352 I
welcome and will,
hopes, lead to better-informed rising generation of doctors. Pre-
one
prescribing by the scriber’s Journal is a useful form of reviews but is tion
as
source
not as
ready
of information in the a source of informa-
the B.N.F.
Guidance, however, is
not enough in any walk of life. Encouragement is needed to follow that guidance. In the case of prescribing, such encouragement might take a positive form: for example, if a doctor, or group of doctors, were able to reduce expenditure on drugs, then money might be available for, say, desired staff or equipment. This would be preferable to another approach whereby increased prescription charges are demanded for medicines which can be had in cheaper but equally satisfactory form. The real issue, of course, is whether a doctor really has the right to prescribe what he likes to whom he likes for as long as he likes. We can hardly criticise civil servants for overspending when the right to prescribe is demanded without acceptance of the respon-
sibilities which go with it.
BRAIN OPERATIONS IN UPRIGHT PATIENTS WHEN posterior-fossa and upper-cervical-cord operations are done with the patient sitting up, a substantial hazard is air embolism. The simplest way to avoid it is, of course, to settle for a different position. Some neurosurgeons accordingly operate with the patient face-down or in a modified lateral ("park-bench"l) position. With the patient sloping head-up, the park-bench position is particularly suitable for removal of acoustic neuromas.2 But the final decision rests with the surgeon, who will want to weigh the better operating conditions of the sitting position against its risks. If he opts for the sitting position, the surgeon himself can lessen the risk of fatal embolism by securing any open veins in the woundparticularly the mastoid emissary vein as soon as it is divided, since a lateral tear in this vessel is a common site of air entry into the venous circulation.2 Quite large amounts of air can enter into the circulation without serious consequences. It takes 8 ml/kg to kill a dog;3 and in rabbits the fatal dose is about 5 mVkg.4 In man air may enter the circulation without clinical evidence of air embolism. For example, in one series of 69 patients the doppler detector revealed air entry on twenty-nine occasions in 22 patients, 7 of whom had no clinical signs of air embolism.6 But even small quantities of air on the left side of the circulation may be disastrous.6 Pleural shock, which used to arise during induction of a pneumothorax for tuberculosis, in fact may have represented entry of air into the pulmonary veins and thence into the coronary arteries. Embolus paradoxus, better known in relation to thrombosis episodes, can also occur with air, particularly in the patient with a patent foramen ovale. The toxicity of air is increased more than threefold in animals inhaling nitrous 1.
Gilbert, R. G. B., Brindle, F., Galindo, A. Anœsthesia for Neurosurgery. London, 1966. 2. Hunter, A. R. Neurosurgical Anœsthesia. Oxford, 1976. 3. Harkins, H. N., Harmon, P. H. Proc. Soc. exp. Biol. Med. 1934, 32, 178. 4. Munson, E. S., Merrick, H. C. Anesthesiology, 1966, 27, 783. 5. Michenfelder, J. D., Miller, R. H., Grontert, G. A. ibid. 1972, 36, 164. 6. Kent, E. M., Blades, B. J. thorac. Surg. 1942, 11, 434.
oxide.4 It has
been suggested that, as a diagnostic test for air embolism, nitrous oxide be added to the in. spired gases in patients under other forms of anaesthesia, since the nitrous oxide expands the air bubbles and thus sharply raises pulmonary arterial pressure.’ If a catheter has been placed in the right atrium, obstruction to pulmonary blood-flow due to air embolism may be detected as an increase in pulmonary arterial pressure, and subsequently in central venous pressure;8 further, froth may be aspirated through the catheter.9 But exact positioning of an atrial catheter is not easy without radiographic assistance: true, E.C,G, potentials recorded from a catheter will reveal inversion of the p-wave as the open end passes the location of the sino-atrial node; 10 but this technique has not proved I completely reliable under other circumstances." The Swan-Ganz catheter facilitates recognition of the haemodynamic consequences of air embolism, and one can be much surer of the exact location of the distal end from pressure changes recorded during its passage; but a Swan-Ganz catheter is by no means easy to pass and the procedure has its own risks and possibly even its own mortality. The immediate result of pulmonary air embolism is a diminution in carbon-dioxide elimination (provided that the tidal volume of ventilation remains constant). Reduction in either end-tidal C02 or even in mixed expired C02 may therefore signal air embolism." Finally, the most sensitive detector of the presence of bubbles in the venous circulation is the doppler (more correctly, ultrasonic) detector. So sensitive is this method that as little as 0.ml of air will be detected," though one has to put the recording head in exactly the right place.14 The doppler detector is also activated by the diathermy apparatus, 15 unless the recording head is screened with aluminium foil. 16 The older signs of air embolism are well-known. Classically, a millwheel murmur is heard. 17 Some say that, in patients with this sound, the mortality will be around 70%.18 An oesopha geal stethoscope may be more satisfactory than a precordial stethoscope for detecting changes in heart-sounds, which initially become drum-like.19 Subsequently a systolic murmur may be heard.20 21 The electrocardiogram may show signs of right-heart strain.22 Many years ago it was stated that any rise in pulse rate of 10 beats a minute or more, any fall in bloodpressure of 10 beats a minute or 10 mm Hg or more. and any disturbance of the rhythm or rate of respiration even
,
x
7.
