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Pain management in recovery.

Introduction

Recovery nurses are key members of the multi-disciplinary team who have the task of providing perioperative patient care (Kehlet & Dahl 2003). Nurses in the recovery unit ensure that postoperative complications are detected and averted. Pain is the predominant adverse effect of the surgical experience for the majority of patients. Failure to treat acute pain from the outset can have adverse physical and psychological consequences for the patient (Kehlet 1997, Liu et al 1995). Furthermore, inadequate treatment of acute pain may result in progression to a persistent, chronic pain state (Macrae 2001, 2008). This can be detrimental to the patient bio-psychosocially and has economic repercussions.

Informed choice and pain

The nurse's knowledge of treatment modalities, their intended benefits and possible side-effects, is of paramount importance during postoperative recovery. This is because those working in recovery units are often best placed to provide or reinforce information, in a timely and relevant manner. They are the practitioners who have an opportunity to develop a relationship with the patient in the immediate perioperative period. Provision of information assists the patient in decision-making regarding their preferred choice of postoperative pain therapy.

It is important to be able to provide the requisite information in an understandable and acceptable format for the patient (Klafta & Roizin 1996, Murtagh & Thorns 2008). This can be difficult for many reasons including organisational barriers (Timmins 2008). For instance, the patient's anaesthetist may have prescribed patient controlled analgesia (PCA) for commencement in the recovery room because they had proposed, discussed and agreed this with the patient, preoperatively. However, when the patient awakens in recovery, he or she may object to having a PCA because they still have unresolved fears regarding side-effects and risks of addiction. It is at this point that accurate, verbal and written information could improve patient participation in care-giving. Clearly, when the patient first awakens, the degree to which each individual retains the information will vary. Moult et al (2004) contend that only 20% of verbal information is remembered. Macfarlane et al (2002) found that 50% more information is retained when it is reinforced by written information.

Pain assessment

Assessment of acute, postoperative pain should be a systematic, clinical process of describing the patient's pain (RSCEng 1990). However, practitioners undertaking pain assessment need to be able to understand what can appear to be a nebulous phenomenon. McCaffery (1968) lays emphasis on the subjectivity of the experience and the International Association for the Study of Pain (IASP) describes it as an unpleasant, multidimensional phenomenon, which we associate with actual or potential tissue damage (Merskey & Bogduk 1994).

The ultimate aim of analgesia is to provide subjective comfort for the patient (Kehlet & Dahl 2003). Difficulties or challenges to pain assessment lie in the nature of what constitutes 'subjective comfort', the need to measure it and the time it takes to achieve it. The assessor must try to develop an understanding of the magnitude, quality, location and meaning of the pain being described in order to treat it appropriately (Brown 2008).

Carr (2007) describes barriers that affect how receptive we are, not only to what patients report but also to non-verbal cues. Some physiological and behavioural manifestations of pain can be seen in Table 1. However, it is important to emphasise that 'pain is not usually written all over a patient's face' (Hawthorn & Redmond 1998).

It has been postulated by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO 2001) that pain intensity should be recorded as the 5th vital sign, at the same time as blood pressure, pulse and so on. Frequency of observation should depend on the intensity of the pain, the type of therapy used to treat it and the need to evaluate that therapy. When the patient is in the recovery unit the level of pain the patient is experiencing at rest can give an indication of how well a patient will be able to sleep, but this is not a reflection of dynamic pain. Dynamic pain or pain on movement is the level of pain the patient experiences when coughing and moving the affected body part. Patients who have mild pain at rest may actually experience severe or unbearable pain on movement. Therefore, it must be stressed that assessment of dynamic pain is of paramount importance.

During an assessment of a patient recovering from an anaesthetic, the practitioner needs a practical, valid, easily administered and understood tool (Brown 2008, Scott & McDonald 2008). Additional factors to consider during pain assessment include:

* Does the practitioner know how to use the tool?

* Is the assessor able to differentiate pain from distress, particularly in the case of children, older or cognitively impaired patients?

* How subjective are the observations of the assessor undertaking the measurement?

* How confident is the assessor to act on their findings--in terms of analgesic administration?

