In a recent 8 year study published in the British Medical Journal (Cesar et al 2010) adults who brushed their teeth less than once a day were 70% more likely to suffer cardiovascular disease than those who brushed twice daily. In a subgroup analysis, poor oral hygiene was also linked to elevated C-reactive protein and fibrinogen levels indicating inflammation. The authors say their findings suggest "a possible role of poor oral hygiene in the risk of cardiovascular disease via systemic inflammation,".
Over the past two decades, there has been a growing body of scientific evidence linking dental disease, specifically periodontal disease, and cardiovascular disease through inflammation. Inflammation plays an important role in the pathogenesis of atherosclerosis, and markers of low-grade inflammation have been consistently associated with a higher risk of cardiovascular disease. Periodontal disease, a chronic infection of the tissue surrounding the teeth is one of the most common chronic infections and is associated with moderate inflammation, such as raised concentrations of C reactive protein and other inflammatory biomarkers. The theory is that oral infections and the associated inflammation might add to the inflammatory burden of the individual and result in increased levels of cardiovascular risk. A little bit of extra inflammation on topic of someone who is already at risk with underlying inflammation, appears to be the straw that breaks the camels back.
The study authors suggest that periodontal disease seems to be associated with a 19% increase in the risk of future cardiovascular disease. This increase in relative risk is more prominent (44%) in people aged under 65. Interestingly the relative risk benefits of cholesterol lowering drugs is in the same order of magnitude, around 20% to 40%. Shouldn’t we recommend cleaning your teeth instead of drugs. Don’t get confused between relative risk and absolute risk. Both these process save only one life in 100, around 1% absolute risk. But tooth brushing is a lot cheaper and no negative side effects.
The message from this research is the need for good oral hygiene and that CVD is an inflammatory disease not a cholesterol imbalance.
Reference:
De Oliveira, Cesar, Richard Watt, Mark Hamer, Toothbrushing, inflammation, and risk of cardiovascular disease: results from Scottish Health Survey. BMJ 2010;340:c2451
Monday, May 31, 2010
Wednesday, May 26, 2010
ADHD and phthalates.
Prenatal (before birth) exposure to a group of chemicals called phthalates has been linked with ADHD like symptoms in a study published on the Environmental Health Perspectives website on January 28, 2010. Phthalates are a group of chemicals often added to plastics to give them their plastic-flexible like qualities, as well as in paints, lubricants and detergents (yep the ones in your supermarket). They are also found in some personal car products such as nail polish, liquid soap, shampoos, perfume and eye shadow. They are pretty well everywhere in our homes.
The study found that mothers with higher levels of the phtalates in their blood reported poorer behaviour in their children (ages 4-9 years), including typical ADHD symptoms. However, ADHD is not the only problem associated with phthaltes. Phthaltes have been linked in both animal experiments and human research with sexual organ and sexual behaviour dysfunction to name a just a few of the problems they can create.
Phthaltes are considered endocrine disruptors because, at incredibly low levels, they interfere with hormones such as estrogen in the body. The most vulnerable stage of these chemicals to have an impact is on the developing foetus in pregnant mothers.
In another study in the Journal of Paediatrics, February 2010, the use of baby personal care products such as lotions, shampoos and powder was associated with higher levels of phthalates in the babies blood.
The message is to become aware of the chemicals in your home and reduce the exposure to everyone but particularly to mums to-be. You can find a lot more on toxic chemical exposure in my book “Is Your Home Making You Sick”
The study found that mothers with higher levels of the phtalates in their blood reported poorer behaviour in their children (ages 4-9 years), including typical ADHD symptoms. However, ADHD is not the only problem associated with phthaltes. Phthaltes have been linked in both animal experiments and human research with sexual organ and sexual behaviour dysfunction to name a just a few of the problems they can create.
Phthaltes are considered endocrine disruptors because, at incredibly low levels, they interfere with hormones such as estrogen in the body. The most vulnerable stage of these chemicals to have an impact is on the developing foetus in pregnant mothers.
In another study in the Journal of Paediatrics, February 2010, the use of baby personal care products such as lotions, shampoos and powder was associated with higher levels of phthalates in the babies blood.
