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- Spinal Cord Compression Syndrome as the Initial Presentation of Non-small Cell Lung Carcinoma of Unknown Primary. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):642A.
Cancer Student/Resident Case Report Posters ISESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Cancer of unknown primary (CUP) is defined as a histologically confirmed metastatic carcinoma in the absence of a detectable primary cancer. The key characteristics of CUP are early dissemination, short duration of clinical symptoms related to sites of metastases, aggressive clinical course, and a metastatic pattern that differs from that expected of a known primary cancer.CASE PRESENTATION: A 62-year-old man with a 125 pack-year smoking history presented with one day of sudden onset bilateral lower extremity weakness and inability to ambulate. Preceding this, the patient had been experiencing gradually worsening lower back pain for 3 months. On initial evaluation, proximal muscle weakness and decreased reflexes were noted in bilateral lower extremities without loss of sensation. CT imaging of the spine confirmed suspicion of spinal cord compression, revealing a large, lytic, soft tissue mass involving the right T7 vertebral body with severe canal stenosis. The patient underwent emergent spinal cord decompression with corpectomy. A tan mass measuring 8 x 7.7 x 2.5 cm in aggregate was removed and histology revealed a metastatic mucin-producing adenocarcinoma with immunostains strongly positive for CK-7 (Fig 1) and Napsin A (Fig 2), suggestive of lung primary. TTF-1, Pax 8, CK-20,CDX-2, CA19-9, and PSA staining were negative, excluding adenocarcinoma of esophageal, colon, pancreas, or prostate origin. CT imaging of the chest/abdomen/pelvis was obtained to identify primary tumor, showing a lytic lesion in the left ischium and a small mediastinal lymph node, without any detectable primary lung mass.DISCUSSION: CUP occurs in 3-5% of all cancer cases and lung cancer presenting as CUP involves the bone in only about 4% of cases. Adenocarcinoma is the most common histopathology of CUP. On immunohistochemical analysis, 85% of lung cancers are positive for CK-7 and Napsin A is a sensitive marker for lung adenocarcinoma with positivity in up to 80% of cases. Lung cancer and CUP represent a significant proportion of spinal cord compression syndrome as initial presentation of malignancy. Optimal treatment strategies for CUP are not clearly defined and choice of therapeutic intervention relies on tissue diagnosis. In our case, combination chemo-radiation therapy was pursued based on the diagnosis of non-small cell lung carcinoma by histopathlogical analysis.CONCLUSIONS: The differential diagnosis of primary lung carcinoma, particularly in a patient with a significant smoking history, should always be considered in cases of CUP in a patient with spinal cord compression syndrome as initial presentation of malignancy. Reference #1: Pavlidis, N. Cancer of unknown primary site. Lancet 2012; 379: 1428-35.Reference #2: Varadhachary, G. et al. Diagnostic Strategies for Unknown Primary Cancer. Cancer 2004; 100(9):1776-85Reference #3: Schiff, D, et al. Spinal epidural metastasis as the initial manifestation of malignancy: clinical features and diagnostic approach. Neurology. 1997;49(2):452.DISCLOSURE: The following authors have nothing to disclose: Larysa Gromko, Shanchita Ghosh, Gregory Conti, Sami Harawi, Madhu ParmarNo Product/Research Disclosure Information.
- A Rare Case of Pulmonary Lymphangitic Carcinomatosis as Primary Manifestation in a Patient With Metastatic Pancreatic Cancer. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):612A.
