International Journal of Pediatric Otorhinolaryngology, 22 (1991) 75-80 0 1991 Elsevier Science Publishers B.V. 0165-5876/91/$03.50
PEDOT
75
00726
Hearing loss and ear disorders in Malaysian school children S. Elango I, G.N. Purohit
‘, M. Hashim 2 and R. Hilmi ’
Departments of ’ Otorhinolaryngology and ’ Community Medicine, School of Medical Sciences, Unil~ersity Sains Malaysia, Kota Bharu (Malaysia) (Received (Accepted
Key words: Hearing loss; Middle ear disorder; Otological examination
31 October 25 February
Pimary
1990) 1991)
school
child;
Malaysia:
Screening
audiometry;
Abstract
In Malaysia 1307 randomly selected primary school children were screened to find out the prevalence of hearing loss and middle ear disorders. Seventy-six students (5.81%) failed the screening audiometric test. There were 95 students (7.26%) with middle ear disorders. History of ear discharge was absent in 24 out of 57 cases with CSOM (42.11%) (P < 0.001). Forty-three out of 95 children having middle ear disorders passed the screening audiometric test (P < 0.01 Fisher exact test). Screening audiometric test fails to detect about 46% of cases with middle ear disorders. Screening audiometric test and otological examination if conducted by the school health medical officers regularly will be able to detect almost all the cases with hearing loss and middle ear disorders.
Introduction Hearing impairment has a significant detrimental effect on educational achievement and on acquiring linguistic skills in school children. Use of screening audiometry to identify children with hearing impairment and middle ear disorders still remains controversial. The prevalence of hearing loss and middle ear disorders in school children in western countries though have been well documented while that of Malaysia has not been done so far. Correspondence: S. Elango, Kota Bharu, Malaysia.
Dept.
of Otorhinolaryngology,
School
of Medical
Sciences
(USM),
16750.
This study was undertaken with the twin objectives of knowing the prevalence of hearing loss and middle ear disorders in Malaysian school children and to find out the usefulness of screening audiometry in detecting middle ear disorders.
Methods The study was conducted in the Kota Bharu District of Kelantan state which is situated on the east coast of Peninsular Malaysia. The Kota Bharu district has a general population of about 375,000. The population in the area is mostly rural and socioeconomically backward. The doctor population ratio in Kelantan is the lowest of all the states i.e. 1: 6898 as compared to 1: 2858 for the rest of Peninsular Malaysia. There are 86 primary schools in Kota Bharu district of Kelantan with a student population of 52,624. The schools were divided into 3 categories by the Department of Education into urban, rural and suburban according to their locations. Study population and the selection of the sample schools
The children studying in the national primary schools from the first to the sixth standards in Kota Bharu district were eligible for inclusion in the study. The sample size of 1197 was derived by using the formula Z2Pcl
n=( d2 + Z2pq/N) (where N is the size of the population, n - the sample size, p and q probabilities, d - absolute sampling error, Z - confidence interval). We decided, however, to select more cases keeping in view the absentees and the children who may not cooperate for the examination. Random sampling methods were used to select schools from each group (urban, rural and suburban). A total of 1369 students from 21 schools were included in the study. The students were selected randomly by including every tenth child from the school register after choosing a number from the table of random numbers. Study procedure
History was elicited from the selected children regarding ENT symptoms. A detailed examination of the ear, nose and throat was done in each case by an otolaryngologist. Pure tone audiogram was done for all children using Peter’s Portable Audiometer CAP32 S> by a trained staff nurse. AI1 children were screened at 20 dB intensity level for 500, 1000,200O and 4000 Hz frequencies. A child who failed to respond to any one signal in any ear was considered to have failed the screening test. After a few weeks, a second audiometric screening was done on the students who failed the first. The children
identified as having hearing loss or ear disorders needing further medical attention were referred to a district hospital or the University Hospital. The class teachers were requested to fill up a form on all children, regarding their awareness about hearing problems in the children, and they were not aware of the results of the screening test.