Munson, E. S., Paul, W. J. L., Perry, J. C., de Padua, C. B., Rhoton,
8.
A. L. Anesthesiology, 1975, 42, 223. Garcia, E., Michenfelder, J. D., Theye,
R. A. Can. anœsth.
,
Soc. J. 1968, 50.
593.
Michenfelder, J. D., Terry, H. R., Daw, E. F., Miller, R. H, Anesth, Analg. curr. Res. 1966, 45, 390. 10. Robertson, J. T., Schick, R. W., Morgan, F., Matson, D. D. J. Neurosurg. 1961, 18, 255. 11. Brocklehurst, G., Greave, J. R. W., Lower, R. A., Adams, A. K. Archs Dis. Childh. 1967, 42, 166. 12. Bethune, R. V. M., Brechner, V. L. Anesthesiology, 1967, 29, 178. 13. Edmonds-Seal, J., Maroon, J. C. Anœsthesia, 1969, 24, 438. 14. Buckland, R. W., Manners, J. M. Anœsthesia, 1976, 31, 633. 15. Campkin, T. V., Perks, J. S. Lancet, 1973, i, 235. 16. Garden, E., Doll, W. Anesthesiology, 1970, 32, 551. 17. Fine, J., Fischman, J. New Engl. J. Med. 1940, 223, 1054. 18. Tissovec, L., Hamilton, W. K. J. Am. med. Ass. 1967, 201, 376 19. Shiupuri, D. N., Viswanathan, R., Sharma, M. L., Singh, P. P. J. Ind. med. Ass. 1959, 33, 86. 20. Michenfelder, J. D., Martin, J. T., Altenberg, B. M., Rehder, K. J. Am. med. Ass. 1969, 208, 1353. 21. O’Higgins, J. W. Br. J. Anœsth. 1970, 42, 549. 9.
22. Marx, G. F., Steen, S. N., Foster, E. S., Jadwal, C. M., Ketas, E. R N.Y. J. Med. 1968, 68, 2801.
353 the spontaneously breathing patient in the sitting pos:[lOn should be regarded as air embolism until the contrary was proved: compression of the jugular vein in the reck congests the operation area and causes any open veins to bleed.23 Even in the absence of clinical signs, the anssthetist was advised to compress the patient’s jugular vein in the neck every five minutes during the operation to disclose any unsecured open veins. A recent investigation’4 singles out the doppler detector as the best means of early diagnosis. It was positive in 10 out of 17 patients. 5 of the same 17 patients had end-tidal CO2 changes, In 4 there was a rise in central venous pressure, aspiration of air from the right atrium, or evidence in the .c,s. 3 patients became hypotensive and in 1 air entry into the heart was detected with an oesophageal stethoscope. These figures are rather different from the Mayo Clinic results.’ It is disturbing that, even with these elaborate aids to diagnosis, 1 of the 17 patients died of air embolism. Another 19 patients were monitored by palpation of the pulse, by intermittent bloodpressure recording, by cesophageal stethoscopy, and by electrocardiography. Only 2 of these patients had evidence of air embolism and 1 died. This patient proved at necropsy to have a patent foramen ovale. Air was also present in the pulmonary arteries. The workers concerned" now use a "necktie" of Pohl’s tubing, which is tightened to compress the jugular vein at the earliest sign of air embolism. But it seems that no measure against air embolism is infallible when operations are done on sitting patients. :n
THE LEUKAEMIC DEATH
ACUTE
myeloid leukaemia
in
adults, though
not cur-
Approaches to the individual patient differ. Bodey and his colleagues,’1 from Texas, have reviewed the necropsy findings in patients dying with acute leukaemia over a seven-year period.2’ Infection was the cause of death in two-thirds of their patients, haemorrhage in 15 %, and a combination of the two in 9%. The frequency of deaths caused by infection did not change over the years, despite improved antibiotics; but the organisms did change. For example, fatal infections with Pseudomonas aeruginosa
able, usually responds
to treatment.