There are many factors, such as language or cultural barriers, which affect the ability of even the most experienced assessor to assess pain effectively. Older people, with severe cognitive impairment, can find it difficult to articulate their pain (British Pain Society 2007). Paediatric pain assessment is a challenge because the group is so heterogeneous. In the field of neonatal and children's nursing there is a requirement to assess the pain of infants and children at different stages of development. Carr (2007) states that there can be obstacles to patients reporting pain, even when asked about it, due to worries about being unpopular and an assumption that they are in the hands of the professional who has authority. Fear of injections and belief that the pain is not harmful is also to be expected.

A plethora of pain measurement tools has been developed for routine use in a variety of clinical settings. Brown (2008) undertook a critique of assessment tools used in the management of pain in the recovery unit. She found that unilateral pain intensity scales were arguably the most straightforward tools to apply in this specialist clinical setting, despite their inability to assess other dimensions. Examples and a brief description of some unilateral intensity scales are cited below:

* A verbal rating scale (VRS) asks the patient to put their pain into a category of either none, mild, moderate, severe or unbearable. Thus:

0 = none

1 = mild

2 = moderate

3 = severe

4 = unbearable

This tool has the advantage of being easy to administer and correlates well with studies involving visual analogue scales (VAS). The main disadvantage is lack of sensitivity, relative to a VAS, which renders it statistically weaker when used in research (Scott & McDonald 2008).

* A numerical rating scale (NRS) can be administered verbally as a 0--10 (or 0 5) scale or visually, with both words and numbers along a vertical or horizontal line--see figure 1. This allows the patient to ascribe a number to their pain intensity. 0 represents no pain and 10 the worst pain imaginable. The visual representation of the NRS is not unlike a VAS, except that there are marks, similar to those on a ruler, which give a linear representation of scale or magnitude. Advantages in its application include the fact that it is quick and easy to administer. The scale is relatively sensitive, particularly if equal spacing is used on numeric increments. It also correlates well with a VAS and FACES of Pain Scale (FPS). Its main disadvantage is that some patients have difficulty conceptualizing their pain in numerical terms. Users must also remain consistent in their choice of end point (for example 5, 10, 20 or 100) in order to achieve meaningful and consistent results (Brown 2008, Scott & McDonald 2008).

* The visual analogue scale (VAS) is a horizontal line, typically 100 mm in length, with two end points: 0 being 'no pain' (usually on the left side) and 100 being the 'worst pain imaginable' (usually on the right side)--see figure 2. The patient is asked to point to where their pain lies, in terms of the position they believe represents their status between the two points. It can be used vertically or horizontally. The main advantage of the VAS is its sensitivity, relative to other scales. Its main disadvantage is the time it takes time to administer to the patient, who may have difficulty grasping the concept of how it works (Brown 2008).

* The Wong-Baker FACES of Pain Scale (FPS) is commonly applied in paediatric pain assessment and can be used with adults--see figure 3. It is simple to administer and can be converted to a numerical value for documentation (Hockenberry & Wilson 2009). A disadvantage is the fact that it is notionally uni-dimensional but can actually have an emotional interpretation taken from the facial expressions. A physical tool is required to present to the patient and, although the numerical data taken on assessment can be ranked, the differences between faces may not be linear in terms of pain intensity (Scott & McDonald 2008).

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Consequences of undertreated pain

Unintended, adverse physiological and psychological consequences of pain include postoperative morbidity, delayed recovery, a delayed return to normal daily life and reduced patient satisfaction (Kehlet 1997, Liu et al 1995, Joshi & Ogunnaike 2005).

Physiological effects

Adverse physiological effects resulting from the combination of tissue injury and pain have been described in several key papers (Liu et al 1995, Kehlet 1997, Kehlet & Nielson 1998, Brodner et al 1998). Responses include increased catabolism, immunosuppression and prolonged maintenance of the sympathetic response to surgery. The effects of this can be sub-classified into systemic responses and may manifest themselves as follows:

Cardiovascular effects

* Increased heart rate

* Increased blood pressure

* Increased stroke volume

* Increased myocardial oxygen demand, reduced myocardial oxygen supply and possible myocardial ischaemia

* Reduced blood flow to viscera and skin causing delayed wound healing (Kehlet 1997).

Respiratory effects

* Stimulation of respiration causing initial hypocapnia and respiratory alkalosis

* Diaphragmatic splinting and hypoventilation, atelectasis, hypoxia and ensuing hypercapnia

* Development of chest infection (Kehlet 1997, Brodner et al 1998).

