Hepatitis A, B, C

Original Editors -Emily Schmidt Allyson Simmonds  from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Allyson Simmonds, Emily Schmidt, Vidya Acharya, Lucinda hampton, Kim Jackson, Admin, Elaine Lonnemann, Rujuta Naik, WikiSysop, 127.0.0.1, Wendy Walker, Evan Thomas, Karen Wilson and Nupur Smit Shah  

Introduction[edit | edit source]

Hepatitis is defined as inflammation of the liver.

  • The condition can be self-limiting or can progress to fibrosis (scarring), cirrhosis or liver cancer.
  • Hepatitis viruses are the most common cause of hepatitis in the world (infections, toxic substances, and autoimmune diseases can also cause hepatitis)[1][2]

The most common types of viral hepatitis are Hepatitis A, Hepatitis B, and Hepatitis C. The other types of viral hepatitis are hepatitis D and E and are less frequently encountered. Based on the etiology of hepatitis, the severity can range from mild and self-limiting to severe illness requiring liver transplantation.

Hepatitis can be further classified

  • Acute - inflammation of the liver lasts for less than 6 months; usually self-resolving but can cause fulminant liver failure depending on the etiology
  • Chronic - inflammation/insult of the liver lasts longer than 6 months; can cause liver damage that includes liver fibrosis, cirrhosis, hepatocellular carcinoma, and features of portal hypertension leading to significant morbidity and mortality[3]

Epidemiology[edit | edit source]

Viral Hepatitis is considered a major public health issue. Viral hepatitis infects millions of people annually causing significant morbidity and mortality.

  • Chronic Hepatitis B and C infection can cause liver damage that includes liver fibrosis, cirrhosis, hepatocellular carcinoma, and features of portal hypertension.
  • Viral hepatitis ends up causing 1.4 million deaths annually, and hepatitis B and C viruses are responsible for about 90% of those deaths.
  • The World Health Organization (WHO) estimated that 1.3 million people have died due to hepatitis in 2015, and 1 in 3 people in the world have had infections with either hepatitis B or hepatitis C virus.
  • Reportedly, infection rates show that 2 billion people infected with the hepatitis B virus, 185 million with the hepatitis C virus, and 20 million with the hepatitis E virus. 
  • Hepatitis A virus affects 90% of children in high endemic regions[3]. 

Characteristics/Clinical Presentation[edit | edit source]

Viral Hepatitis

Can be different in every individual depending on the type of virus causing the infection. Patients can be entirely asymptomatic or only mildly symptomatic at presentation. A small number of patients can present with rapid onset of fulminant hepatic failure.

Typically patients with viral hepatitis go through 4 phases.

  • Phase 1 (viral replication phase) - Patients are usually asymptomatic in this phase, and laboratory studies are positive for markers of hepatitis.
  • Phase 2 (prodromal phase) - Patients in this phase usually present with anorexia, nausea, vomiting, malaise, pruritus, urticaria, arthralgias, and fatigue. Many times these patients are misdiagnosed as having gastroenteritis or viral infection.
  • Phase 3 (jaundice phase) - Patients in this phase present with dark-colored urine and pale-colored stool. Some patients develop jaundice and right upper quadrant pain with liver enlargement.
  • Phase 4 (convalescent phase) - Patients typically start noticing the resolution of symptoms, and laboratory studies show liver enzymes returning to normal levels[3].

Hepatitis A - Usually present with symptoms similar to gastroenteritis or viral respiratory infection, including symptoms of fatigue, nausea, vomiting, fever, jaundice, anorexia, and dark urine. Symptoms usually start after the incubation period is over, and they resolve spontaneously in a majority of patients

Hepatitis B - Enter the prodromal phase after the incubation period and have symptoms of anorexia, malaise, and fatigue which are the most common initial clinical symptoms.  Some patients may experience right upper quadrant pain due to hepatic inflammation.  Once these patients progress to the jaundice phase, they develop jaundice and painful hepatomegaly.  dark-colored urine and pale-colored stools. After this phase, clinical course can be variable, some patients experience rapid improvement in the symptoms, and others can develop a prolonged illness with a slow resolution with periodic flareups.  A small number of patients can have rapid progression of the disease that can lead to fulminant hepatic failure over a few days to weeks.