Cancer Case Report Posters ISESSION TYPE: Affiliate Case Report PosterPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Pulmonary lymphangitic carcinomatosis (PLC) is a rare metastatic lung disease, characterized by infiltration of the pulmonary lymphatic system by tumor cells. We present a case where lymphangitic spread in lungs manifesting as dyspnea and cough, was the primary presentation in a patient with metastatic pancreatic cancer.A 61 y.o. man with atrial fibrillation, diabetes and 35 pack year history of smoking, presented with progressive dyspnea and dry cough for two months. CT scan showed multifocal opacities including ground glass and areas of nodularities and septal thickening. Right thoracoscopic lung biopsy was performed which showed well differentiated metastatic adenocarcinoma with lymphangitic spread. Immunohistochemical studies showed strong CK 7 and CK 19 expression by the tumor cells and weak to moderate CDX-2 expression. There was no expression of napsin, TTF-1, calretinin, WT-1, PAX-8, CK 20, or Ki-19. These were consistent with a pancreatic ductal or biliary tree primary adenocarcinoma. CT abdomen was then performed and showed a complex lesion within pancreatic body/tail concerning for primary neoplasm.DISCUSSION: Intrathoracic metastasis occur in 30-40% patients with malignant disease, 6-8% have lymphangitic carcinomatosa. Common primary tumors associated with PLC include breast,stomach,lung, pancreas and prostate. Pathogenesis involves spread of tumor cells into the pulmonary lymphatic system or adjacent interstitium leading to thickening of bronchovascular bundles and septa. Desmoplastic reaction due to proliferation of neoplastic cells and lymphatic dilation by tumor secretions cause interstitial thickening. Spread to adjacent parenchyma leads to nodular pattern. Dyspnea and cough is the initial manifestation in most. PFT commonly shows a restrictive pattern and decreased diffusion capacity. Radiologic features include thickening of interlobular septa and peribronchovascular interstitium on CT scan. Biopsy is the gold standard for diagnosis. Prognosis is poor, around 50% patients die within first three months of symptom onset.In summary, PLC is a rare but important cause of respiratory compromise, especially when present with characteristic radiologic features. Reference #1: Bruce DM, Heys SD, Eremin O. Lymphangitis carcinomatosa: a literature review. J R Coll Surg Edinb. 1996 Feb;41(1):7-13Reference #2: Thomas A, Lenox R. Pulmonary lymphangitic carcinomatosis as a primary manifestation of colon cancer in a young adult. CMAJ. 2008 Aug 12;179(4):338-40DISCLOSURE: The following authors have nothing to disclose: Nabamita Bisen, Vikram Bisen, Subhraleena Das, Robert LenoxNo Product/Research Disclosure Information.
- A Curious Case of a Reaccumulating Black Colored Pleural Effusion! [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):482A.
Pleural Student/Resident Case Report PostersSESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: A persistent black colored pleural effusion is an unusual sight to come across with unusual etiologies, one of which being a pancreaticopleural fistula! Diagnosis of such fistula should be entertained when faced with a reaccumulating, black colored, pleural effusion.CASE PRESENTATION: A 37 year old female with unknown PMH presented to the hospital with progressive dyspnea, right sided chest pain and tenderness, palpitations and orthopnea for the past 2 weeks. On presentation, CXR showed a right sided pleural effusion. A diagnostic and therapeutic thoracentesis was performed which revealed a black colored effusion! Analysis of the pleural fluid via Light's criteria revealed an exudative effusion . Anticipating a parapneumonic effusion, gram stain and culture were drawn, but returned unremarkable. Following CXR was evident for reaccumulation. CT surgery was consulted for chest tube insertion. Follow up CXRs were significant for persistent right sided pleural effusion despite adequate drainage. Outside hospital records were obtained, revealing that the patient had a history of chronic pancreatitis secondary to alcohol abuse, complicated with pancreatic pseudocysts requiring a lengthy hospital course. Patient was questioned again about her social history. She admitted to drinking socially despite her chronic pancreatitis. In light of possible pancreatic etiology, pleural amylase was drawn, revealing an astounding value of 26,673 IU/L! Further investigation via CT and MRCP revealed a well defined walled off peripherally enhancing tubular structure extending from pancreatic body cranially to the inferior mediastinum and right inferiomedial pleural space suggestive of a fistulous connection. Diagnostic and therapeutic ERCP was performed which confirmed presence of the fistula. The main pancreatic duct was stented, allowing for resolution of fistula by facilitating flow of pancreatic enzymes to the duodenum, aided by enzyme inhibiting action of octreotide. This intervention allowed for resolution of the chronic pleural effusion and resolution of the patient's symtoms.DISCUSSION: A recurring black colored pleural effusion should remind one to entertain the possible diagnosis of pancreaticopleural fistula. Key to diagnosis includes procuring a pertinent history, which typically includes a history of chronic pancreatitis. Subsequently, pleural amylase should be drawn, 1000+ is indicative, 50,000 is diagnostic. Fistulas mostly result in left sided pleural effusions due to proximity of pancreas, but may occur on the right as in this case. CT, MRCP, ERCP confirm the diagnosis.CONCLUSIONS: A reaccumulating, black colored pleural effusion in either lung can be caused by a pancreaticopleural fistula. A high pleural amylase and history of chronic pancreatitis are indicative. Diagnosis can be confirmed by CT, MRCP, and ERCP.Reference #1: Black pleural effusion The American Journal of Medicine (2013) 126, 641.e1-641.e6DISCLOSURE: The following authors have nothing to disclose: Swagatam Mookherjee, Nathan Minkoff, Vishal Shah, Brian ChanglaiNo Product/Research Disclosure Information.