declined from 27% to 8% while Klebsiella/Enterobacter/Serratia infections increased from 11% to 26%. Fatal Escherichia coli infections were steady at 11%, and 30% of all fatal infections were caused by multiple organisms. Fatal infections are often related to neutropenia-the result either of the disease itself or of intensive treatment-and antibiotics are less effective in these circumstances. Fungal infections have been increasing as a cause of death in leuksemia. In Bodey’s series, in .1,hich 20% of the fatal infections were fungal, Candida spp, were the main culprit. Platelet transfusions seem to have reduced the frequency of death from haemorrhage due to thrombocytopenia alone, but have had little effect ihen hxmorrhage was associated with disseminated in’ravascular coagulation. Store than half the patients acquiring acute myeloid will be over 60 years old. These patients, and
those between 45 and 60, do
with aggressive regimens,2 having a median survival of less than 3 months. Because of these poor results, a group at University College Hospital3 tried less aggressive treatment in this disease with results at least as good as those of other centres.3 Some points emerge from the correspondence which followed their report. It is clearly not enough to measure success or failure by quantity of life alone, when this is likely to be short: quality of survival should be incorporated into future trials. The main argument against less aggressive treatment is that the approach is negative and unlikely to advance treatment ; but a better life is a substantial advance in the patients eyes-particularly when it means he can be treated in a hospital near his home. Some patients are prepared to try anything in the hope of cure, and for them the quality-of-life argument may not apply. Others, properly informed, may be able to decide with their doctor what the aims of treatment should be.
particularly badly
TOP OF THE POPS
WHEN aerated drinks came in bottles, the bottles broke and children cut themselves on the glass; in addition, bicycle tyres were punctured, and sometimes fires were started by the sun shining through the glass. Now that many manufacturers have changed to aluminium cans, children have found a new hazard. They are swallowing the ring pull-tabs. Burrington4 reports seven cases from the U.S.A. where young children from four months to two years had serious complications. One child died from an aorto-resophageal fistula and others required thoracotomy. Unfortunately the aluminium does not show well on radiography and the tabs cannot be seen in frontal projection if they overlie the vertebral bodies. So a posterior-anterior and lateral radiograph should be done in any toddler with unexplained alteration of feeding habit or persistent respiratory symptoms. Perhaps a radiodense piece could be incorporated into the manufacture of the tabs? Why do children swallow them? For a toddler the
small, shining ring is obviously attractive and he -may not remember, or admit to, having put one in his mouth. Older children, taught to be tidy, put the tab through the opening in the can before they drink the contents, and then proceed to swallow it with the pop. It is not only children who suffer. The tabs have been carelessly thrown into pond or river, and a duck, diving to pick up food from the bottom, may push its bill through the ring and eventually starve to death. The tops of pop cans can be deposited somewhere more useful than down children’s throats, on ducks’ bills, or around the countryside? In parts of Britain collecting jars have appeared marked "for kidney patients". The tops are collected and sold to provide amenities for dialysis units. Pop tops should be directed to helping renal patients, not to providing work for paediatric surgeons. 25. M. R. C.
26.
23 Hunter, A. R. Anœsthesia, 1962, 17, 467. H. Y., Rodriguez, V., Narboni, G., Frereich, E. J. Medicine, 1976, 55, 259.
24 Chang,
Bodey,
G. P., Luna, M. A., 27.
Working Party. Br. J. Hœmat 1974, 27, 373. Burge, P. S., Richards, J. D. M., Thompson, D. S., Prankerd, T. M., Wright, P. Lancet, 1975, ii, 621. Burrington, J. D. J. Am. med. Ass. 1976, 235, 2614.
A.