Hepatitis C - Develop similar symptoms after the incubation period to those of hepatitis B virus infection during the acute infection phase with symptoms of anorexia, malaise, and fatigue.  However, 80% of patients remain asymptomatic and do not develop jaundice[3]

Associated Co-morbidities[edit | edit source]

Some co-morbidities that may be associated with Hepatitis A, B, C include:

  • Diabetes
  • Obesity
  • HIV
  • ESRD
  • Maladaptive lifestyle habits
  • Poor quality of life[4]
  • Liver disease
  • Disorders of lipid metabolism
  • Non-traumatic joint disorders
  • GI disorders[5]
  • Alcoholism
  • Blood-clotting disorders
  • Hypertension[6]

Aetiology/Causes[edit | edit source]


Systemic Involvement[edit | edit source]

Variable systemic involvement can occur with Hepatitis due to the nature of the virus causing a widespread infection in the body.  Most predominantly the infection involves the liver and lymphatic system.  Other systemic areas of involvement include progression into renal, endocrine, dermatological, cardiovascular, rheumatologic, and central nervous system diseases.[7]

Diagnostic Tests/Lab Tests/Lab Values[edit | edit source]

Depending on the cause and how advanced the disease is, hepatitis typically is diagnosed with some combination of blood tests, imaging tests, and liver biopsy.

  1. Blood tests are run to
  • Detect the presence of a specific hepatitis virus or for antibodies produced by the immune system to fight the virus
  • May include- Liver Function Tests, Antibody Tests,Antibody Tests.
  • Look for signs of liver damage .

2. Imaging tests - cannot detect a viral infection of the liver, but can reveal inflammation, changes in size, and tumors that can be consequences of chronic infection or liver disease caused by hepatitis.

3. Liver biopsy - a section of tissue taken from the liver and evaluated under a microscope to look for identifying features disease.The most common type of liver biopsy is a percutaneous biopsy[8],

Management[edit | edit source]

The most effective treatment plan for viral hepatitis uses a multifaceted approach and varies depending on the specific type of viral hepatitis. Treatment plans are individualized to best fit the patient's age, medical history, and type and stage of the disease. The goal of treatment is to stop or slow the progression of damage to the liver and minimize and quickly treat any complications, such as such as chronic hepatitis, cirrhosis of the liver, liver failure, liver cancer and death.

The first step in treatment is prevention.

With all three of the diseases preventing contraction of the virus, and therefore the infection is key. Prevention can help avoid passing on the disease or contracting the illness. The risk of infection can be reduced by:

  • Receiving Hepatitis A and B vaccines
  • Avoiding unnecessary and unsafe injections
  • Avoiding unsafe blood products
  • Avoiding unsafe sharps and waste collection and disposal
  • Avoiding the use of illicit drugs and sharing injection equipment
  • Avoiding unprotected sex with infected individuals
  • Avoiding the sharing of sharp personal items that may be contaminated with infected blood
  • Avoiding tattoos, piercings, and acupuncture performed with contaminated equipment[9][2]

Viral hepatitis is not treated with antibiotics because it is caused by a virus and antibiotics are not effective in treating viral infections. Some forms of viral hepatitis are treated with antiviral medications. General treatment of viral hepatitis also includes rest and ensuring good nutrition.

People with viral hepatitis should not drink alcohol or take any supplements, over-the-counter medications or prescription drugs without consulting their health care provider, because they can cause liver damage.

For serious cases of viral hepatitis, especially if there is liver damage, hospitalization may be necessary. Treatment in the hospital may include medications, a liver biopsy, and other diagnostic testing and treatment.

Complications of viral hepatitis are also treated as appropriate. Treatment of the life-threatening complications of liver failure may include liver transplant for some people. This major surgical procedure involves using a healthy donor liver to replace a severely diseased liver[10].