Results Out of 1369 selected students from 21 primary schools there were 52 absentees and 10 children refused examination. Hence we were able to examine only 1307 school chiIdren. The age of children varied from 7 to 12 years. There were 676 (51.72%) boys and 631 (48.28%) girls. Otological examination findings
Congenital abnormalities of the ear (like microtia, atresia of the external auditory meatus and bat ear) were present in 12 children (0.92%). Presence of wax in the ear was the commonest ear finding and was present in 491 children (37.56%). Out of these, 218 children had impacted wax (16.67%). There were 95 students (7.26%) with middle ear disorders. Secretory otitis media was present in 38 children (2.9%). Chronic suppurative otitis media was present in 57 children (4.36%), 7 of whom (0.53%) had attico-antral pathology whereas the rest of the 50 children (3.82%) had tubo-tympanic type of infection. Out of these 57 cases, history of ear discharge was absent in 24 students (42.11%) (P < 0.001). Tuning fork test was abnormal in 49 children (3.74%). Screening audiometry
All the children were subjected failed the second screening test.
to the screening audiometry
and 76 (5.81%)
Screening audiometry in detecting middle ear disorders
Forty-three out of 95 children (46.31%) having middle ear disorders passed the screening audiometry. Out of the 57 students who had CSOM 24 failed the screening audiometric test (42.1%) (P < 0.01; Fisher exact test> (Table I). Out of
TABLE
I
Screening audiometry and CSOM CSOM
Screening audiometry Pass
Fail
Total
Present
24
33
57
Absent
1207
43
1250
Total
1231
76
1307
TABLE II Secretory otitis media and screening audiometry Secretory otitis media
Screening audiometry Pass
Fail
Total
Present
19
19
38
Absent
1212
51
1269
Total
1231
16
1307
the 38 students with secretory otitis media, 19 passed the screening test (50%) (P < 0.01; Fisher exact test) (Table II). Teachers’ awareness about hearing problem
Teachers were aware of the hearing problem in 35 students (46.05%) who failed the screening test.
Discussion
Hearing loss in children is of special importance because it often goes unrecognised for a long time and creates serious problems. The hearing loss not only handicaps a child in academic performance and in acquiring linguistic skills but also hampers psychosocial growth and development. A direct relationship between ear disorders and academic attainment has not been documented [3]. The screening of primary school children will help to detect cases of hearing loss and ear disorders which might not have been noticed by the student, parent and teacher. Ideally, a hearing conservation program in the schools must attempt to identify not only those children with significant hearing impairment but also identify children with middle ear disorders. Traditionally, most hearing screening programs have used air conduction hearing tests to identify children with peripheral hearing impairments. These tests, though they can identify significant hearing loss, fail to identify cases with otological problems. Previous studies have shown [ll] that audiometric screening alone will fail to detect about one half of the children with confirmed otologic problems. With the emergence of impedance audiometry many schools implemented acoustic impedance screening programs to identify ear disorders in school children. The high false positive rate given by impedance audiometry and sometimes transient nature of the middle ear disorder has significantly affected the widespread use of impedance in screening programs 1151.The International Conference on Impedance Screening held in 1977 in Nashville, Tennessee, did not favor universal mass screening with impedance on a routine basis for the detection of middle ear disorders [l]. Considering the high rate of spontaneous resolution and the low test specificity (high false positive rate) for screening
tympanometry, there is no justification for mass screening for middle ear effusion at this time [2]. In our study we used otological examination and screening audiometry for screening the children. We used tympanometry only in suspected cases of secretory otitis media. The prevalence of hearing loss in school children varies in different countries from 2.5 to 26% [6-9,12-141. In this study 76 students (5.81%) failed the second screening test. The students with middle ear disorders (7.26%) are a far greater group than those who failed the screening test (5.81%), in accordance with other reports [5]. Chronic suppurative otitis media has been noted to be common in some races like Eskimos [81, native children of North America [6] and West Africa [lo]. Seasonal variations in the incidence of active CSOM has been noted [lo] in Gambia, where the incidence was 3.1% in the rainy season compared to 1.3% in dry season. A prevalence of CSOM as low as 0.3% has also been reported in school children [4]. Chronic suppurative otitis media seems to be the commonest middle ear disorder (4.3%) in the present study. Considering the facts that the majority of the students come from a lower income group and the standards of hygiene at home are low, the higher incidence of CSOM is not totally surprising. Of those children with CSOM 42.11% did not give a history of ear discharge. If regular screening is not performed these cases which are treatable or which may require rehabilitation may be missed and their academic performance will be affected. Secretory otitis media has been found the most common cause for hearing loss in other studies done in western countries [13]. Jerger has stated that estimates of prevalence of otitis media with effusion, the primary middle ear disorder that causes hearing loss in children, range up to 30%, and have seldom been lower than 15%. In the present study, 38 students (2.9%) had secretory otitis media which was later confirmed by tympanometry. The lower prevalence of secretory otitis media compared to CSOM may be because of the temperate climate. In the present study, the screening audiometry has missed 46.31% of the cases having middle ear disorders. So there must be other means to identify children needing otolaryngologists’ attention. In a developing country like Malaysia where the number of otolaryngologists are limited, it may not be feasible for the otolaryngologist to screen all the school children regularly. The school health medical officers, after a short training in otolaryngology, must be in a position to identify cases of middle ear disorders, which need attention. Regular otological screening of the school children along with screening audiometry may be able to detect almost all cases of hearing loss and middle ear disorders.