J., Sare,
welcome and will,
hopes, lead to better-informed rising generation of doctors. Pre-
one
prescribing by the scriber’s Journal is a useful form of reviews but is tion
as
source
not as
ready
of information in the a source of informa-
the B.N.F.
Guidance, however, is
not enough in any walk of life. Encouragement is needed to follow that guidance. In the case of prescribing, such encouragement might take a positive form: for example, if a doctor, or group of doctors, were able to reduce expenditure on drugs, then money might be available for, say, desired staff or equipment. This would be preferable to another approach whereby increased prescription charges are demanded for medicines which can be had in cheaper but equally satisfactory form. The real issue, of course, is whether a doctor really has the right to prescribe what he likes to whom he likes for as long as he likes. We can hardly criticise civil servants for overspending when the right to prescribe is demanded without acceptance of the respon-
sibilities which go with it.
BRAIN OPERATIONS IN UPRIGHT PATIENTS WHEN posterior-fossa and upper-cervical-cord operations are done with the patient sitting up, a substantial hazard is air embolism. The simplest way to avoid it is, of course, to settle for a different position. Some neurosurgeons accordingly operate with the patient face-down or in a modified lateral ("park-bench"l) position. With the patient sloping head-up, the park-bench position is particularly suitable for removal of acoustic neuromas.2 But the final decision rests with the surgeon, who will want to weigh the better operating conditions of the sitting position against its risks. If he opts for the sitting position, the surgeon himself can lessen the risk of fatal embolism by securing any open veins in the woundparticularly the mastoid emissary vein as soon as it is divided, since a lateral tear in this vessel is a common site of air entry into the venous circulation.2 Quite large amounts of air can enter into the circulation without serious consequences. It takes 8 ml/kg to kill a dog;3 and in rabbits the fatal dose is about 5 mVkg.4 In man air may enter the circulation without clinical evidence of air embolism. For example, in one series of 69 patients the doppler detector revealed air entry on twenty-nine occasions in 22 patients, 7 of whom had no clinical signs of air embolism.6 But even small quantities of air on the left side of the circulation may be disastrous.6 Pleural shock, which used to arise during induction of a pneumothorax for tuberculosis, in fact may have represented entry of air into the pulmonary veins and thence into the coronary arteries. Embolus paradoxus, better known in relation to thrombosis episodes, can also occur with air, particularly in the patient with a patent foramen ovale. The toxicity of air is increased more than threefold in animals inhaling nitrous 1.
Gilbert, R. G. B., Brindle, F., Galindo, A. Anœsthesia for Neurosurgery. London, 1966. 2. Hunter, A. R. Neurosurgical Anœsthesia. Oxford, 1976. 3. Harkins, H. N., Harmon, P. H. Proc. Soc. exp. Biol. Med. 1934, 32, 178. 4. Munson, E. S., Merrick, H. C. Anesthesiology, 1966, 27, 783. 5. Michenfelder, J. D., Miller, R. H., Grontert, G. A. ibid. 1972, 36, 164. 6. Kent, E. M., Blades, B. J. thorac. Surg. 1942, 11, 434.
oxide.4 It has
been suggested that, as a diagnostic test for air embolism, nitrous oxide be added to the in. spired gases in patients under other forms of anaesthesia, since the nitrous oxide expands the air bubbles and thus sharply raises pulmonary arterial pressure.’ If a catheter has been placed in the right atrium, obstruction to pulmonary blood-flow due to air embolism may be detected as an increase in pulmonary arterial pressure, and subsequently in central venous pressure;8 further, froth may be aspirated through the catheter.9 But exact positioning of an atrial catheter is not easy without radiographic assistance: true, E.C,G, potentials recorded from a catheter will reveal inversion of the p-wave as the open end passes the location of the sino-atrial node; 10 but this technique has not proved I completely reliable under other circumstances." The Swan-Ganz catheter facilitates recognition of the haemodynamic consequences of air embolism, and one can be much surer of the exact location of the distal end from pressure changes recorded during its passage; but a Swan-Ganz catheter is by no means easy to pass and the procedure has its own risks and possibly even its own mortality. The immediate result of pulmonary air embolism is a diminution in carbon-dioxide elimination (provided that the tidal volume of ventilation remains constant). Reduction in either end-tidal C02 or even in mixed expired C02 may therefore signal air embolism." Finally, the most sensitive detector of the presence of bubbles in the venous circulation is the doppler (more correctly, ultrasonic) detector. So sensitive is this method that as little as 0.ml of air will be detected," though one has to put the recording head in exactly the right place.14 The doppler detector is also activated by the diathermy apparatus, 15 unless the recording head is screened with aluminium foil. 16 The older signs of air embolism are well-known. Classically, a millwheel murmur is heard. 17 Some say that, in patients with this sound, the mortality will be around 70%.18 An oesopha geal stethoscope may be more satisfactory than a precordial stethoscope for detecting changes in heart-sounds, which initially become drum-like.19 Subsequently a systolic murmur may be heard.20 21 The electrocardiogram may show signs of right-heart strain.22 Many years ago it was stated that any rise in pulse rate of 10 beats a minute or more, any fall in bloodpressure of 10 beats a minute or 10 mm Hg or more. and any disturbance of the rhythm or rate of respiration even
,
x
7.