The message is to become aware of the chemicals in your home and reduce the exposure to everyone but particularly to mums to-be. You can find a lot more on toxic chemical exposure in my book “Is Your Home Making You Sick”
ADD/ADHD Real Evaluation
Sadly, little real evaluation of ADD/ADHD children is actually carried out. They are not routinely evaluated for chemical, nutritional or allergic factors, or assessed for behavioural or environmental issues arising from their home environment. Instead they are given drugs. This is despite the fact that there is growing body of scientific literature showing significant nutritional deficiencies in many of these children. There is growing evidence that a significant number of ADD/ADHD sufferers have a high body burden of heavy metals, particularly lead, mercury, cadmium and the organophosphate pesticdes. These metals are potent toxins which block thousands of important chemical reactions in the body and can play havoc with the nervous system. At even moderate concentrations, lead can lower a child’s IQ. Recent research links infant and maternal exposure to lead with higher rates of schizophrenia.
Nutritional deficiency is an underlying cause of ADD/ADHD in a significant number of children. Correcting these deficiencies and inbalances can make substantial improvements in childrens’ behaviour. Sometimes improvement is almost immediate.
The basic problem appears to be deficient levels of neurotransmitters (chemicals that coordinate many of the body’s and mind’s activities) in brain cells. Various chemical substances affect the transmission of messages across the synapse, the gap between individual nerve cells. Acetylcholine, adrenalin, noradrenaline, dopamine, gamma-aminobutyric acid (GABA) and serotonin are all examples of neurotransmitters. Some of these chemicals are responsible for other chemical secretions and uptake. They control muscular activity, mood and behaviour. So you can see how they are likely be involved in ADD/ADHD.
Nutritional deficiency is an underlying cause of ADD/ADHD in a significant number of children. Correcting these deficiencies and inbalances can make substantial improvements in childrens’ behaviour. Sometimes improvement is almost immediate.
The basic problem appears to be deficient levels of neurotransmitters (chemicals that coordinate many of the body’s and mind’s activities) in brain cells. Various chemical substances affect the transmission of messages across the synapse, the gap between individual nerve cells. Acetylcholine, adrenalin, noradrenaline, dopamine, gamma-aminobutyric acid (GABA) and serotonin are all examples of neurotransmitters. Some of these chemicals are responsible for other chemical secretions and uptake. They control muscular activity, mood and behaviour. So you can see how they are likely be involved in ADD/ADHD.
Wednesday, May 19, 2010
Pesticide Exposure Linked to Attention-Deficit/Hyperactivity Disorder in Kids
Pesticides linked to ADHD
A recent study (Pediatrics, may 17, 2010) of 1139 children aged 8 to 15 years of age found children with greater exposure to widely used pesticides are more likely to have attention-deficit/hyperactivity disorder.
As levels of the organophosphate pesticide metabolite (breakdown product) dialkyl phosphate metabolites increased, so did ADHD prevalence. In particular, children with elevations in the most commonly detected metabolite, dimethyl thiophosphate, had twice the odds of having ADHD. That is the higher the levels the greater the risk of being diagnosed with ADHD. These pesticides have their effect on the nervous system so it is easy to understand how they can contribute to ADHD
The authors of the study concluded that organophosphate pesticide exposure, at levels common among US children, may contribute to ADHD prevalence. Common organophosphate pesticides in the home include diazanon, chlorpyrifos and dichlorvos used in insect sprays and treatments. Unfortunately, because of our poor understanding of these kids we then treat them with other highly toxic chemicals such as Ritalin and similar drugs instead of finding out the cause of the problem.
Perhaps we should be asking what other chemicals may be contributing to the symptoms of ADHD? And the answer would be heavy metals such as mercury and lead and the food colours common in every kids food.
A recent study (Pediatrics, may 17, 2010) of 1139 children aged 8 to 15 years of age found children with greater exposure to widely used pesticides are more likely to have attention-deficit/hyperactivity disorder.
As levels of the organophosphate pesticide metabolite (breakdown product) dialkyl phosphate metabolites increased, so did ADHD prevalence. In particular, children with elevations in the most commonly detected metabolite, dimethyl thiophosphate, had twice the odds of having ADHD. That is the higher the levels the greater the risk of being diagnosed with ADHD. These pesticides have their effect on the nervous system so it is easy to understand how they can contribute to ADHD
The authors of the study concluded that organophosphate pesticide exposure, at levels common among US children, may contribute to ADHD prevalence. Common organophosphate pesticides in the home include diazanon, chlorpyrifos and dichlorvos used in insect sprays and treatments. Unfortunately, because of our poor understanding of these kids we then treat them with other highly toxic chemicals such as Ritalin and similar drugs instead of finding out the cause of the problem.