Vaccines

If you have been exposed to the Hepatitis A infection and have not had it before or have not received the vaccine, ask your doctor or nurse about receiving either immune globulin or the Hepatitis A vaccine. Vaccines that protect against the virus are available and begin to protect you for weeks after receiving the initial dose. The 6-12 month booster is required for long-term protection.[11] It is especially important that children age 12-23 months or adults at high risk for contracting the virus get a vaccine. Also it is important for anyone one year of age and older traveling to or working in countries with high or intermediate prevalence of Hepatitis A (central or south America, Mexico, Asia), children and adolescents 2-18 who live in states or communities where routine vaccination has been implanted because of high disease prevalence, men who have sex with men, people who use street drugs, people with chronic liver disease, people who are treated with clotting factors, and people who work in HAV laboratories to get vaccinated for safety reasons.[12][13]

Hepatitis B can be prevented in 95% of recipients with the proper vaccine.[14] Individuals who believe they may have contracted the Hepatitis B virus can receive the Hepatitis B vaccine, the Hepatitis B immune globulin, within 24 hours to potentially prevent infection.[2] A surface antigen of the Hepatitis B virus is what makes up the vaccine.  These vaccines are produced by two methods: plasma-derived or recombinant DNA.[14]

All individuals suffering from chronic liver diseases, such as Hepatitis B and C, should receive Hepatitis A immunization as well as the Hepatitis B immunization.[15]

Physical Therapy Management[edit | edit source]

A multifaceted approach is needed in the treatment of Hepatitis A, B, and C. No specific physical therapy intervention is appropriate for the specific infection of Hepatitis, but Hepatitis may likely be a comorbidity of a patient seen in physical therapy. With any other medical condition, it is important to educate patients on their disease and risk factors to promote awareness and improvement in their healthy lifestyle.  In physical therapy, an emphasis on proper musculoskeletal health will be an important foundation for the patient's overall health. Stretching to improve flexibility could help alleviate symptoms of muscle pain. It is also important for the patient to remain physically active in order to maintain the healthiest lifestyle possible and prevent the patient from developing secondary co-morbidities due to inactivity. General strengthening and aerobic activity might be appropriate for a deconditioned patient. Individualizing a physical therapy program focusing on the impairments of the patient is of utmost importance for any patient.

During physical activity, it is important to monitor the patient for signs and symptoms of fatigue. For Hepatitis A bed rest is the recommended form of treatment and being aware of the acuteness of the Hepatitis infection is important when screening for physical therapy. Supportive therapy and patient education are used to ensure the patient is comfortable and has an adequate nutritional balance for all three infections. It is also important to remind the patient to refrain from the use of alcohol or intake of fatty substances.[16]


Differential Diagnosis[edit | edit source]

Differential diagnosis for acute Hepatitis includes:[17][edit | edit source]

  • Epstein-Barr Virus (EBV): leads to infectious mononucleosis with presenting symptoms of fever, sore throat, swollen lymph glands, swollen liver or spleen, jaundice, right upper quadrant pain[18][19]
  • EBV Hepatitis is an uncommon diagnosis and causes a self‐limiting hepatitis. It predominantly affects older people, with almost 30 per cent of patients being over the age of 60. The diagnosis of EBV hepatitis is usually made in patients with unexplained hepatitis regardless of age [20]
  • Cytomegalovirus: usually affecting infants where the symptoms of the infection vary[21]
  • Alcoholic Hepatitis: jaundice, scleral icterus, muscle wasting, ascites, oedema, spider angiomata, asterixis,
  • Drug-Induced Liver Injury
  • Mushroom Ingestion: stomachaches, drowsiness, confusion, gastrointestinal issues, heart, liver or kidney damage[22]
  • "Shock Liver:" low cardiac output leading to hepatic ischemia presenting with low blood pressure to cause weakness and lightheadedness and liver damage[23]

Differential diagnosis for chronic Hepatitis includes:[17][edit | edit source]

