By ANISH KOKA It’s been a while but Anish Koka, a one time regular writer on THCB and occasional THCB Gang member, is back publishing up a storm on his Substack channel. You may recall that his political and clinical views don’t always mesh with some of the wooly liberals we feature on THCB (cough, …
US Cardiac electrophysiologists meet reimbursement reality and don’t like it. Read More »
Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt In this edition’s tidbits, I have to return …
Matthew’s health care tidbits: Texas is the present future of abortion care Read More »
By HANS DUVEFELT In some practices, patients with seemingly simple problems are scheduled to be seen by a nurse or medical assistant. Sometimes they can even just drop off a urine sample in case of a suspected urinary tract infection. This is a dangerous trap. What if the patient rarely gets urinary infections, has back …
Health Care Through the Back Door: The Dangers of Nurse Visits Read More »
by JESSICA DAMASSA, WTF HEALTH BREAKING! Livongo-famous Jenny Schneider stops by to talk to us first, on-site at ViVE in Miami, about the brand-new business she’s just launched today to “rearchitect” rural health and care. Called Homeward, the startup is coming out with a $20 million Series A backed by General Catalyst, and a novel …
BREAKING at ViVE: Jenny Schneider on Launch of New Biz, Homeward Read More »
BY HANS DUVEFELT Workflows are all the rage with EMR people. But doctors, NPs and PAs are smart. Nothing burns us out as fast or as completely as being told how to do things instead of why. We are not circus animals. Let me explain: If we had no professional education at all, we would …
How to Talk to Clinicians: Forget Workflows, Just Tell Us How Things Work Read More »
BY MARTIN SAMUELS Those of us in medicine have all seen the famous painting of the Tuesday afternoon lessons at the Salpȇtrière in Paris in the 19th century. In Pierre Aristide André Brouillet’s painting, one can clearly see the great professor, Jean-Martin Charcot, holding forth while the patient, Blanche Whitman, is being supported by a …
By RICHARD ISSACS You’ll recall that we ran a long piece (pt 1, pt 2) about Medicare Advantage from former Kaiser Permanente CEO George Halvorson earlier this year. Here’s a somewhat related piece from the current head of the Permanente Medical Group about what actually happened there and elsewhere during the pandemic–Matthew Holt The COVID-19 …
What the Pandemic Taught Us About Value-based Care Read More »
By MATTHEW HOLT I went for an annual physical with my doctor at One Medical in December. OK it wasn’t actually annual as the last time I went was 2 & 1/2 years ago, but it was covered under the ACA, and my doc Andrew Diamond was bugging me because I’m old & fat. So …
By HANS DUVEFELT Almost two years into this new age of varying degrees of self quarantine, I am registering that my own social interactions through technology have been an important part of my life. I text with my son, 175 miles away, morning and night and often in between. I talk and text with my …
The Healing Power of Even Virtual Human Connection Read More »
By KIM BELLARD It has been said that if your company has a Chief Innovation Officer or an Innovation Department, it’s probably not a very innovative company. To be successful, innovation has to be part of a company’s culture, embraced widely, and practiced constantly. Similarly, if your company has a Chief Digital Officer, chances …
By HANS DUVEFELT Today I saw a patient I have known for years. He suddenly pulled his mask down and said, “I’d like to know what you think I should do about this”. On his nose was an 8 mm (1/3”) brownish-red flat spot with a crack or scrape through it. “How long have you …
By GAIL PEACE We have heard the phrases “physician fatigue” and “burnout” too often in the last year – and for good reason. Covid-19 has placed an incredible burden on our healthcare providers. However, as healthcare professionals, the stats representing physician burnout are not new for us. We have seen similar trends and stats for …
We are Asking Our Physicians to Do Too Much. It’s No Wonder They are Burnt Out. Read More »
By HANS DUVEFELT I happened to read about the pharmacodynamics of parenteral versus oral furosemide when I came across a unique interaction between this commonest of diuretics and risperidone: Elderly dementia patients on risperidone have twice their expected mortality if also given furosemide. I knew that all atypical antipsychotics can double mortality in elderly dementia patients, but …
We Use Too Many Medications: Be Very Afraid of Interactions Read More »
By HANS DUVEFELT (Desperate times called for desperate measures.) In the tech world, we have come to expect our devices to become outdated and obsolete very quickly. The biggest tech companies in the world didn’t even exist a few years ago. Bitcoin, a virtual currency which at least I can’t wrap my head around, seems …