Perhaps we should be asking what other chemicals may be contributing to the symptoms of ADHD? And the answer would be heavy metals such as mercury and lead and the food colours common in every kids food.
Wednesday, May 5, 2010
Multiple Sclerosis (MS) a preventable disease
Just over a year ago a student of mine motivated me to look into multiple Sclerosis. Bruce put up a slide quoting the official authorities saying there was no link between MS and nutrition. He then presented a slide with more than 40 peer reviewed scientific papers on the link between MS and nutrition. Along with Bruce it continually confuses me as to why such supposed authorities continue to deny the existence of nutritional treatments and even worse the role of poor nutrition in the causes. Since inspiring me I have now seen dozens of people suffering from MS begin a new life through really simple changes in nutrition and one of the simplest changes follows on from one of my earlier articles on vitamin D. Many Australians just don’t get enough sun anymore. But more on that later. What is even more important is that this information can help prevent the development of MS in the beginning.
There is now overwhelming evidence of the risk of developing MS is linked to a number of environmental factors such as excessive dietary intake of saturated fats and deficiencies in polyunsaturated fatty acids, vitamin D and antioxidants 1,2. As a result of these findings good nutrition appears critical in limiting the development and ongoing effects of MS and enhance quality of life while limiting the risk of secondary conditions 3.
Over the past 200 years MS has significantly increased in incidence and prevalence. MS is a disease that effects an estimated 2.5 million people worldwide with over 18, 000 people in Australia with the disease, the incidence rate in Australia is increasing by 7% each year and financially costs approximately 2 billion dollars each year 4. It is twice as common in females (who have lower vitamin D than males) as in males and is the most frequent neurodegenerative disease in young adults 5,1. Geographically MS is common across northern Europe, Scandinavia and across the US and is much higher in incidence among whites then other racial groups 5.The disease is very rare in Japan, the Indian subcontinent and is unknown to black Africans however these groups are at significant risk to developing MS, when they go to other places to live, which supports the concept that an environmental factor is responsible for MS 5.
MS is a chronic, degenerative and autoimmune initiated inflammatory disease of the central nervous system, which may involve the brain, optic nerve or spinal cord and is characterized by demyelination 5,6. That is the myelin, that wraps around and insulates the nerve axons in the central nervous system, suffers self-destruction and degeneration 7. This means damaged myelin results in damaged nerve axons and causes the various disabilities of MS7. It is worth noting here that myelin is around 80% lipids (fats) and cholesterol (which I have written on in past articles) makes up an indispensable component of myelin membranes 8. The inflammatory reactions are poorly controlled and result in substantial damage to the myelin 7. As a result of demyelination MS patients suffer functional impairments such as abnormal walking mechanics, poor balance, muscle weakness and fatigue which result in individuals reduced ability to perform activities of daily living 9.
The single most important factor linked to the development of MS is a reduced supply of vitamin D 7, which I have written on extensively in the past. Research has shown that the active hormonal form of vitamin D, 1,25-dihydroxyvitamin is a natural immune system regulator with anti-inflammatory action 10. Vitamin D is received from two sources, diet and sunshine, however it is considered diet provides insignificant amounts and therefore sensible exposure to sunlight is considered the most effective source 11. Even Scandinavian diets (rich in oily fish) scarcely exceed a few hundred IU/d of vitamin D 12. Sunshine is therefore the principal natural source of vitamin D, providing approximately 90% of requirements. Sunbathing can provide 10,000–20,000 IU in 15–30 min, but this will only last a few weeks before it needs to be replenished 13,14. It is interesting to note that women generally have lower serum levels than men 15,16 and have significantly higher levels of MS.
There is a 41% decrease in MS risk for every 50 nanomoles per liter increase in vitamin D (1,25-hydroxyvitamin) in the blood. The prevalence of MS is highest where environmental supplies of vitamin D are lowest 18. There is significant epidemiological data from Australia that shows a very strong correlation between vitamin D supply from ultraviolet (UV) radiation and MS prevalence 7. The correlation is indeed stronger than that of UV radiation exposure and melanoma development 7. Globally countries of high latitudes with insufficient UV radiation for most of the year report a higher incidence of MS 19,20. One case-control study has also shown that vitamin D status in individuals at the time of diagnosis of MS is significantly lower then healthy controls, indicating a further link 19.