Endocrine effects

* Catabolic and anabolic changes

* Decrease in insulin production

* Reduction in testosterone levels (Kehlet & Nielson 1998).

Metabolic effects

* Raised blood sugar levels (Kehlet & Nielson 1998).

Gastro-intestinal effects

* Delayed gastric emptying

* Nausea

* Reduced gastro-intestinal motility and ileus (Kehlet 1997).

Haemostasis

* Immobility

* Increased blood viscosity

* Hypercoagulability and risk of deep vein thrombosis (Kehlet 1997, Liu et al 1995).

Psychological effects of pain

Pain is also an emotional phenomenon (Merskey & Bogduk 1994). Generally, patients will, to a greater or lesser extent, expect to suffer acute pain because they need to have surgery. However, if pain is poorly controlled and becomes persistent, the patient no longer deems it to be useful. According to Eccleston (2001) psychological changes tend to occur more insidiously over time. Therefore, they may be less apparent to recovery room practitioners.

Psychological and behavioural outcomes on how the pain experience is viewed can be influenced by gender, age, cultural or religious beliefs, what feelings have been internalised regarding the significance of their injury, surgery and the reason for their pain (Chapman & Okifuji 2004, Geisser 2004). Some patterns of cognition, emotion and behaviour are listed below:

* Fear avoidance behaviour

* Worry and catastrophising

* Anxiety

* Anger

* Sleep deprivation

* Low mood

* Depression (Eccleston 2001, Hooten 2008).

All of this can have implications for response to future pain beyond the recovery room setting and can form the basis for long-term behavioural changes (Eccleston 2001, Gatchel & Kishino 2008).

Persistent pain after surgery

A clear relationship between having surgery and suffering from persistent pain has been identified (Macrae 2001, 2008, Perkins & Kehlet 2000, Kehlet et al, 2006). Pathophysiological processes occurring after surgery can cause a chronic pain condition to develop. This has been demonstrated by Crombie et al (1998) who undertook an audit of 5130 patients attending 10 chronic pain clinics and found that surgery had contributed to the referral in 22.5% of cases. Thus, the Australian and New Zealand College of Anaesthetists proposed that appropriate analgesic intervention may reduce the incidence of chronic pain referrals (ANZCA 2005).

Interventions used to manage acute pain in the recovery unit

Management of acute pain requires an imaginative, multi-modal and bio-psychosocial approach. Management strategies and evidence for their use are described and discussed in the ANZCA guidelines (2005). Treatment choice will depend on the type of surgery and the status of the patient and falls into the following categories:

* Systemic

* Regional/ local

* Cognitive-behavioural.

Pharmacological management

Systemic analgesics

Designed to relieve pain through direct action, these analgesics can be administered alone or in combination with other drugs and techniques (see below for classification).

* Non opioids--paracetamol or (rarely) nefopam.

* Non steroidal anti-inflammatory drugs diclofenac and parecoxib.

* Opioids--morphine, codeine, tramadol, fentanyl and oxycodone.

* Adjuvant medication--pregabalin, amitriptyline and ketamine.

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The analgesic ladder

The World Health Organisation's analgesic ladder (1996), originally devised to provide guidance in the management of cancer pain, is the framework most often applied in logical prescription and titration of analgesia in acute and chronic pain. The idea is that analgesia is prescribed and administered according to the intensity of pain. Understanding and application of the ladder's guidance can be of assistance to practitioners when discussing pain management plans with multi-disciplinary clinicians.

Step I recommends the use of non-opioid analgesia for mild pain; Step II advocates the use of 'weak opioids', with or without non-opioids for moderate pain; Step III is comprised of 'strong opioids', with or without non-opioids, for severe pain. The term 'adjuvant' describes a drug with a primary indication, other than pain but with analgesic properties in some painful conditions. For example amitriptyline, although an anti-depressant, is used for treatment of neuropathic pain; it can also promote sleep, if given at night (Rang et al 2003)--see figure 4.

A variation of the ladder model has been adapted to suit a scenario for acute, postoperative pain (Bandolier 2003), see figure 5.