Munson, E. S., Paul, W. J. L., Perry, J. C., de Padua, C. B., Rhoton,
8.
A. L. Anesthesiology, 1975, 42, 223. Garcia, E., Michenfelder, J. D., Theye,
R. A. Can. anœsth.
,
Soc. J. 1968, 50.
593.
Michenfelder, J. D., Terry, H. R., Daw, E. F., Miller, R. H, Anesth, Analg. curr. Res. 1966, 45, 390. 10. Robertson, J. T., Schick, R. W., Morgan, F., Matson, D. D. J. Neurosurg. 1961, 18, 255. 11. Brocklehurst, G., Greave, J. R. W., Lower, R. A., Adams, A. K. Archs Dis. Childh. 1967, 42, 166. 12. Bethune, R. V. M., Brechner, V. L. Anesthesiology, 1967, 29, 178. 13. Edmonds-Seal, J., Maroon, J. C. Anœsthesia, 1969, 24, 438. 14. Buckland, R. W., Manners, J. M. Anœsthesia, 1976, 31, 633. 15. Campkin, T. V., Perks, J. S. Lancet, 1973, i, 235. 16. Garden, E., Doll, W. Anesthesiology, 1970, 32, 551. 17. Fine, J., Fischman, J. New Engl. J. Med. 1940, 223, 1054. 18. Tissovec, L., Hamilton, W. K. J. Am. med. Ass. 1967, 201, 376 19. Shiupuri, D. N., Viswanathan, R., Sharma, M. L., Singh, P. P. J. Ind. med. Ass. 1959, 33, 86. 20. Michenfelder, J. D., Martin, J. T., Altenberg, B. M., Rehder, K. J. Am. med. Ass. 1969, 208, 1353. 21. O’Higgins, J. W. Br. J. Anœsth. 1970, 42, 549. 9.
22. Marx, G. F., Steen, S. N., Foster, E. S., Jadwal, C. M., Ketas, E. R N.Y. J. Med. 1968, 68, 2801.
353 the spontaneously breathing patient in the sitting pos:[lOn should be regarded as air embolism until the contrary was proved: compression of the jugular vein in the reck congests the operation area and causes any open veins to bleed.23 Even in the absence of clinical signs, the anssthetist was advised to compress the patient’s jugular vein in the neck every five minutes during the operation to disclose any unsecured open veins. A recent investigation’4 singles out the doppler detector as the best means of early diagnosis. It was positive in 10 out of 17 patients. 5 of the same 17 patients had end-tidal CO2 changes, In 4 there was a rise in central venous pressure, aspiration of air from the right atrium, or evidence in the .c,s. 3 patients became hypotensive and in 1 air entry into the heart was detected with an oesophageal stethoscope. These figures are rather different from the Mayo Clinic results.’ It is disturbing that, even with these elaborate aids to diagnosis, 1 of the 17 patients died of air embolism. Another 19 patients were monitored by palpation of the pulse, by intermittent bloodpressure recording, by cesophageal stethoscopy, and by electrocardiography. Only 2 of these patients had evidence of air embolism and 1 died. This patient proved at necropsy to have a patent foramen ovale. Air was also present in the pulmonary arteries. The workers concerned" now use a "necktie" of Pohl’s tubing, which is tightened to compress the jugular vein at the earliest sign of air embolism. But it seems that no measure against air embolism is infallible when operations are done on sitting patients. :n
THE LEUKAEMIC DEATH
ACUTE
myeloid leukaemia
in
adults, though
not cur-
Approaches to the individual patient differ. Bodey and his colleagues,’1 from Texas, have reviewed the necropsy findings in patients dying with acute leukaemia over a seven-year period.2’ Infection was the cause of death in two-thirds of their patients, haemorrhage in 15 %, and a combination of the two in 9%. The frequency of deaths caused by infection did not change over the years, despite improved antibiotics; but the organisms did change. For example, fatal infections with Pseudomonas aeruginosa
able, usually responds
to treatment.