  • Non-alcoholic steatohepatitis: diagnosed by excluding other causes and the presence of a fatty liver because there are few symptoms of the disease that could possibly include fatigue, weight loss, weakness, cirrhosis in late stages[24]
  • Chronic Alcoholic Hepatitis: pain and swelling in abdomen, decreased appetite and weight loss, nausea and vomiting, fatigue, dry mouth, increased thirst, bleeding of the esophagus, jaundice, spider-like veins, dry or pale skin, redness of feet/hands, itching, cognitive issues, fainting, numbness in legs and feet[25]
  • Primary Biliary Cirrhosis: inflamed and damaged bile ducts presenting with fatigue, pruritus, dry eyes/mouth, jaundice[26]
  • Primary Sclerosing Cholangitis: swelling and scarring of bile ducts presenting with fatigue, itching, jaundice, enlarged liver or spleen, weight loss, repeat cholangitis[27]
  • Hereditary Hemochromatosis: genetically inherited iron overload disease presenting with joint pain, fatigue, abdominal pain, loss of sex drive, cardiovascular issues[28]
  • Wilson's Disease: genetically inherited disease of copper overload presenting with swelling of the liver or spleen, jaundice, fluid buildup in the legs/abdomen, easily bruised, fatigue, physical coordination, tremors, muscle stiffness, behavioral changes, anemia, low platelet count, low WBC count, slower clotting time[29]
  • Alpha-1-antitrypsin deficiency: genetically inherited disease that presents as lung disease but can be associated with liver disease and cirrhosis of the liver[30]
  • Celiac Disease: condition that damages the lining of the small intestine to prevent absorption of parts of food that presents with abdominal pain, constipation, decreased appetite, lactose intolerance, diarrhoea, nausea and vomiting, unexplained weight loss, stools that float or are foul-smelling, bruising easily, depression, fatigue, delay of growth, hair loss, itchy skin, missed menstrual periods, mouth ulcers, muscle cramps, joint pain, nosebleeds, seizures, tingling/numbness in hands/feet[31]
  • Primary liver cancer
  • Metastatic cancer
  • Herpes Simplex Virus: visceral involvement in infants and pregnant women specifically the oesophagus, lungs, and liver with HSV viremia[19]
  • Varicella-Zoster Virus: generalized rash is typical but can also present with encephalitis, pneumonitis, myocarditis, and hepatitis[19]
  • Human Parvovirus: can present with haematological disorders that may present similar to hepatitis[19]

Alternate diagnosis for Hepatitis A[edit | edit source]

Some alternate diagnoses for Hepatitis A that could be made based on the presenting signs and symptoms could be:

  • Budd-Chiari Syndrome: uncommon condition induced by thrombotic or non-thrombotic obstruction to hepatic venous outflow. Hepatomegaly, ascites, and abdominal pain are characteristics of the disorder[32]
  • Cytomegalovirus: resulting in fever of unknown origin, pneumonia, hepatitis, encephalitis, myelitis, colitis, uveitis, retinitis, and neuropathy[33]
  • Other Hepatitis Virus[34]

Differential diagnosis for Hepatitis B include:[35][edit | edit source]

  • Alcoholic liver disease
  • Non-alcoholic fatty liver disease
  • Autoimmune hepatitis
  • Metabolic and genetic disorders
  • Drug-induced liver disease
  • Granulomatous disorders

Differential diagnosis for Hepatitis C are:[edit | edit source]

  • Alcohol Liver Disease: Complications such as oesophageal or gastric variceal bleeding, ascites, coagulopathy, hepatic encephalopathy, and liver cancer are associated with the disease.[36]
  • Hepatic Steatosis: Non-alcoholic hepatic steatosis, or non-alcoholic fatty liver disease, is the most common cause of chronic liver disease.[37]
  • Hemochromatosis: An autosomal-recessive disorder of inappropriately increased dietary iron absorption and increased iron release from erythrophagocytosis; Presenting features include fatigue, arthralgias, and diabetes mellitus[38]
  • Other Chronic Liver Dieases[39]
  • Autoimmune Hepatitis: Autoimmune hepatitis is a chronic disease of unknown cause, characterized by continuing hepatocellular inflammation and necrosis and tending to progress to cirrhosis.[40]
  • Cholangitis: an infection of the biliary tract with the potential to cause significant morbidity and mortality.[41]
  • Viral Hepatitis[42]

Case Reports/ Case Studies[edit | edit source]

Hepatitis C Case Study

Resources[edit | edit source]

Chronic Liver Disease Foundation

Hepatitis Central

Hepatitis A Vaccine Information Sheet

Hepatitis B Foundation Resources and Links

Hepatitis B Advocate

Hepatitis C Virus Advocate

References[edit | edit source]