- Black Pleural Effusion in an Alcoholic: Make the Connection. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):467A.
Pleural Case Report PostersSESSION TYPE: Affiliate Case Report PosterPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: A black pleural effusion is extremely rare, and only 8 cases have been reported to date. The causes can be divided into infectious, malignant and hemorrhagic.1CASE PRESENTATION: Our patient is a 37 year old female, former alcoholic, who presented with 2 weeks of coryza followed by 5 days of dyspnea, orthopnea and pleuritic chest pain. She was found to have a right sided pleural effusion. 1 litre of pleural fluid was drained. It was black in color, transudative on analysis but with very high amylase level of 23,000 U/l. Serum amylase was normal. Fluid cytology was benign. CT scan abdomen showed a 2 cm fluid collection superior to the body of pancreas with heterogenous thickening of pancreas. No definite fistula was seen. Esophagogram was normal. MRCP only showed prominent pancreatic duct. Repeat amylase level in pleural fluid was normal. She was treated for presumptive parapneumonic effusion. Patient's pleural effusion and symptoms recurred and a chest tube had to be placed. She also underwent decortication which was complicated by hemothorax. Amylase level in fluid became high again.Thus a repeat CT abdomen was done which showed well-defined walled off tubular structure extending from the pancreatic body cranially to the inferior mediastinum and right inferomedial pleural space suggestive of fistulous connection. Patient finally underwent ERCP guided pancreatic duct stent placement. This led to the resolution of pleural effusion.DISCUSSION: Rupture of a pancreatic pseudocyst is one of the hemorrhagic causes of a black pleural effusion.1Pancreaticopleural fistulas (PPF) develop from leakage of pancreatic exocrine secretions cephalad through openings in the diaphragm in chronic pancreatitis.2 It is different from acute pancreatitis as it is recurrent and without acute pancreatic inflammation. Only 20% of patients complained of abdominal pain.2 A fluid amylase level greater than five times the serum amylase is highly characteristic of PPFs.CONCLUSIONS: PPF should be considered as a cause of black, massive, recurrent pleural effusion in an alcoholic patient even without abdominal symptoms. The predominance of thoracic symptoms often causes initial efforts to be directed toward finding a thoracic pathology, thus resulting in a delay in diagnosis and increase in morbidity.Reference #1: Saraya T, Light RW,Hajime Takizawa H, Goto H.Black pleural effusion.Am J Med. 2013 JulReference #2: Clifton Ming Tay, Stephen King Yong Chang. Diagnosis and management of pancreaticopleural fistula. Singapore Med J 2013.54(4): 190-194DISCLOSURE: The following authors have nothing to disclose: Dilpreet Kaur, Gaganjot Singh, Emerald Banas, Dana SaviciNo Product/Research Disclosure Information.
- Atypical Presentation of Rhizopus Pneumonia in a Multivisceral Transplant Patient. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):462A.