Conclusion The prevalence of hearing loss in Malaysian primary school children is 5.81%. The prevalence of middle ear disorders is 7.2%. Screening audiometry fails to
80
detect about 46% of cases with middle ear disorders. The prevalence of ear disorders in school children is much higher than the incidence of hearing loss. Otoscopic examination helps to detect most of the cases with middle ear disorders. We recommend regular screening audiometry and otologica1 examination by the school health doctor so that middle ear disorders can be detected early.
Acknowledgements This study was supported by University Sains Malaysia short-term research grant. The authors wish to thank the Dean, Prof. (Dr.) Mohd. Roslani Abdul Majid, School of Medical Sciences (USM), Kota Bharu, for permitting us to publish this article. Our thanks also to Drs. Daw Win Kyi, Low Heng Chin and Zahara Manap for their contributions.
References 1 Bess, F.H., Impedance screening for children:. a need for more research, Ann. Otol. Rhinol. Laryngol., 89 Suppl. 68 (1980), 228-232. 2 Bluestone, CD. et. al., Controversies in screening for middle ear disease and hearing loss in children, Paediatrics, 77 (1986) 57-70. 3 Brooks, D.N., Otitis media with effusion and academic attainment, Int. J. Pediat. Otorhinolaryngol., 12 (1986) 39-47. 4 Cohen, D. and Tamir, D., The prevalence of middle ear pathologies in Jerusalem school children, Am. J. Otol., 10 (198?) 456-459. 5 Jerger, J., Dissenting report: mass impedance screening, Ann. Otol. Rhinol. Laryngol., 89 Suppl. 69 (1980) 21-22. 6 Julien, G., Baxter, J.D., Crago, M., Ilecki, H.J. and Therien, F., Chronic otitis media and hearing deficit among native children of Kuujjuaraapik (Northern Quebec): a pilot project, Can. J. Publ. Health, 78 (1987) 57-61. 7 Kapur, Y.P., A study of hearing loss in school children in India, J. Speech Hear. Disord., 30 (1965) 225-233. 8 Ling, D., Katsarkas, A. and Baxter, J.D., Ear disease and hearing loss among Eskimo elementary school children, Can. J. PubI. Health, 65 (1974) 37-40. 9 Martila, T.I., Results of audiometrical screening in Finnish school children, Int. J. Pediat. Otorhinolaryngol., 11 (1986) 39-46. 10 McPherson, B. and Holborow, C.A., A study of deafness in West Africa: the Gambian hearing health project, Int. J. Pediat. Otorhinolaryngol., 10 (1985) 115-135. 11 Melnick, W., Eagles, E.L. and Levine, H.S., Evaluation of a recommended program of identification audiometry with school age children, J. Speech Hear. Disord., 29 (1964) 3-13. 12 Mikaelian, D.O. and Barsoumian, V.M., Hearing loss in elementary school children in Lebanon, Laryngoscope, 81 (1970) 447-451. 13 Robinson, G.C., Anderson, D.O., Moghadam, H.K., Cambon, K.G. and Murray, A.B., A survey of hearing loss in Vancouver school children, Can. Med. Ass. J., 97 (1967) 1199-1207. 14 Stephens, M.M., Rounthwaite, F.J. and Hutchison, D.A., Identification of hearing loss in school children: a model program and results, Can. J. Publ. Health, 61 (1970) 297-300. 15 Tos, M., Spontaneous improvement of secretory otitis media and impedance screening, Arch. Otolaryngol., 106 (1980) 345-349.