This model was devised as a tool of prediction, on the premise that patients having major surgery will experience severe pain and those having minor procedures will experience pain of more moderate intensity. However, it is important that inter-patient variability is taken into account. A cancer patient, established on strong opioids preoperatively, may require larger quantities of opioid than another patient having the same procedure. Neither model describes techniques or routes used to administer strong opioids in patients who are likely to have a 'nil by mouth' status. Also, local anaesthesia is not included in the ladder but is often the mainstay of pain relief in the early postoperative phase for many patients having major surgery. Eisenberg and colleagues (2005) recommend that additional options to pharmacological treatment are considered. This may reduce the risk of patients suffering unacceptable side-effects and inadequate levels of pain relief.

Routes of administration

Systemic routes

* Whilst in the recovery unit the intravenous route is described as the 'gold standard' against which other routes are compared; patient-controlled analgesia is usually administered in this manner but can also be administered subcutaneously, if venous access poses a problem.

* The oral or gastro-intestinal route is best if the patient is able to take fluids by mouth, but bear in mind the delay between drug administration and time of onset.

* The rectal route is another possibility but can pose practical difficulties for administration. In addition, many patients view this route of administration with disfavour, considering it to be undignified, uncomfortable and embarrassing.

* Other common routes of administration include intermittent, intramuscular (IM) or sub-cutaneous (S/C) administration, which is painful for the patient. An alternative method of intermittent drug administration is placement of a well identified, subcutaneous cannula, but absorption from IM and SC routes can be unpredictable (Cashman 2008).

Regional and local analgesics

Local anaesthetics bind to sodium channels and block the action potentials for nerve conduction in every type of nerve fibre (depending on the concentration, route and rate of administration of the drug). They can produce an absence of sensation in the part of the body to which they are applied, without impairment of central control of vital functions or loss of consciousness (Rang et al 2003). Clinical application of local anaesthesia can be topical, ophthalmic, wound infiltration, intra-articular, peripheral nerve, spinal or epidural routes of administration (Grape & Shug 2008, Russon & Harrop-Griffiths 2008).

Non-pharmacological management

Cognitive-behavioural strategies (CBT) The threat of pain or illness invokes physiological, psychological and behavioural responses and CBT is a therapeutic method of taking all of this into account. Simple cognitive and behavioural strategies can be used to supplement traditional modes of pain relief by recovery unit practitioners in the form of distraction, imagery and relaxation (Morely & Eccleston 2008).

Summary

Recovery practitioners play a key role in support of patient recuperation. Verbal and written information promote the patient's feelings of self-direction and control. Unidimensional pain assessment tools may be best suited to patients in the clinical setting of the recovery unit but limit our ability to assess the patient's multi-dimensional and subjective experience of pain. Consequences of under-treated pain were explained and treatment modalities described.

Additional Learning Resources

Associated AfPP on line modules:

Patient Assessment in Recovery

Pain Management in Recovery

Hand Washing

Airway Management

Breathing Management

Breathing Circuits and Their Uses

Anaesthetic Drugs

Supportive Pharmacology

Circulation and Invasive Monitoring

Patient Care: Knowing and Doing

The Multi-disciplinary Team in the Operating Theatre

Communication Skills

Patient Care in the Operating Department

Organisational Skills and Tools

Liability and Accountability

Care and Responsibility

Consent

The Human Rights Act

Reflective model

You will find several reflective module templates for you to utilise when utilising reflective practice for your CPD under the career development tab on the AfPP web site.

Provenance and Peer review: Commissioned by the Editor; Peer reviewed; Accepted for publication September 2009.

References

Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine 2005 Acute Pain Management: Scientific Evidence 2nd Edn Australian Government National Health and Medical Research Council

Bandolier 2003 Acute Pain Available from: http://www.medicine.ox.ac.uk/bandolier/booth/painp ag/acutehtml [Accessed June 2009]

British Pain Society and British Geriatrics Society 2007 Guidance on the Assessment of Pain in Older People London, British Pain Society

Brodner G, Pogatski E, Van Aken H et al 1998 A multimodal approach to control postoperative pathophysiology and rehabilitation in patients undergoing abdominothoracic esophagectomy Anesthesia & Analgesia 86 228-334

Brown DN 2008 Pain assessment in the recovery room Journal of Perioperative Practice 18 (11) 480-489