Medicine is a Moving Missile, Aiming for a Dangerous, Elusive Target Read More »
By HANS DUVEFELT The medication and allergy lists seem like they would be the most important parts of a health record to keep current and accurate. But we all see errors too often. I think it shouldn’t be possible to enter an allergy without describing the reaction. Because without that information the list becomes completely …
By HANS DUVEFELT Before Johannes Gutenberg invented the printing press in 1450, books in Europe were copied by hand, mostly by monks and clergy. Ironically, they were often called scribes, the same word we now use for the new class of healthcare workers employed to improve the efficiency of physician documentation. Think about that for …
American Primary Care is a Big Waste of Time (When…) Read More »
By HANS DUVEFELT Perhaps it is because I love doctoring so much that I find some of the tools and tasks of my trade so tediously frustrating. I keep wishing the technology I work with wasn’t so painfully inept. On my 2016 iPhone SE I can authorize a purchase, a download or a money transfer …
By BRYAN CARMODY If you’re involved in medical education or residency selection, you know we’ve got problems. And starting a couple of years ago, the corporations that govern much of those processes decided to start having meetings to consider solutions to those problems. One meeting begat another, bigger meeting, until last year, in the wake …
By HANS DUVEFELT Leo Dufour is not a diabetic. He is in his mid 50s, a light smoker with hypertension and a known hiatal hernia. He has had occasional heartburn and has taken famotidine for a few years along with his blood pressure and cholesterol pills. Over the past few months, he started to experience …
By KIM BELLARD There was a lot going on this week, as there always is, including the 20th anniversary of 9/11 and the beginning of the NFL season, so you may have missed a big event: the announcement of the 31st First Annual Ig Nobel Awards (no, those are not typos). What’s that you …
By RONALD DIXON Week after week, I hear from colleagues in diverse specialties about how exhausted they are from practicing medicine. It’s no surprise that they are looking for careers outside of medicine. The demands and strain are unsustainable. So it’s also no surprise that a recent survey showed 40% of primary care clinicians are worried that their …
As Doctor Burnout Climbs, Can We Save Primary Care? Read More »
By HANS DUVEFELT Especially in these strange and uncertain times, many people feel uneasy. Some of them come to us with concerns over their state of mind. In primary care, our job is in large part to perform triage. We strive to identify patients who need referral, medication or further evaluation. We also strive, or …
Anxiety, Worry or Fear? Disappointment, Grief or Depression? Read More »
By DEBORAH AFEZOLLI, CARL-PHILIPPE ROUSSEAU, HELEN FERNANDEZ, ELIZABETH LINDENBERGER “Why did you choose this field?” Most physicians are asked this question at some point in their early careers. We are geriatrics and palliative medicine physicians, so when that question is posed to us, it is invariably followed by another: “Isn’t your job depressing?” No, our …
Does Our Healthcare System Work for the Most Vulnerable Americans? Read More »
By HANS DUVEFELT I am a 68 year old family physician in rural Maine. This morning I read yet another article about physician burnout, this time in The New York Times. (I’m not linking to it, because they have a “paywall”.) I did not end up exactly where and how I expected to be at …
By HANS DUVEFELT I have a patient with no health insurance but a brand new Mercedes. He says he can’t afford health insurance. He cringes at the cost of his medications and our office visit charges. His car cost a lot of money and I know that authorized Mercedes dealers charge around $140/hour for their …
Health Insurance is a Stumbling Block in Many Patients’ Thinking Read More »
By HANS DUVEFELT IT GUY: Hey, Doc, don’t make up workarounds, use the EHR the way it was designed. DOCTOR: Listen, your whole EHR is a workaround itself – around the way medicine is practiced. – Hans Duvefelt, MD This was a tweet I posted a while ago. I expected it to either go viral …
EHRs Are Workarounds, Rerouting the Way Physicians Work Read More »
By MARTIN A. SAMUELS A 35 year old woman complains of weakness of the right side of her face and pain behind the right ear. She lives in an urban environment and denies any recent illnesses. She is not vaccinated against COVID-19 but is COVID negative. What do you think, I was asked at our …