PEDOT
75
00726
Hearing loss and ear disorders in Malaysian school children S. Elango I, G.N. Purohit
‘, M. Hashim 2 and R. Hilmi ’
Departments of ’ Otorhinolaryngology and ’ Community Medicine, School of Medical Sciences, Unil~ersity Sains Malaysia, Kota Bharu (Malaysia) (Received (Accepted
Key words: Hearing loss; Middle ear disorder; Otological examination
31 October 25 February
Pimary
1990) 1991)
school
child;
Malaysia:
Screening
audiometry;
Abstract
In Malaysia 1307 randomly selected primary school children were screened to find out the prevalence of hearing loss and middle ear disorders. Seventy-six students (5.81%) failed the screening audiometric test. There were 95 students (7.26%) with middle ear disorders. History of ear discharge was absent in 24 out of 57 cases with CSOM (42.11%) (P < 0.001). Forty-three out of 95 children having middle ear disorders passed the screening audiometric test (P < 0.01 Fisher exact test). Screening audiometric test fails to detect about 46% of cases with middle ear disorders. Screening audiometric test and otological examination if conducted by the school health medical officers regularly will be able to detect almost all the cases with hearing loss and middle ear disorders.
Introduction Hearing impairment has a significant detrimental effect on educational achievement and on acquiring linguistic skills in school children. Use of screening audiometry to identify children with hearing impairment and middle ear disorders still remains controversial. The prevalence of hearing loss and middle ear disorders in school children in western countries though have been well documented while that of Malaysia has not been done so far. Correspondence: S. Elango, Kota Bharu, Malaysia.
Dept.
of Otorhinolaryngology,
School
of Medical
Sciences
(USM),
16750.
This study was undertaken with the twin objectives of knowing the prevalence of hearing loss and middle ear disorders in Malaysian school children and to find out the usefulness of screening audiometry in detecting middle ear disorders.
Methods The study was conducted in the Kota Bharu District of Kelantan state which is situated on the east coast of Peninsular Malaysia. The Kota Bharu district has a general population of about 375,000. The population in the area is mostly rural and socioeconomically backward. The doctor population ratio in Kelantan is the lowest of all the states i.e. 1: 6898 as compared to 1: 2858 for the rest of Peninsular Malaysia. There are 86 primary schools in Kota Bharu district of Kelantan with a student population of 52,624. The schools were divided into 3 categories by the Department of Education into urban, rural and suburban according to their locations. Study population and the selection of the sample schools
The children studying in the national primary schools from the first to the sixth standards in Kota Bharu district were eligible for inclusion in the study. The sample size of 1197 was derived by using the formula Z2Pcl
n=( d2 + Z2pq/N) (where N is the size of the population, n - the sample size, p and q probabilities, d - absolute sampling error, Z - confidence interval). We decided, however, to select more cases keeping in view the absentees and the children who may not cooperate for the examination. Random sampling methods were used to select schools from each group (urban, rural and suburban). A total of 1369 students from 21 schools were included in the study. The students were selected randomly by including every tenth child from the school register after choosing a number from the table of random numbers. Study procedure
History was elicited from the selected children regarding ENT symptoms. A detailed examination of the ear, nose and throat was done in each case by an otolaryngologist. Pure tone audiogram was done for all children using Peter’s Portable Audiometer CAP32 S> by a trained staff nurse. AI1 children were screened at 20 dB intensity level for 500, 1000,200O and 4000 Hz frequencies. A child who failed to respond to any one signal in any ear was considered to have failed the screening test. After a few weeks, a second audiometric screening was done on the students who failed the first. The children
identified as having hearing loss or ear disorders needing further medical attention were referred to a district hospital or the University Hospital. The class teachers were requested to fill up a form on all children, regarding their awareness about hearing problems in the children, and they were not aware of the results of the screening test.