It is theorized that vitamin D deficiencies may lead to an increase in T-helper cell autoimmune responses and therefore resulting in excessive damage to the myelin and MS symptoms 21.
Vitamin D supply through dietary intake also appears critical, as it has been reported that through vitamin D supplements there is an inverse relationship with MS 19. The role of vitamin D is supported by animal studies where mouse models have shown that vitamin D deficient mice succumb faster to MS but once administered with vitamin D the symptoms diminish 22.
The idea that an increase in saturated fats in modern diets may result in increased risks for MS (and diabetes type 2) has been known since the early 1950’s and reinforced on several occasions 23. Epidemiological studies in Norway have shown inland farming communities with high intake of animal products had higher MS incidence rates then coastal communities where consumption of fish is high while subsequent studies have also shown a negative correlation between MS and the consumption of fish, fruits and vegetables 23. Any wonder the rates of MS are increasing so fast in Australia knowing the poor diet most kids are having. It has been shown that MS sufferers have deficiencies in essential polyunsaturated fatty acids (PUFA), primarily the omega 3 fats which is demonstrated in that the lipid and fatty acid composition in plaque tissue from the MS brain is altered compared to the normal brain white matter 1.
It is believed that humans evolved on a diet with a ratio of omega-6 to omega-3 of approximately 1:1 where as in western diets the ratio is varied between 15:1 – 20:1 24. We just have too much vegetable oil (omega 6) in our diet. It is literally added liberally to all processed foods.
A large study conducted over a 35 year period showed MS patients on a diet with low saturated fat and supplementation with cod liver oil provided long term benefits on mortality, relapse severity and disability, particularly if initiated during the earliest stages of MS 25. The results of this have shown that MS patients can expect to survive and be ambulant and otherwise normal to an advanced age if following an extreme low fat diet and omega-3 supplementation 26. The rarity of MS in the Japanese, whose diet consist of low saturated fat and high omega-3 fatty acids is another indication of the role of omega 3 oils in MS 27. There is now significant evidence to show it is a contributing factor to the development of the disease in conjunction with other environmental factors 7.
The development of MS is also believed to be linked to oxidant stress in the body from a lack of antioxidants 28. Along with other possible environmental factors the actual role of oxidative stress in patients with MS is poorly understood 29. The brain and nervous system are particularly susceptible to oxidative damage due to the low content of antioxidants in this area of the body due to them having to be imported 30.
Studies have shown that oxidative stress causes an activation where the production of pro-inflammatory chemical messengers called cytokines occurs which then contributes to the process of demyelination 31. Having sufficient antioxidants therefore ensures neuroprotection through suppression of inflammation, this limits the effects of MS 29,31,32.
Oligodendrocytes, a particular type of brain cell, that produce the extensive myelin sheaths are known to be particularly vulnerable to oxidative stress, this helps explain the lack of remyelination during remission stages 1. Oxidation (free radicals) literally stops the repair work on any damage to the myelin sheath.
In helping to prevent and restrict the development of MS there are a number of recommendations that can be applied as determined through scientific studies:
• Regular moderate sun exposure (15-30 min/day)
• Decreased intake of saturated fat and omega-6 PUFA accompanied with an increased consumption of omega-3 PUFA through consumption of fish and supplementation
• Daily supplement of vitamin D to ensure circulating level of vitamin D remains between 100 – 150 nanomoles per liter
• Consume at least 5-7 serves of antioxidant rich fruits and vegetables each day and supplement.