By HANS DUVEFELT Specialists in orthopedics and general surgery often want us, the primary care doctors, to manage postoperative pain. I don’t like that. First, I don’t know as much as the surgeons about the typical, expected recovery from their procedures. My own appendectomy in Sweden in 1972 was an open one that I stayed …
“This Doesn’t Usually Hurt that Much”: Patients With Fibromyalgia Spectrum Disorder Read More »
By HANS DUVEFELT I suspect the notion of calling in narrower specialties is quite different from mine. Surgeons operate, neurologists treat diseases of the nervous system, even as the methods they use change over time. Primary care has changed fundamentally since I started out. Others have actually altered the definition of what primary care is, …
By HANS DUVEFELT I suspect the notion of calling in narrower specialties is quite different from mine. Surgeons operate, neurologists treat diseases of the nervous system, even as the methods they use change over time. Primary care has changed fundamentally since I started out. Others have actually altered the definition of what primary care is, …
By STEVEN ZECOLA If asked, the leaders of the research organizations working on Parkinson’s disease would say that they have made tremendous progress and are optimistic on finding a cure for the disease. In truth, this viewpoint understates the magnitude of the challenge and results in insufficient resources being devoted to PD. Given the size …
The Case to Realign Parkinson’s Disease Research Read More »
By HANS DUVEFELT When I first lost power and then saw my generator fail during a storm last winter, two other failures struck. As I scrambled to fill my water containers for the horses, the failing generator delivered just enough electricity for dim lights and a slow trickle of water. And then, when the power …
Can the Practice of Primary Care Medicine ever be Practical Again? Read More »
By HANS DUVEFELT The Art of Medicine is Doing the Ordinary Well Primary care doctors don’t usually operate any sophisticated medical instruments or perform any advanced procedures. But there is still art in what we do. We take care of ordinary ailments in ordinary people and that can be done well or not so well. …
The Art and Soul of Medicine Exist in the Ordinary Read More »
By HANS DUVEFELT In 2002, Dr. Trisha Greenhalgh published a piece in the British Journal of General Practice titled Intuition and Evidence – Uneasy Bedfellows? In it she writes eloquently about the things Christer Petersson and I have written articles on and emailed each other about. He mentioned her name and also Italian philosopher Lisa Bortolotti, and …
By HANS DUVEFELT People here in northern Maine, as in my native Sweden, don’t get a whole lot of natural sunlight a good part of the year. As a kid, I had to swallow a daily spoonful of cod liver oil to get the extra vitamin D my mother and many others believed we all …
By MATTHEW HOLT I recently interviewed Subha Airan-Javia, the CEO of CareAlign. CareAlign is a small company that is working to fix the clinician workflow by creating a tool for all those interstitial gaps that the big EMRs leave, and now get moved to and from paper by the care team. In this interview she …
CareAlign, fixing that physician workflow–demo & interview Read More »
By HANS DUVEFELT Left to my own devices, I would be selective about when and how much of a physical exam I do: either not at all or very detailed for just those things that can help me make the diagnosis. I have no patience for boilerplate normal exams. Any doctor who uses the term …
Did Covid and Telemedicine Finally Make the Physical Exam Obsolete? Read More »
By JAY T. RIPTON Not to sound too alarmist, but the radiopharmaceutical industry is on the verge of an explosion. But don’t worry; it’s not the type of explosion one often associates with nuclear materials… I love those movies too! It’s the beginning of a new wave of innovation for the diagnosis and treatment of …
Why “Radiopharmaceutical” Should be Part of your Healthcare Vocabulary Read More »
By HANS DUVEFELT The Art of Medicine is such a common phrase because, for many centuries, medicine has not been a cookie cutter activity. It has been a personalized craft, based on the science of the day, practiced by individual clinicians for diverse patients, one at a time. Unlike industrial mass production, where everything from …
By HANS DUVEFELT My nurse regularly gets at least 50 voicemails every day, many saying “please call me back”. I have one patient who frequently tests the patience of our clinic staff by calling multiple times for the same thing. He is the most dramatic example of what seems to be a widely held belief …
Voicemail, Repeat Requests and Multitasking: Inefficiencies in Today’s Healthcare Read More »