  1. ↑ WHO Hepatitis Available from:https://www.who.int/news-room/q-a-detail/hepatitis (last accessed 2.11.2020)
  2. ↑ 2.0 2.1 2.2 Centers for Disease Control and Prevention. Information for the Public: Hepatitis B FAQs. http://www.cdc.gov/hepatitis/b/bFAQ.htm#statistics (accessed March 3, 2013).
  3. ↑ 3.0 3.1 3.2 3.3 Mehta P, Reddivari AK. Hepatitis.2020 Available from:https://www.ncbi.nlm.nih.gov/books/NBK554549/ (last accessed 2.11.2020)
  4. ↑ Basseri B, Yamini D,Chee G, and et al. Comorbidities associated with the increasing burden of hepatitis C infection. Liver International. Volume 30, Issue 7, pages 1012–1018, August 2010. Article first published online: 8 APR 2010fckLRDOI: 10.1111/j.1478-3231.2010.02235.x. http://onlinelibrary.wiley.com/doi/10.1111/j.1478-3231.2010.02235.x/abstract (accessed February 19, 2013)
  5. ↑ Louie K, Laurent S, Forssen U, & et al. The high comorbidity burden of the hepatitis C virus infected population in the United States. BMC Infectious Diseases 2012, 12:86 doi:10.1186/1471-2334-12-86. http://www.biomedcentral.com/1471-2334/12/86 (accessed February 19, 2013)
  6. ↑ Patel D, Shah P. A case report on comorbidities and laboratory abnormalities of Telbivudine in Hepatitis B Patients. Jaipur-302025. http://www.pharmatutor.org/articles/report-on-comorbidities-and-laboratory-abnormalities-of-telbivudine-in-hepatitis-b (accessed March 4, 2013).
  7. ↑ Zignego AL, Gragnani L, Giannini C, Laffi G. The Hepatitis C Virus Infection as a Systemic Disease.Intern Emerg Med 2012;7(Suppl 3):S201-S208.
  8. ↑ verywellhealth Hepatitis Available from:https://www.verywellhealth.com/hepatitis-diagnosis-1759919 (last accessed 2.11.2020)
  9. ↑ World Health Organization. Hepatitis C. http://www.who.int/mediacentre/factsheets/fs164/en/ (accessed February 19,2013)
  10. ↑ rightdiagnosis Hepatitis Available from:https://www.rightdiagnosis.com/v/viral_hepatitis/treatments.htm (last accessed 2.11.2020)
  11. ↑ PubMed Health. Hepatitis A. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001323/ (accessed February 19, 2013)
  12. ↑ Center for Disease Control. Hepatitis A Vaccine. http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-hep-a.pdf (accessed February 19, 2013)
  13. ↑ PubMed Health. Hepatitis C. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001329/ (accessed February 19, 2013)
  14. ↑ 14.0 14.1 World Health Organization, Global Alert and Response (GAR). Hepatitis B. http://www.who.int/csr/disease/hepatitis/whocdscsrlyo20022/en/index4.html (accessed March 3 2013).
  15. ↑ Center for Disease Control. Medical Management of Chronic Hepatitis B and Chronic Hepatitis C. http://www.cdc.gov/idu/hepatitis/manage_chronich_hep_b-c.pdf (accessed March 2, 2013).
  16. ↑ World Health Organization. Hepatitis A. http://www.who.int/mediacentre/factsheets/fs328/en/ (accessed February 19, 2013)
  17. ↑ 17.0 17.1 Differential Diagnosis of Elevated Liver Tests. http://members.aapa.org/aapaconf2006/syllabus/6206MoonAbnormalLiverFunction.pdf (accessed March 3, 2013).
  18. ↑ X-Plain. Epstein-Barr Virus/Mono Reference Summary. http://www.nlm.nih.gov/medlineplus/tutorials/epsteinbarrvirusmono/id299104.pdf (accessed March 3, 2013)
  19. ↑ 19.0 19.1 19.2 19.3 Gallegos-Orozco JF, Rakela-Brodner J. Hepatitis Viruses: Not Always What it Seems to Be. Rev Med Chile 2010; 138:1302-1311
  20. ↑ Vine LJ, Shepherd K, Hunter JG, Madden R, Thornton C, Ellis V, Bendall RP, Dalton HR. Characteristics of Epstein–Barr virus hepatitis among patients with jaundice or acute hepatitis. Alimentary pharmacology & therapeutics. 2012 Jul;36(1):16-21.