Acknowledgements. Bruce Greatwitch
References:
1. Meeteren et. al. 2005
2. Liuzzi et. al. 2007
3. Timmerman, Stuifbergin 1999
4. MS research Australia 2008
5. Undurti 2003
6. Kanwar, 2005
7. Embry 2004
8. Saher et al 2005
9. White et. al. 2004
10. Van Amerongen 2004
11. Cantorna, Mahon 2004
12. Mark and Carson, 2006
13. Hollis, 2005
14. Vieth, 2007
15. Yetley, 2008
16. Zadshir et al 2005
17. Anonymous 2007
18. VanAmerongen et. al. 2004
19. Barnes et. al. 2007
20. Kampman et. al. 2007
21. Toohey 2004
22. Mandavilli 2007
23. Nordvik et. al. 2000
24. Simopoulos 2002
25. Swank cited in Weinstock-Guttman et. al. 2005
26. Swank, Goodwin 2003
27. Undurti 2003
28. Lutskii, Esaulenko 2007
29. Koch et. al. 2006
30. Syburra, Passi, 1999
31. Gonsette 2008
32. Gilgun-Sherki et. al. 2004
There is now overwhelming evidence of the risk of developing MS is linked to a number of environmental factors such as excessive dietary intake of saturated fats and deficiencies in polyunsaturated fatty acids, vitamin D and antioxidants 1,2. As a result of these findings good nutrition appears critical in limiting the development and ongoing effects of MS and enhance quality of life while limiting the risk of secondary conditions 3.
Over the past 200 years MS has significantly increased in incidence and prevalence. MS is a disease that effects an estimated 2.5 million people worldwide with over 18, 000 people in Australia with the disease, the incidence rate in Australia is increasing by 7% each year and financially costs approximately 2 billion dollars each year 4. It is twice as common in females (who have lower vitamin D than males) as in males and is the most frequent neurodegenerative disease in young adults 5,1. Geographically MS is common across northern Europe, Scandinavia and across the US and is much higher in incidence among whites then other racial groups 5.The disease is very rare in Japan, the Indian subcontinent and is unknown to black Africans however these groups are at significant risk to developing MS, when they go to other places to live, which supports the concept that an environmental factor is responsible for MS 5.
MS is a chronic, degenerative and autoimmune initiated inflammatory disease of the central nervous system, which may involve the brain, optic nerve or spinal cord and is characterized by demyelination 5,6. That is the myelin, that wraps around and insulates the nerve axons in the central nervous system, suffers self-destruction and degeneration 7. This means damaged myelin results in damaged nerve axons and causes the various disabilities of MS7. It is worth noting here that myelin is around 80% lipids (fats) and cholesterol (which I have written on in past articles) makes up an indispensable component of myelin membranes 8. The inflammatory reactions are poorly controlled and result in substantial damage to the myelin 7. As a result of demyelination MS patients suffer functional impairments such as abnormal walking mechanics, poor balance, muscle weakness and fatigue which result in individuals reduced ability to perform activities of daily living 9.
The single most important factor linked to the development of MS is a reduced supply of vitamin D 7, which I have written on extensively in the past. Research has shown that the active hormonal form of vitamin D, 1,25-dihydroxyvitamin is a natural immune system regulator with anti-inflammatory action 10. Vitamin D is received from two sources, diet and sunshine, however it is considered diet provides insignificant amounts and therefore sensible exposure to sunlight is considered the most effective source 11. Even Scandinavian diets (rich in oily fish) scarcely exceed a few hundred IU/d of vitamin D 12. Sunshine is therefore the principal natural source of vitamin D, providing approximately 90% of requirements. Sunbathing can provide 10,000–20,000 IU in 15–30 min, but this will only last a few weeks before it needs to be replenished 13,14. It is interesting to note that women generally have lower serum levels than men 15,16 and have significantly higher levels of MS.
There is a 41% decrease in MS risk for every 50 nanomoles per liter increase in vitamin D (1,25-hydroxyvitamin) in the blood. The prevalence of MS is highest where environmental supplies of vitamin D are lowest 18. There is significant epidemiological data from Australia that shows a very strong correlation between vitamin D supply from ultraviolet (UV) radiation and MS prevalence 7. The correlation is indeed stronger than that of UV radiation exposure and melanoma development 7. Globally countries of high latitudes with insufficient UV radiation for most of the year report a higher incidence of MS 19,20. One case-control study has also shown that vitamin D status in individuals at the time of diagnosis of MS is significantly lower then healthy controls, indicating a further link 19.
It is theorized that vitamin D deficiencies may lead to an increase in T-helper cell autoimmune responses and therefore resulting in excessive damage to the myelin and MS symptoms 21.
Vitamin D supply through dietary intake also appears critical, as it has been reported that through vitamin D supplements there is an inverse relationship with MS 19. The role of vitamin D is supported by animal studies where mouse models have shown that vitamin D deficient mice succumb faster to MS but once administered with vitamin D the symptoms diminish 22.