By CHADI NABHAN She was a successful corporate lawyer turned professional volunteer and a housewife. He was a charismatic, successful, and world-renowned researcher in gastrointestinal oncology. He was jealous of all breast cancer research funding and had declared that disease his nemesis. They were married; life was becoming a routine, and borderline predictable. Both appeared …
By HANS DUVEFELT Today a patient told me a cancer doctor had told her husband that he only had a year to live. She was angry, because she felt that statement robbed her husband of hope and she knew well enough that doctors don’t always know a patient’s prognosis in such detail. “Would you want …
What Does Your Patient Need to Hear You Say Right Now? Read More »
By HANS DUVEFELT Words can be misleading. Medical terms work really well when shared between clinicians. But we can’t assume our patients speak the same language we do. If we “run with” whatever key words we pick up from our patient’s chief complaint, we can easily get lost chasing the wrong target. Where I work, …
By HANS DUVEFELT 1) EXERCISE MORE I talk to people almost every day who think they can lose weight by exercising. I tell them that is impossible. I explain that it takes almost an hour of brisk walking to burn 100 calories, which equals one apple or a ten second binge on junk food. To …
By HANS DUVEFELT Primary Care is now mandated to screen for depression, among a growing host of other conditions. That makes intuitive sense to a lot of people. But the actual outcomes data for this are sketchy. “Don’t order a test if the results won’t change the outcome” was often drilled into my cohort of …
By HANS DUVEFELT Almost every day I catch a suspicious fax needing my signature. Often it is an out of state vendor who wants my permission to provide a back brace for a diabetic patient, a continuous blood glucose monitor for a non-diabetic or a compounded (custom made) ointment of some sort that makes no …
Please Sign Below: Fraudsters Phishing for Physician Signatures Read More »
By HANS DUVEFELT Every patient is unique, with some common basic and measurable features and parameters. For a couple of decades now, healthcare has professed to be patient centered. But the prevailing culture of “quality” (and the reality of getting paid for what you do) has us spending at least half our time documenting for …
The Parallel Realities of Health Care: Ratio and Intellectus Read More »
By HANS DUVEFELT A “frozen shoulder” can be manipulated to move freely again under general anesthesia. The medications we use to put patients to sleep for such procedures work on the brain and don’t concentrate in the shoulder joints at all. An ingrown toenail can be removed or an arthritic knee can be replaced by …
The Pain Is In Your Brain: Your Knees Know Next to Nothing Read More »
By HANS DUVEFELT A while back I was able to completely stop my mastocytosis patient’s chronic hives, which the allergist had been unable to control. I did it with a drug that has been on the market since 1969 and is taken once a day at a cost of 40 cents per capsule at Walmart pharmacies. …
Doxepin, a Little Known Super Drug in My Personal Black Bag of Tricks Read More »
By HANS DUVEFELT The timeline of a patient’s symptoms is often crucial in making a correct diagnosis. Similarly, the timeline of our own clinical decisions is necessary to document and review when following a patient through their treatment. In the old paper charts, particularly when they were handwritten, office notes, phone calls, refills and many …
By HANS DUVEFELT The faxes keep coming in, sometimes several at a time. “Your (Medicare) patient has received a temporary supply, but the drug you prescribed is not on our formulary or the dose is exceeding our limits.” Well, which is it? Nine times out of ten, the fax doesn’t say. They don’t explain what their …
By HANS DUVEFELT The hackneyed windows phrase, about what a domestic employee will and will not do for an employer, represents a concept that applies to the life of a doctor, too. Personally, I have to do Windows, the default computer system of corporate America, even though I despise it. But in my personal life …
By HANS DUVEFELT The woman had a bleeding ulcer and required a blood transfusion. The hospital discharge summary said to see me in three days for a repeat CBC. But she had a late Friday appointment and there was no way we would get a result before the end of the day. She also had …
The Art of Clinical Decision Making: Friday Afternoon Dilemmas Read More »
By HANS DUVEFELT Walter Brown’s blood sugars were out of control. Ellen Meek had put on 15 lbs. Diane Meserve’s blood pressure was suddenly 30 points higher than ever before. In Walter’s case, he turned out to have an acute thyroiditis that caused many other symptoms that came to light during our standard Review of …