Results Out of 1369 selected students from 21 primary schools there were 52 absentees and 10 children refused examination. Hence we were able to examine only 1307 school chiIdren. The age of children varied from 7 to 12 years. There were 676 (51.72%) boys and 631 (48.28%) girls. Otological examination findings
Congenital abnormalities of the ear (like microtia, atresia of the external auditory meatus and bat ear) were present in 12 children (0.92%). Presence of wax in the ear was the commonest ear finding and was present in 491 children (37.56%). Out of these, 218 children had impacted wax (16.67%). There were 95 students (7.26%) with middle ear disorders. Secretory otitis media was present in 38 children (2.9%). Chronic suppurative otitis media was present in 57 children (4.36%), 7 of whom (0.53%) had attico-antral pathology whereas the rest of the 50 children (3.82%) had tubo-tympanic type of infection. Out of these 57 cases, history of ear discharge was absent in 24 students (42.11%) (P < 0.001). Tuning fork test was abnormal in 49 children (3.74%). Screening audiometry
All the children were subjected failed the second screening test.
to the screening audiometry
and 76 (5.81%)
Screening audiometry in detecting middle ear disorders
Forty-three out of 95 children (46.31%) having middle ear disorders passed the screening audiometry. Out of the 57 students who had CSOM 24 failed the screening audiometric test (42.1%) (P < 0.01; Fisher exact test> (Table I). Out of
TABLE
I
Screening audiometry and CSOM CSOM
Screening audiometry Pass
Fail
Total
Present
24
33
57
Absent
1207
43
1250
Total
1231
76
1307
TABLE II Secretory otitis media and screening audiometry Secretory otitis media
Screening audiometry Pass
Fail
Total
Present
19
19
38
Absent
1212
51
1269
Total
1231
16
1307
the 38 students with secretory otitis media, 19 passed the screening test (50%) (P < 0.01; Fisher exact test) (Table II). Teachers’ awareness about hearing problem
Teachers were aware of the hearing problem in 35 students (46.05%) who failed the screening test.
Discussion
Hearing loss in children is of special importance because it often goes unrecognised for a long time and creates serious problems. The hearing loss not only handicaps a child in academic performance and in acquiring linguistic skills but also hampers psychosocial growth and development. A direct relationship between ear disorders and academic attainment has not been documented [3]. The screening of primary school children will help to detect cases of hearing loss and ear disorders which might not have been noticed by the student, parent and teacher. Ideally, a hearing conservation program in the schools must attempt to identify not only those children with significant hearing impairment but also identify children with middle ear disorders. Traditionally, most hearing screening programs have used air conduction hearing tests to identify children with peripheral hearing impairments. These tests, though they can identify significant hearing loss, fail to identify cases with otological problems. Previous studies have shown [ll] that audiometric screening alone will fail to detect about one half of the children with confirmed otologic problems. With the emergence of impedance audiometry many schools implemented acoustic impedance screening programs to identify ear disorders in school children. The high false positive rate given by impedance audiometry and sometimes transient nature of the middle ear disorder has significantly affected the widespread use of impedance in screening programs 1151.The International Conference on Impedance Screening held in 1977 in Nashville, Tennessee, did not favor universal mass screening with impedance on a routine basis for the detection of middle ear disorders [l]. Considering the high rate of spontaneous resolution and the low test specificity (high false positive rate) for screening
tympanometry, there is no justification for mass screening for middle ear effusion at this time [2]. In our study we used otological examination and screening audiometry for screening the children. We used tympanometry only in suspected cases of secretory otitis media. The prevalence of hearing loss in school children varies in different countries from 2.5 to 26% [6-9,12-141. In this study 76 students (5.81%) failed the second screening test. The students with middle ear disorders (7.26%) are a far greater group than those who failed the screening test (5.81%), in accordance with other reports [5]. Chronic suppurative otitis media has been noted to be common in some races like Eskimos [81, native children of North America [6] and West Africa [lo]. Seasonal variations in the incidence of active CSOM has been noted [lo] in Gambia, where the incidence was 3.1% in the rainy season compared to 1.3% in dry season. A prevalence of CSOM as low as 0.3% has also been reported in school children [4]. Chronic suppurative otitis media seems to be the commonest middle ear disorder (4.3%) in the present study. Considering the facts that the majority of the students come from a lower income group and the standards of hygiene at home are low, the higher incidence of CSOM is not totally surprising. Of those children with CSOM 42.11% did not give a history of ear discharge. If regular screening is not performed these cases which are treatable or which may require rehabilitation may be missed and their academic performance will be affected. Secretory otitis media has been found the most common cause for hearing loss in other studies done in western countries [13]. Jerger has stated that estimates of prevalence of otitis media with effusion, the primary middle ear disorder that causes hearing loss in children, range up to 30%, and have seldom been lower than 15%. In the present study, 38 students (2.9%) had secretory otitis media which was later confirmed by tympanometry. The lower prevalence of secretory otitis media compared to CSOM may be because of the temperate climate. In the present study, the screening audiometry has missed 46.31% of the cases having middle ear disorders. So there must be other means to identify children needing otolaryngologists’ attention. In a developing country like Malaysia where the number of otolaryngologists are limited, it may not be feasible for the otolaryngologist to screen all the school children regularly. The school health medical officers, after a short training in otolaryngology, must be in a position to identify cases of middle ear disorders, which need attention. Regular otological screening of the school children along with screening audiometry may be able to detect almost all cases of hearing loss and middle ear disorders.