The idea that an increase in saturated fats in modern diets may result in increased risks for MS (and diabetes type 2) has been known since the early 1950’s and reinforced on several occasions 23. Epidemiological studies in Norway have shown inland farming communities with high intake of animal products had higher MS incidence rates then coastal communities where consumption of fish is high while subsequent studies have also shown a negative correlation between MS and the consumption of fish, fruits and vegetables 23. Any wonder the rates of MS are increasing so fast in Australia knowing the poor diet most kids are having. It has been shown that MS sufferers have deficiencies in essential polyunsaturated fatty acids (PUFA), primarily the omega 3 fats which is demonstrated in that the lipid and fatty acid composition in plaque tissue from the MS brain is altered compared to the normal brain white matter 1.
It is believed that humans evolved on a diet with a ratio of omega-6 to omega-3 of approximately 1:1 where as in western diets the ratio is varied between 15:1 – 20:1 24. We just have too much vegetable oil (omega 6) in our diet. It is literally added liberally to all processed foods.
A large study conducted over a 35 year period showed MS patients on a diet with low saturated fat and supplementation with cod liver oil provided long term benefits on mortality, relapse severity and disability, particularly if initiated during the earliest stages of MS 25. The results of this have shown that MS patients can expect to survive and be ambulant and otherwise normal to an advanced age if following an extreme low fat diet and omega-3 supplementation 26. The rarity of MS in the Japanese, whose diet consist of low saturated fat and high omega-3 fatty acids is another indication of the role of omega 3 oils in MS 27. There is now significant evidence to show it is a contributing factor to the development of the disease in conjunction with other environmental factors 7.
The development of MS is also believed to be linked to oxidant stress in the body from a lack of antioxidants 28. Along with other possible environmental factors the actual role of oxidative stress in patients with MS is poorly understood 29. The brain and nervous system are particularly susceptible to oxidative damage due to the low content of antioxidants in this area of the body due to them having to be imported 30.
Studies have shown that oxidative stress causes an activation where the production of pro-inflammatory chemical messengers called cytokines occurs which then contributes to the process of demyelination 31. Having sufficient antioxidants therefore ensures neuroprotection through suppression of inflammation, this limits the effects of MS 29,31,32.
Oligodendrocytes, a particular type of brain cell, that produce the extensive myelin sheaths are known to be particularly vulnerable to oxidative stress, this helps explain the lack of remyelination during remission stages 1. Oxidation (free radicals) literally stops the repair work on any damage to the myelin sheath.
In helping to prevent and restrict the development of MS there are a number of recommendations that can be applied as determined through scientific studies:
• Regular moderate sun exposure (15-30 min/day)
• Decreased intake of saturated fat and omega-6 PUFA accompanied with an increased consumption of omega-3 PUFA through consumption of fish and supplementation
• Daily supplement of vitamin D to ensure circulating level of vitamin D remains between 100 – 150 nanomoles per liter
• Consume at least 5-7 serves of antioxidant rich fruits and vegetables each day and supplement.
Acknowledgements. Bruce Greatwitch
References:
1. Meeteren et. al. 2005
2. Liuzzi et. al. 2007
3. Timmerman, Stuifbergin 1999
4. MS research Australia 2008
5. Undurti 2003
6. Kanwar, 2005
7. Embry 2004
8. Saher et al 2005
9. White et. al. 2004
10. Van Amerongen 2004
11. Cantorna, Mahon 2004
12. Mark and Carson, 2006
13. Hollis, 2005
14. Vieth, 2007
15. Yetley, 2008
16. Zadshir et al 2005
17. Anonymous 2007
18. VanAmerongen et. al. 2004
19. Barnes et. al. 2007
20. Kampman et. al. 2007
21. Toohey 2004
22. Mandavilli 2007
23. Nordvik et. al. 2000
24. Simopoulos 2002
25. Swank cited in Weinstock-Guttman et. al. 2005
26. Swank, Goodwin 2003
27. Undurti 2003
28. Lutskii, Esaulenko 2007
29. Koch et. al. 2006
30. Syburra, Passi, 1999
31. Gonsette 2008
32. Gilgun-Sherki et. al. 2004
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