  21. ↑ Kid's Health. Cytomegalovirus. http://kidshealth.org/parent/infections/bacterial_viral/cytomegalovirus.html (accessed March 3, 2013).
  22. ↑ Children's Hospital of Philadelphia. The Poison Control Center- Mushrooms. http://www.chop.edu/service/poison-control-center/resources-for-families/mushrooms.html (accessed March 13, 2013).
  23. ↑ PubMedHealth. A.D.A.M. Medical Encyclopedia- Hepatic Ischemia. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001262/ (accessed March 3, 2013).
  24. ↑ U.S. Department of Health and Human Services. National Digestive Diseases Information Clearinghouse- Nonalcoholic Steatohepatitis. http://www.digestive.niddk.nih.gov/ddiseases/pubs/nash/#symptoms (accessed March 3, 2013).
  25. ↑ MedlinePlus. Alcoholic liver disease. http://www.nlm.nih.gov/medlineplus/ency/article/000281.htm (accessed March 3, 2013).
  26. ↑ U.S. Department of Health and Human Services. National Digestive Disease Information Clearinghouse- Primary Biliary Cirrhosis. http://digestive.niddk.nih.gov/ddiseases/pubs/primarybiliarycirrhosis/index.aspx (accessed March 3, 2013).
  27. ↑ PubMed Health. A.D.A.M Medical Encyclopedia- Sclerosing Cholangitis. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001330/ (accessed March 3, 2013).
  28. ↑ Gene Gateway-Exploring Genes and Genetic Disorders. Genetic Disorder Profile: Hemochromatosis. http://www.ornl.gov/sci/techresources/Human_Genome/posters/chromosome/hh.shtml (accessed March 3, 2013).
  29. ↑ U.S. Department of Health and Human Services. National Digestive Disease Information Clearinghouse- Wilson Disease. http://digestive.niddk.nih.gov/ddiseases/pubs/wilson/ (accessed March 3, 2013).
  30. ↑ National Human Genome Research Institute. Learning About Alpha-1 Antitrypsin Deficiency (AATD). http://www.genome.gov/19518992 (accessed March 3, 2013).
  31. ↑ PubMed Health. A.D.A.M Medical Encyclopedia- Celiac Disease-Sprue. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001280/ (accessed March 3, 2013).
  32. ↑ Medscape Reference. Budd-Chiari Syndrome. http://emedicine.medscape.com/article/184430-overview (accessed February 19, 2013)
  33. ↑ Medscape Reference. Cytomegalovirus. http://emedicine.medscape.com/article/215702-overview (accessed February 19, 2013)
  34. ↑ Medscape Reference. Viral Hepatitis. http://emedicine.medscape.com/article/775507-overview (accessed February 19, 2013)
  35. ↑ Clinical Knowledge Summaries. Hepatitis B Management. http://www.cks.nhs.uk/hepatitis_b/management/scenario_diagnosis/differential_diagnosis (accessed March 3, 2013).
  36. ↑ British Medical Journal. Alcohol Liver Disease. http://bestpractice.bmj.com/best-practice/monograph/1116.html (accessed February 19, 2013)
  37. ↑ British Medical Journal. Hepatic Steatosis. http://bestpractice.bmj.com/best-practice/monograph/796.html (accessed February 19, 2013)
  38. ↑ British Medical Journal. Haemochromatosis. http://bestpractice.bmj.com/best-practice/monograph/134.html (accessed February 19, 2013)
  39. ↑ British Medical Journal. Assessment of Liver Dysfunction. http://bestpractice.bmj.com/best-practice/monograph/1122.html (accessed February 19, 2013)
  40. ↑ Medscape Reference. Autoimmune Hepatitis. http://emedicine.medscape.com/article/172356-overview (accessed February 19, 2013)
  41. ↑ Medscape Reference. Cholangitis. http://emedicine.medscape.com/article/184043-overview (accessed February 19, 2013)
  42. ↑ Medscape Reference. Hepatitis C Differential Diagnoses. http://emedicine.medscape.com/article/177792-differential (accessed February 19, 2013)


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