Miscellaneous Student/Resident Case Report Posters ISESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Mucormycosis is a rare opportunistic fungal infection. Rhizopus spp is the most common class of Mucorales to cause infection in the immunocompromised population. Pulmonary mucormycosis commonly presents with angioinvasion and pulmonary infarction with cavitary lesions, at times requiring surgical resection.CASE PRESENTATION: A 53 year old female was admitted to the surgical intensive care unit after undergoing a multivisceral transplant including stomach, pancreas, liver, and small intestine. She previously underwent a failed small bowel transplant one year prior requiring lifelong total parenteral nutrition, complicated by Candida albicans fungemia. Her protracted hospital course included chronic respiratory failure, requiring mechanical ventilatory support. Imaging studies revealed bilateral ground glass opacities consistent with multifocal pneumonia and large bilateral loculated pleural effusions. Multiple bronchial alveolar lavage (BAL) specimens demonstrated Rhizopus spp. Liposomal Amphotericin B and Posaconazole were started, and her immunosuppression was minimized. Liposomal Amphotericin B was eventually discontinued due to nephrotoxicity. Additional investigation lead to the isolation of an intra-abdominal abscess with Candida albicans and pleural effusions with Pseumdomonas putida and vancomycin-resistant enterococcus. The antibiotics were adjusted to daptomycin, meropenem and colistin. Further BAL cultures did not demonstrate Rhizopus and imaging studies showed a resolution of pneumonia. She continued on Posaconazole for a 6 month duration.The primary site of mucormycosis infection varies dependent on host factors. Solid organ transplant patients have a threefold risk of developing pulmonary mucormycosis. An atypical presentation of pulmonary mucormycosis includes a less fulminant chronic respiratory infection with prolonged constitutional symptoms. Early isolation and diagnosis is crucial to prevent dissemination. In transplant patients, minimizing immunosuppression is beneficial. Recommendations for antifungal treatment include Liposomal Amphotericin B and Posaconazole until cultures are negative, radiographic improvement, and recovery from immunosuppression.This case demonstrates how a high index of suspicion for rare fungal infections with an atypical presentation led to a prompt diagnosis of Rhizopus pneumonia. Early treatment and adjustment of immunosuppression medications led to a favorable outcome in a post multivisceral transplant immunocompromised host.Reference #1: Kontoyiannis D, Lewis R. Invasive Zygomycosis: Update on Pathogenesis, Clinical Manifestations, and Management. Infect Dis Clin N Am 2006;60:581-607.Reference #2: Roden M, Zaoutis T, Buchanan W, et al. Epidemiology and Outcome of Zygomycosis: A Review of 929 Reported Cases. Clin Inf Dis 2005;41:634-53.Reference #3: Spellberg B, Edwards J, Ibrahim A. Novel Perspectives on Mucormycosis: Pathophysiology, Presentation, and Management. Clin Microb 2005;556-569.DISCLOSURE: The following authors have nothing to disclose: Nina Kolbe, Keith Killu, Lisa Louwers, Stephanie Bakey, Dionne Blyden, Victor Coba, Mathilda HorstNo Product/Research Disclosure Information.
- The Impact of Pleural Catheter Position on the Success of Bedside Pleurodesis. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):452A.