declined from 27% to 8% while Klebsiella/Enterobacter/Serratia infections increased from 11% to 26%. Fatal Escherichia coli infections were steady at 11%, and 30% of all fatal infections were caused by multiple organisms. Fatal infections are often related to neutropenia-the result either of the disease itself or of intensive treatment-and antibiotics are less effective in these circumstances. Fungal infections have been increasing as a cause of death in leuksemia. In Bodey’s series, in .1,hich 20% of the fatal infections were fungal, Candida spp, were the main culprit. Platelet transfusions seem to have reduced the frequency of death from haemorrhage due to thrombocytopenia alone, but have had little effect ihen hxmorrhage was associated with disseminated in’ravascular coagulation. Store than half the patients acquiring acute myeloid will be over 60 years old. These patients, and
those between 45 and 60, do
with aggressive regimens,2 having a median survival of less than 3 months. Because of these poor results, a group at University College Hospital3 tried less aggressive treatment in this disease with results at least as good as those of other centres.3 Some points emerge from the correspondence which followed their report. It is clearly not enough to measure success or failure by quantity of life alone, when this is likely to be short: quality of survival should be incorporated into future trials. The main argument against less aggressive treatment is that the approach is negative and unlikely to advance treatment ; but a better life is a substantial advance in the patients eyes-particularly when it means he can be treated in a hospital near his home. Some patients are prepared to try anything in the hope of cure, and for them the quality-of-life argument may not apply. Others, properly informed, may be able to decide with their doctor what the aims of treatment should be.
particularly badly
TOP OF THE POPS
WHEN aerated drinks came in bottles, the bottles broke and children cut themselves on the glass; in addition, bicycle tyres were punctured, and sometimes fires were started by the sun shining through the glass. Now that many manufacturers have changed to aluminium cans, children have found a new hazard. They are swallowing the ring pull-tabs. Burrington4 reports seven cases from the U.S.A. where young children from four months to two years had serious complications. One child died from an aorto-resophageal fistula and others required thoracotomy. Unfortunately the aluminium does not show well on radiography and the tabs cannot be seen in frontal projection if they overlie the vertebral bodies. So a posterior-anterior and lateral radiograph should be done in any toddler with unexplained alteration of feeding habit or persistent respiratory symptoms. Perhaps a radiodense piece could be incorporated into the manufacture of the tabs? Why do children swallow them? For a toddler the
small, shining ring is obviously attractive and he -may not remember, or admit to, having put one in his mouth. Older children, taught to be tidy, put the tab through the opening in the can before they drink the contents, and then proceed to swallow it with the pop. It is not only children who suffer. The tabs have been carelessly thrown into pond or river, and a duck, diving to pick up food from the bottom, may push its bill through the ring and eventually starve to death. The tops of pop cans can be deposited somewhere more useful than down children’s throats, on ducks’ bills, or around the countryside? In parts of Britain collecting jars have appeared marked "for kidney patients". The tops are collected and sold to provide amenities for dialysis units. Pop tops should be directed to helping renal patients, not to providing work for paediatric surgeons. 25. M. R. C.
26.
23 Hunter, A. R. Anœsthesia, 1962, 17, 467. H. Y., Rodriguez, V., Narboni, G., Frereich, E. J. Medicine, 1976, 55, 259.
24 Chang,
Bodey,
G. P., Luna, M. A., 27.
Working Party. Br. J. Hœmat 1974, 27, 373. Burge, P. S., Richards, J. D. M., Thompson, D. S., Prankerd, T. M., Wright, P. Lancet, 1975, ii, 621. Burrington, J. D. J. Am. med. Ass. 1976, 235, 2614.
A.
J., Sare,