By HANS DUVEFELT “I worry, so you don’t have to”, is how I explain to patients when something about their story or physical exam makes me consider that they may have something serious going on. The worst thing you can do is give false reassurance without serious consideration. And the next worst thing you can …
The Art of Listening: When the Inner Voice Whispers Read More »
By MATTHEW HOLT Kelsey Mellard is CEO of Sitka, one of the emerging companies that’s providing specialty consults online to primary care docs. They’ve been building a specialty care network that can be accessed by asynchronous video, slightly different to some of their competition. Most of their customers are capitated medical groups, like ChenMed, trying …
By ANISH KOKA A recent email that arrived in my in-box a few weeks ago from an academic hailed the latest “paradigm shift” in cardiology as it relates to the management of stable angina. (Stable angina refers to chronic,non-accelerating chest pain with a moderate level of exertion). The points made in the email were as …
The Paradigm Shift That Wasn’t: The ISCHEMIA Trial Read More »
By HANS DUVEFELT I love cars and dislike computers. My car takes me where I need to go, but it also gives me pleasure along the way. I have had it for just about ten years now and I have driven it almost 300,000 miles. It feels like an extension of me. Everything about it …
Driverless Cars or Keyboardless EMRs? Which Do We Need Most? Read More »
By SAURABH JHA and JEANNE ELKIN Mr. Smith’s pneumonia was clinically shy. He didn’t have a fever. His white blood cells hadn’t increased. The only sign of an infection, other than his cough, was that his lung wasn’t as dark as it should be on the radiograph. The radiologist, taught to see, noticed that the …
By HANS DUVEFELT I sometimes tell patients “I work for the government”, but sometimes I say the opposite, “I work for you”. Herein lies a dichotomy that is eating away at primary care in this country, like a slow growing cancer. I suspect everybody is aware of it, but it seems nobody has the inclination …
By YASMIN ASVAT An estimated 1.8 million people in this country may face a cancer diagnosis this year, in what has already been a bleak year of isolation and loss. While news of the COVID-19 vaccine rolling out across the U.S. offers hope in a year of 311,000 deaths, 11 million people face the financial pressure of unemployment, and, approximately 43 percent of …
3 Patient Lessons: What Cancer Patients Teach Me Read More »
By HANS DUVEFELT, MD Growing up in Sweden without a Thanksgiving holiday, Christmas has been a time for me to reflect on where I am and where I have been and New Year’s is when I look forward. I have written different kinds of Christmas reflections before: sometimes in jest, asking Santa for a better EMR; sometimes filled …
A Christmas Message to All Physicians From a Swedish-American Country Doctor in Maine Read More »
By MICHAEL E. LIPKIN and RUSSELL S. TERRY, JR. Burnout has always been a concern in medicine, and that concern has been amplified by the added stress of COVID-19. Many months into an unpredictable and distressing situation, we have both hung on to our mental health and professional passion by seeking out strategies that work …
Two Surgeons—a Veteran and a Newcomer—Talk Fighting COVID Burnout Read More »
By HANS DUVEFELT Life as we knew it and medicine as we had viewed it shapeshifted so dramatically in the past year that it is still hard to believe. Medicine has started to move from an in-person only profession to one that finally recognizes that clinical assessment and treatment have fewer boundaries than people assumed. …
The Year When Everything Changed: Covid, Self Care and High Tech Innovation In Medicine Read More »
By HANS DUVEFELT Insurance is the wrong word for what we have here. Our private health insurance system’s prioritization of sometimes frivolous screenings but non-coverage for common illnesses and emergencies is a travesty and an insult to typical American middle class families. State Medicaid insurance for the underemployed has minimal copays of just a few dollars …
By HANS DUVEFELT Sooner, rather than later, we will be driving electric cars because of the environment. We use energy efficient light bulbs and recyclable packaging for the same reason. And there is a growing debate about the environmental impact of what kind of food we produce and consume. But I still don’t hear enough …
Stewardship: We Worry More About the Environment than Our Own Bodies Read More »
By HANS DUVEFELT A doctor’s schedule as typical EMR templates see it only has “Visit Types”: New Patient, 15 minute, 30 minute. But as clinicians we like to know more than that. One patient may have a brand new worrisome problem we must start evaluating from scratch, while another is just coming in for a …
The Art of Listening: Beyond the Chief Complaint Read More »