Pleural DiseaseSESSION TYPE: Original Investigation SlidePRESENTED ON: Wednesday, October 29, 2014 at 02:45 PM - 04:15 PMPURPOSE: To investigate the impact of the pleural catheter position on the success of bedside pleurodesis, residual pleural space after effusion's drainage and acumulation of effusion pos pleurodesis in patientes with recurrent malignant pleural effusions (RMPEs).METHODS: We retrospectively analysed 80 patients with RMPEs treated with pleurodesis (talc or silver nitrate slurry) at our hospital between June 2009 and September 2013. The position of the pleural catheter (14 Fr pigtail) was categorized as posterolateral (PL), anterior (A), fissural (F) and subpulmonary(SP) based on the location of the fenestrated portion of the cateter visualized at chest CT. Pleurodesis was considered successful when no additional pleural procedure was necessary. The pleural volume on CT was measured after drainage of the pleural effusion and one month after that. We used that data to calculated the residual pleural space after effusion drainage and the accumulation of effusion pos pleurodesis.RESULTS: A total of 80 patients (61 female, 19 males, mean age 60.5 years) were included. The median Karnofsky Performance Status index was 60. In 45 patients we used talc and in 35 silver nitrate. The primary neoplasm was breast in 40 patients, lung in 20, ovary in 9, colon, prostate, kidney and indeterminate in 2 and thyroid, stomach and pancreas in 1. The position of the pleural catheter was posterolateral in 17 cases, anterior in 20, fissural in 10 and subpulmonary in 33. Successful pleurodesis was achieved in 71 patients (88.8%), with a similar distribution between groups (88.2 % in PL, 85% in A, 90% in F and 90.9% in SP, p=0.928). The mean initial pleural volume was 587.1ml (458.5-715.7), there was no significant difference between the groups (643.8 (288.5-999.2) in PL, 720.8 (405.8-1035.9) in A, 368 (164.8-571.2) in F and 555.4 (365.9-744.9) in SP, p=0.44). The mean difference between one month and initial pleural volumes was -104.5ml (-253.8-44.7), there was no significant difference between the groups (-61.6 (-315.5-192.1) in PL, -294.4 (-707.3-118.5) in A, 10.1 (-316.7-336.9) in F and -68.9 (-320.7-182.5) in SP, p=0.60).CONCLUSIONS: In this study, the success of bedside pleurodesis, the residual pleural space after effusion drainage and the acumulation of effusion after pleurodesis were not affected by the position of the pleural catheter.CLINICAL IMPLICATIONS: Regardless the pleural catheter position, bedside pleurodesis could be used to palliate the symptoms in patients with RMPEs.DISCLOSURE: The following authors have nothing to disclose: Pedro de Araujo, Ricardo Terra, Paulo Pêgo-Fernandes, Rodrigo ChateNo Product/Research Disclosure Information.
- Relationship Between the Success of Bedside Pleurodesis and Pleural Elastance in Recurrent Malignant Pleural Effusion. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):432A.
Malignant Pleural Disease PostersSESSION TYPE: Original Investigation PosterPRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PMPURPOSE: To investigate the relationships between pleural elastance and the acumulation of effusion, clinical effectiveness, quality of life, dyspnea, pain and complications in patientes with recurrent malignant pleural effusions (RMPEs) treated with bedside pleurodesis.METHODS: Prospective study including patients with RMPEs candidates for treatment with bedside pleurodesis recruited in our hospital between June 2009 and September 2013. Pleural elastance was measure after insertion of pleural catheter (14 Fr pigtail) and analysed after emptying of 800 ml (E800) and at the ending of the effusion drainage (Total Elastance, TE). The pleural volume on CT was measured after effusion drainage and one month after that. We used the difference between them to calculate the accumulation of effusion after the pleurodesis (radiological effectiveness, RE). Pleurodesis was considered successful when no additional pleural procedure was necessary. Life quality (analyzed in its various aspects), dyspnea and pain were evaluated before and 30 days after pleurodesis. Complications were registered and graded according to the CTCAE3.0.RESULTS: A total of 119 patients were included. 39 were excluded (16 died before 30 days, 12 showed incomplete lung expansion, 5 had effusion with less than 800 ml and 6 did not return). 80 cases were analysed (61 female, 19 males, mean age 60.5 years). The median Karnofsky Performance Status index was 60. The primary neoplasm was breast in 40 patients, lung in 20, ovary in 9, colon, prostate, kidney and indeterminate in 2 and thyroid, stomach and pancreas in 1. We did not find significant correlation between E800 and RE (correlation coefficient -0,164, p=0,181) or TE and RE (correlation coefficient -0,215, p=0,74). There were no significant improvements in quality of life in every aspect reviewed. There were improvements in dyspnea and pain, but there were no significant correlation between both and E800 or RE. Successful pleurodesis was achieved in 71 patients (88.8%), but there were no significant correlation between it and E800 or TE. 5 patients had major complications and 8 had minor, there were no significant correlation between occurrence of major or minor complications and E800 or TE.CONCLUSIONS: In this study, we did not find significant correlations between E800 or TE and radiological or clinical effectiveness of pleurodesis, quality of life, dyspnea, pain and complications.CLINICAL IMPLICATIONS: Pleural elastance could not predict clinical or radiological outcomes of bedside pleurodesis.DISCLOSURE: The following authors have nothing to disclose: Pedro de Araujo, Ricardo Terra, Rodrigo Chate, Paulo Pêgo-FernandesNo Product/Research Disclosure Information.