Carr E 2007 Barriers to effective pain management Journal of Perioperative Practice 17 (5) 200-208

Cashman J 2008 Routes of administration In: Rice ASC, Justins D, Newton-John T, Howard RF, Miaskowski CA (eds) Clinical Pain Management: Acute Pain 2nd Edition London, Hodder Arnold

Chapman CR, Okifuji A. 2004 Pain: Basic mechanisms and conscious experience. In: Dworkin RH, Breitbart, WS (eds) Psychosocial Aspects of Pain: A Handbook for Healthcare Providers Seattle, IASP Press

Crombie IK, Talfryn O, Davies H, Macrae WA 1998 Cut and thrust: antecedent surgery and trauma among patients attending a chronic pain clinic Pain 76 167-171

Eccleston C 2001 Role of psychology in pain management British Journal of Anaesthesia 87 (1) 144-52

Eisenberg E, Marinangeli F, Birkhahn J, Paladini A, Varassi G 2005 Time to modify the WHO analgesic ladder? IASP Pain: clinical updates 13 (5) 1-4 http//www.iasp-pain.org [Accessed June 2009]

Gatchel RJ, Kishino ND 2008 Chronic pain, impairment and disability. In: Wilson PR, Watson PJ, Haythornthwaite JA, Jensen TS (eds) Clinical Pain Management: Chronic Pain 2nd Edition London, Hodder Arnold

Geisser ME 2004 The influence on coping styles and personality traits on pain. In: Dworkin RH, Breitbart WS (eds) Psychosocial Aspects of Pain: A Handbook for Healthcare Providers Seattle, IASP Press

Grape S, Shug S 2008 Epidural and spinal analgesia In: Rice ASC, Justins D, Newton-John T, Howard RF, Miaskowski CA (eds) Clinical Pain Management: Acute Pain 2nd Edition London, Hodder Arnold

Hawthorn J, Redmond K 1998 Pain Causes and Management Oxford, Blackwell Science

Hockenberry MJ, Wilson D 2009 Wong's Essentials of Pediatric Nursing (8th Ed) St Louis, Mosby

Hooten WM 2008 Chronic pain and depression In: Wilson PR, Watson PJ, Haythornthwaite JA, Jensen TS (eds) Clinical Pain Management: Chronic Pain 2nd Edition. London, Hodder Arnold

Joint Commission on the Accreditation of Healthcare Organisations 2001 Implementing the New Pain Management Standards Oakbrook, Illinois, JCAHO

Joshi GP, Ogunnaike B 2005 Consequences of inadequate postoperative pain relief and chronic persistent postoperative pain Anesthesiology Clinics of North America 23 21-36

Kehlet H 1997 A multi-modal approach to control postoperative pathophysiology and rehabilitation British Journal of Anaesthesia 78 606-617

Kehlet H, Jensen TS, Woolf CJ 2006 Persistent postsurgical pain: risk factors and prevention Lancet 367 (9522) 1618-25

Kehlet H, Nielson HJ 1998 Impact of laparascopic surgery on stress responses, immunofunction and risk of infectious complications New Horizons 6 (2 supplement) S80-88

Kehlet H, Dahl JB 2003 Anaesthesia, surgery and challenges to postoperative recovery Lancet 362 1921-1928

Klafta JM, Roizin MF 1996 Current understanding of patients' attitudes toward and preparation for anesthesia: a review Anesthesia & Analgesia 83 1314-1321

Liu SS, Carpenter RL, Neal JM 1995 Epidural anesthesia and analgesia. Their role in postoperative outcome Anesthesiology 82 1474-1506

Macfarlane J, Holmes W, Gard P, Thornhill D, Macfarlane R, Hubbard R 2002 Reducing antibiotic use for acute bronchitis in primary care: blinded, randomized controlled trial of patient information leaflet British Medical Journal 324 (7329) 91-4

Macrae WA 2001 Chronic pain after surgery British Journal of Anaesthesia 87 (1) 88-98

Macrae WA 2008 Chronic post surgical pain: 10 years on British Journal of Anaesthesia 101 77--86

Merskey H, Bogduk N 1994 Classification of Chronic Pain: Description of chronic pain syndromes & definition of pain terms Seattle, IASP Press