By MIKE MAGEE The patient/health-professional relationship is fundamentally grounded in science and trust, and involves the exchange of compassion, understanding and partnership. The Covid-19 pandemic has challenged this relationship by acutely increasing the nation’s burden of disease, creating new barriers to face-to-face contact, and injecting high levels of fear and misinformation. Dr. Sean Conley, Trump’s …
By MIKE MAGEE The patient/health-professional relationship is fundamentally grounded in science and trust, and involves the exchange of compassion, understanding and partnership. The Covid-19 pandemic has challenged this relationship by acutely increasing the nation’s burden of disease, creating new barriers to face-to-face contact, and injecting high levels of fear and misinformation. Dr. Sean Conley, Trump’s …
By GRACE CORDOVANO, DEVEN McGRAW, and AARON MIRI The HIPAA Privacy Rule gives patients the right to copies of their medical records, with rare exceptions. When patients need a copy of their medical records, most start the process by calling their doctor’s office and asking for how to get access. The receptionist or office staff …
How Can Patients Get Medical Records from a Closed Medical Practice? Read More »
By HANS DUVEFELT Interviewing celebrities can make you a celebrity yourself, and it can make you very rich. So there’s got to be something to it or it would be a commodity. The world of media certainly recognizes the special skill it takes to get people to reveal their true selves. At the other end …
Physicians’ Communication Skills are Overlooked and Undervalued Read More »
By HAYWARD ZWERLING I walked into my exam room to see a patient I first met two decades ago. On presentation, his co-morbidities included poorly controlled DM-1, hypertension, hyperlipidemia, and a substance abuse disorder. Over the years our healthcare system has served him well as he has remained free of diabetic complications and now leads …
By HANS DUVEFELT Meaningful Use was a vision for EMRs that in many ways turned out to be a joke. Consider my list of Meaningful U’s for medical providers instead. When electronic medical records became mandatory, Federal monies were showered over the companies that make them by way of inexperienced, ill-prepared practices rushing to pick …
By HANS DUVEFELT He cancelled his followup appointment because he was feeling fine. He didn’t see the point in wasting a Saturday to come to my clinic when he had lawns to mow and chores to do. Less than two weeks before that he was sitting on the exam table in my office, again and …
By SHVETALI THATTE Late one evening, a trauma patient, a mother of three, comes through on an ambulance. She’s having trouble breathing, despite the breathing tube lodged in her throat. Dr. Nikhil K. Murthy, the neurosurgeon on the case, assesses the situation and orders a CT, which reveals a ruptured aneurysm, or a burst blood …
By HANS DUVEFELT, MD Now that we are seeing patients via telemedicine or even getting reimbursed for handling their issues over the phone, our existing healthcare institutions are more and more starting to look like shopping malls. They were once traffic magnets, so large that they created new developments far away from where people lived …
By SYLVIE STACY, MD, MPH As a physician and writer on the topic medical careers, I’ve noticed extensive interest in nonclinical career options for physicians. These include jobs in health care administration, management consulting, pharmaceuticals, health care financing, and medical writing, to name a few. This anecdotal evidence is supported by survey data. Of over …
Medical Education Must Adapt to Support the Broadening Role of Physicians Read More »
By RUCHI GUPTA, MD, MPH The average American elementary school class includes two students living with one or multiple food allergies. That’s nearly six million children in the United States alone. And these numbers are climbing. There was a staggering 377 percent increase in medical claims with diagnoses of anaphylactic food reactions between 2007 and …
Everyone has a role to play: Reducing your child’s risk of developing food allergies Read More »
By MICHEL ACCAD, MD I recently participated in a debate opposing me to Professor Adam Cifu on the topic of “Evidence-based medicine in the age of COVID.” The debate took place on an episode of Dr. Chadi Nabhan’s Outspoken Oncology podcast. Dr. Saurabh Jha was the moderator and he did a great job keeping us on …
By CHADI NABHAN, MD, MBA, FACP “The goal for me and for my clinical and research colleagues is to put ourselves out of a job as quickly as possible”. This is how Mikkael Sekeres ends his book “When Blood Breaks Down” based on true stories of patients with leukemia. I share Mikkael’s sentiments and have …
“When Blood Breaks Down”: It Can Break Your Heart Read More »
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