- Role of NKG2D in Obesity-Induced Adipose Tissue Inflammation and Insulin Resistance. [JOURNAL ARTICLE]
- PLoS One 2014; 9(10):e110108.
The early events that initiate inflammation in the adipose tissue during obesity are not well defined. It is unclear whether the recruitment of CD8 T cells to the adipose tissue during onset of obesity occurs through antigen-dependent or -independent processes. We have previously shown that interaction between NKG2D (natural-killer group 2, member D) and its ligand Rae-1ε is sufficient to recruit cytotoxic T lymphocytes to the pancreas and induce insulitis. Here, we tested whether NKG2D-NKG2D ligand interaction is also involved in obesity-induced adipose tissue inflammation and insulin resistance. We observed a significant induction of NKG2D ligand expression in the adipose tissue of obese mice, especially during the early stages of obesity. However, mice lacking NKG2D developed similar levels of insulin resistance and adipose tissue inflammation compared to control mice when placed on a high-fat diet. Moreover, overexpression of Rae-1ε in the adipose tissue did not increase immune cell infiltration to the adipose tissue either in the setting of a normal or high-fat diet. These results indicate that, unlike in the pancreas, NKG2D-NKG2D ligand interaction does not play a critical role in obesity-induced inflammation in the adipose tissue.
- 22. TESTICULAR INVOLVEMENT IN SYSTEMIC DISEASES. [JOURNAL ARTICLE]
- Pediatr Dev Pathol 2014 Oct 21.
Abstract Normal testicular physiology requires appropriate function of endocrine glands and other tissues. Testicular lesions have been described in disorders involving the hypothalamus-hypophysis, thyroid glands, adrenal glands, pancreas, liver, kidney, and gastrointestinal tract. Testicular abnormalities can also associate with chronic anemia, obesity, and neoplasia. Although many of the disorders that affect the above-mentioned glands and tissues are congenital, acquired lesions may result in hypogonadism in children and adolescents.
- Select Biomarkers for Tumors of the Gastrointestinal Tract: Present and Future. [JOURNAL ARTICLE]
- Arch Pathol Lab Med 2014 Oct 21.
Context .- Advances in molecular biomarkers of the gastrointestinal tract have contributed to a decline in the incidence of and mortality from these diseases. The discovery and clinical validation of new biomarkers are important to personalized cancer therapy, and numerous clinical trials are currently ongoing to help identify individualized therapy affecting these biomarkers and molecular mechanisms they represent. Distinct molecular pathways leading to cancers of the colorectum, esophagus, stomach, small bowel, and pancreas have been identified. Using biomarkers in these pathways to direct patient care, including selection of proper molecular testing for identification of actionable mutations and reporting the results of these biomarkers to guide clinicians and genetic counselors, is paramount. Objective .- To examine and review select clinically actionable biomarkers of the colon, esophagus, stomach, small bowel, and pancreas, including present and future biomarkers with relevant clinical trials. Data Sources .- Extensive literature review and practical and consultation experience of the authors. Conclusions .- Although numerous biomarkers have been identified and are currently guiding patient therapy, few have shown evidence of clinical utility in the management of patients with gastrointestinal cancers. Inconsistent results and discordant proposed algorithms for testing were identified throughout the literature; however, the potential for biomarkers to improve outcomes for patients with gastrointestinal cancer remains high. Continued advances through high-quality studies are needed.