Morley S, Eccleston C 2008 Cognitive-behaviour therapy for chronic pain in adults In: Wilson PR, Watson PJ, Haythornthwaite JA, Jensen TS (eds) Clinical Pain Management: Chronic Pain 2nd Edition London, Hodder Arnold

Moult B, Franck l, Brady H 2004 Ensuring quality information for patients: development and preliminary validation of a new instrument to improve the quality of written healthcare material Health Expectations 7 (2) 165-173

Murtagh FEM, Thorns A 2006 Evaluation and ethical review of a tool to explore patient preferences for information and involvement in decision making Journal of Medical Ethics 32 311-315

McCaffery M 1968 Nursing Theories Related to Cognition, Bodily Pain, and Man-environment Interactions Los Angeles, UCLA Students' Store

Perkins FM, Kehlet H 2000 Chronic pain as an outcome of surgery Anesthesiology 93 (4) 1123-1133

Rang HP, Dale MM, Ritter JM, Moore PK 2003 Pharmacology 5th Edn London, Churchill Livingstone

Royal College of Surgeons of England and College of Anaesthetists 1990 Commission on the Provision of Surgical Services. Report of the Working Party on Pain after Surgery London, Royal College of Surgeons of England and College of Anaesthetists

Russon KE, Harrop-Griffiths W 2008 Continuous peripheral neural blockade for acute pain In: Rice ASC, Justins D, Newton-John T, Howard RF, Miaskowski CA (eds) Clinical Pain Management: Acute Pain 2nd Edition London, Hodder Arnold

Scott DA, McDonald WM 2008 Assessment, measurement and history In: Rice ASC, Justins D, Newton-John T, Howard RF, Miaskowski CA (eds) Clinical Pain Management: Acute Pain 2nd Edition London, Hodder Arnold

Timmins F 2008 Communication skills: challenges encountered Nurse Prescribing 6 (1) 11-15

World Health Organization 1996 Cancer Pain Relief Geneva, WHO

Task 1

Reflect

How do you assess pain within your unit? Explore the methods used and reflect on their appropriateness

Notional Learning Hours

30 mins

Knowledge and Skills Dimension

Core 1: Communication

Core 4: Service Improvement

Core 5: Quality

Core 6: Equality and Diversity

Task 1

Reflect

How do you manage potential communication and cultural barriers when assessing pain in the post anaesthetic care unit and reflect on the tools you use and your practice. Is there something more you can do to enhance the patient's experience?

Notional Learning Hours

30 mins

Knowledge and Skills Dimension

Core 1: Communication

Core 4: Service Improvement

Core 5: Quality

Core 6: Equality and Diversity

Task 3

Reflect

How many patient groups do you deal with in your unit? Are there subtle differences in their pain management? Reflect on your practice within these areas and ask yourself can you improve your practice.

Notional Learning Hours

30 mins

Knowledge and Skills Dimension

Core 1: Communication

Core 4: Service Improvement

Core 5: Quality

Core 6: Equality and Diversity

Task 4

Reflect

Read the following publication

Bandolier 2003 Acute pain available from: http://www.medicine.ox.ac.uk/band olier/booth/painpag/aucte.html [Accessed June 2009]

Notional Learning Hours

Knowledge and Skills Dimension

Core 1: Communication

Core 4: Service Improvement

Core 5: Quality

Core 6: Equality and Diversity

Correspondence address: W B Loan Pain Centre, Gardner Robb Building, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB. Email: Lorraine.mcmain@belfasttrust.hscni.net

Lorraine McMain RGN, BSc(hons), MSc

Chronic Pain Nurse, Belfast City Hospital
Table 1: Some physiological and behavioural manifestations of pain
(Hawthorn & Redmond 1998)

        Physical                  Behavioural

      Tachycardia                Vocalisation
      Hypertension         Crying, moaning, groaning
         Pallor                 Immobilisation
   Nausea & vomiting       Rubbing the affected area
     Dilated pupils           Frowning/grimacing
Increased muscle tension         Restlessness
   Shallow breathing             Sleeplessness
Decreased blood flow to      Shielding, supporting
        the skin               the painful area
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Title Annotation:OPEN LEARNING ZONE
Author:McMain, Lorraine
Publication:Journal of Perioperative Practice
Article Type:Report
Geographic Code:4EUUK
Date:Feb 1, 2010
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