeks after the intervention (p>0.05). There was a significant difference between the two groups in terms of satisfaction with the drug (p=0.019) and the participants in the Myrtus communis ointment group were more satisfied with their drug use. Conclusions Myrtus communis herbal ointment was able to reduce the symptoms of hemorrhoid in the affected women. Therefore, it is likely that the use of this drug will promote the health of mothers with hemorrhoid.

Effect of chlorhexidine gluconate and benzydamine hydrochloride mouth spray on clinical signs and quality of life of patients with streptococcal tonsillopharyngitis: multicentre, prospective, randomised, double-blinded, placebo-controlled study

2011 ◽  
Vol 125 (6) ◽  
pp. 620-625 ◽  
Author(s):  
C Cingi ◽  
M Songu ◽  
A Ural ◽  
N Erdogmus ◽  
M Yildirim ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Treatment Group ◽  
Antibiotic Treatment ◽  
Clinical Signs ◽  
Chlorhexidine Gluconate ◽  
Controlled Study ◽  
Control Group ◽  
Control Groups ◽  
Significant Difference

AbstractObjective:To assess the effect of chlorhexidine gluconate and benzydamine hydrochloride mouth spray, used in conjunction with antibiotic treatment, on the intensity of clinical signs and quality of life of patients with group A streptococcal tonsillopharyngitis.Methods:Patients (n = 147) with streptococcal tonsillopharyngitis were recruited and randomly allocated to either the treatment group (penicillin plus chlorhexidine and benzydamine; n = 72) or control group (penicillin plus placebo; n = 75). Blinded assessments were conducted before and after 10 days' treatment, using an intensity rating scale for clinical sign severity, a visual analogue scale for subjective health state, the Short Form 36 Health Questionnaire for quality of life, and a customised questionnaire for side effects.Results:The treatment group showed a statistically significant reduction in the intensity of clinical signs, compared with the control group. On treatment day 7, there was no significant difference in quality of life between the treatment and control groups. The treatment drugs were well tolerated, and no serious adverse events were observed.Conclusion:Chlorhexidine gluconate and benzydamine hydrochloride mouth spray, added to standard antibiotic treatment, significantly alleviate the intensity of clinical signs in patients with streptococcal pharyngitis. Further research is needed using larger sample sizes or alternative control groups.

scholarly journals The Role of Education, Monitoring, and Symptom Perception in Internet-Based Self-management Among Adolescents With Asthma: Secondary Analysis of a Randomized Controlled Trial (Preprint)

2020 ◽  
Author(s):  
Thijs Beerthuizen ◽  
E R V M Rikkers-Mutsaerts ◽  
Jiska B Snoeck-Stroband ◽  
Jacob K Sont
Keyword(s):  
Quality Of Life ◽  
Asthma Control ◽  
Controlled Trial ◽  
Self Management ◽  
Life Questionnaire ◽  
Symptom Perception ◽  
Web Based ◽  
Randomized Controlled ◽  
Related Quality

BACKGROUND Internet-based self-management programs improve asthma control and the asthma-related quality of life in adults and adolescents. The components of self-management programs include education and the web-based self-monitoring of symptoms; the latter requires adequate perception in order to timely adjust lifestyle or medication or to contact a care provider. OBJECTIVE We aimed to test the hypothesis that adherence to education and web-based monitoring and adequate symptom perception are important determinants for the improvement of asthma control in self-management programs. METHODS We conducted a subgroup analysis of the intervention group of a randomized controlled trial, which included adolescents who participated in the internet-based self-management arm. We assessed the impacts that attendance in education sessions, the frequency of web-based monitoring, and the level of perception had on changes in asthma control (Asthma Control Questionnaire [ACQ]) and asthma-related quality of life (Pediatric Asthma Quality of Life Questionnaire) from baseline to 12 months after intervention. RESULTS Adolescents who attended education sessions had significant and clinically relevant improvements in asthma control (ACQ score difference: −0.6; <i>P</i>=.03) and exhibited a nonsignificant trend of improvement in asthma-related quality of life (Pediatric Asthma Quality of Life Questionnaire score difference: −0.45; <i>P</i>=.15) when compared to those who did not adhere to education. Frequent monitoring alone did not improve asthma control (<i>P</i>=.07) and quality of life (<i>P</i>=.44) significantly, but its combination with education did result in improved ACQ scores (difference: −0.88; <i>P</i>=.02). There were no significant differences in outcomes between normoperceivers and hypoperceivers. CONCLUSIONS Education, especially in combination with frequent web-based monitoring, is an important determinant for the 1-year outcomes of asthma control in internet-based self-management programs for adolescents with partly controlled and uncontrolled asthma; however, we could not establish the effect of symptom perception. This study provides important knowledge on the effects of asthma education and monitoring in daily life.

scholarly journals TENDENCY TO BRUXISM IN PHYSIOTHERAPY TEACHERS AND CONSEQUENCES IN THE QUALITY OF LIFE

2020 ◽  
pp. 1-5
Author(s):  
Joelma Magalhães da Costa ◽  
Aline de Carvalho Santos ◽  
Renata Bezerra Braga ◽  
Tairine Correa de Melo ◽  
Raisa Seabra Carvalho ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Negative Impact ◽  
Statistical Significance ◽  
Female Gender ◽  
Life Questionnaire ◽  
Self Perception ◽  
Cross Sectional ◽  
Sf 36 ◽  
Significant Difference

Introduction: Bruxism is characterized by the parafunctional act of tightening or grinding the teeth, which may occur in a conscious or unconscious way, during sleep or in wakefulness. It has become a growing concern in recent years due to its negative impact on quality of life (QOL) and also because it is considered an important risk factor for temporomandibular disorders. Objective: This study aimed to evaluate the QOL related to bruxism in physiotherapy teachers from a private institution through a questionnaire and their perception for such parafunction. Method: A cross-sectional, quantitative and exploratory study. The self-perception of bruxism was assessed through three questions from the Fonseca Anamnestic Indexand the perspective of QLV through the Quality of Life Questionnaire (SF-36), with a sample of 38 teachers of both genders. Results: Based on the results found, the level of statistical significance was set at p<0,05 for all tests. Among the 38 interviewees, 47,4% (n = 18) of professionals were observed with bruxism, with a higher prevalence in the female gender. Regarding the comparisons of QOL in relation to bruxism, a statistically significant difference was found in relation to the dimension of Pain (p=0,014), in which the mean for the bruxism group was (59,8) and without bruxism (78,5). Conclusion: There is a relation of the bruxism with the quality of life of the interviewees, and this habit mainly interferes in the domain of pain. Another aspect that was shown to be significantly associated with bruxism was nervous tension, in which the tense and nervous professionals were associated with self-perception of bruxism.

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