Conclusion The prevalence of hearing loss in Malaysian primary school children is 5.81%. The prevalence of middle ear disorders is 7.2%. Screening audiometry fails to
80
detect about 46% of cases with middle ear disorders. The prevalence of ear disorders in school children is much higher than the incidence of hearing loss. Otoscopic examination helps to detect most of the cases with middle ear disorders. We recommend regular screening audiometry and otologica1 examination by the school health doctor so that middle ear disorders can be detected early.
Acknowledgements This study was supported by University Sains Malaysia short-term research grant. The authors wish to thank the Dean, Prof. (Dr.) Mohd. Roslani Abdul Majid, School of Medical Sciences (USM), Kota Bharu, for permitting us to publish this article. Our thanks also to Drs. Daw Win Kyi, Low Heng Chin and Zahara Manap for their contributions.
References 1 Bess, F.H., Impedance screening for children:. a need for more research, Ann. Otol. Rhinol. Laryngol., 89 Suppl. 68 (1980), 228-232. 2 Bluestone, CD. et. al., Controversies in screening for middle ear disease and hearing loss in children, Paediatrics, 77 (1986) 57-70. 3 Brooks, D.N., Otitis media with effusion and academic attainment, Int. J. Pediat. Otorhinolaryngol., 12 (1986) 39-47. 4 Cohen, D. and Tamir, D., The prevalence of middle ear pathologies in Jerusalem school children, Am. J. Otol., 10 (198?) 456-459. 5 Jerger, J., Dissenting report: mass impedance screening, Ann. Otol. Rhinol. Laryngol., 89 Suppl. 69 (1980) 21-22. 6 Julien, G., Baxter, J.D., Crago, M., Ilecki, H.J. and Therien, F., Chronic otitis media and hearing deficit among native children of Kuujjuaraapik (Northern Quebec): a pilot project, Can. J. Publ. Health, 78 (1987) 57-61. 7 Kapur, Y.P., A study of hearing loss in school children in India, J. Speech Hear. Disord., 30 (1965) 225-233. 8 Ling, D., Katsarkas, A. and Baxter, J.D., Ear disease and hearing loss among Eskimo elementary school children, Can. J. PubI. Health, 65 (1974) 37-40. 9 Martila, T.I., Results of audiometrical screening in Finnish school children, Int. J. Pediat. Otorhinolaryngol., 11 (1986) 39-46. 10 McPherson, B. and Holborow, C.A., A study of deafness in West Africa: the Gambian hearing health project, Int. J. Pediat. Otorhinolaryngol., 10 (1985) 115-135. 11 Melnick, W., Eagles, E.L. and Levine, H.S., Evaluation of a recommended program of identification audiometry with school age children, J. Speech Hear. Disord., 29 (1964) 3-13. 12 Mikaelian, D.O. and Barsoumian, V.M., Hearing loss in elementary school children in Lebanon, Laryngoscope, 81 (1970) 447-451. 13 Robinson, G.C., Anderson, D.O., Moghadam, H.K., Cambon, K.G. and Murray, A.B., A survey of hearing loss in Vancouver school children, Can. Med. Ass. J., 97 (1967) 1199-1207. 14 Stephens, M.M., Rounthwaite, F.J. and Hutchison, D.A., Identification of hearing loss in school children: a model program and results, Can. J. Publ. Health, 61 (1970) 297-300. 15 Tos, M., Spontaneous improvement of secretory otitis media and impedance screening, Arch. Otolaryngol., 106 (1980) 345-349.
