Thank you for inviting us to come and talk to your class today, 
we really appreciate it!  
My name is Alex Edwards.
 I'm the project Coordinator for the Arctic FASD Regional Training Center 
here at the UAA Center of Behavioral Health Research and Services.  
We're funded by the Centers for Disease Control and Prevention,
 to train and educate health and allied health care students 
about preventing, 
diagnosing, assisting and working with individuals who are experiencing an FASD.
So today we're going to talk about the biological effects of alcohol spectrum. 
This means we're going to talk about how alcohol disrupts 
the developmental processes during fetal development 
and how that then can impact a person throughout their life.  
Now I do babble on 
and unless people raise their hands 
so I can see you and ask a question, 
so unless I see raised hands I'll keep going.
So please feel free to wave a hand at me and I'll stop.  
Okay? 
 Alright, so. 
Okay, so we're going to talk about the birth defects 
associated with alcohol use.  
Alcohol metabolism and pharmacology.  
Alcohol-induced injuries on the developing nervous system.  
The cellular response to alcohol exposure 
and some neurobehavioral effects as well.  
So basically how alcohol impacts the central nervous system.  
So how familiar are you guys with the FASDs?  
Pretty familiar, you've heard the term, right?  
You're heard at least of fetal alcohol syndrome, right?  
When we talk about FASD we're actually talking about an umbrella term.  
What that means FASD is not a diagnosis in and of itself; 
it is a group of diagnoses 
that we know are related to prenatal alcohol exposure, okay.   
So when we talk about individuals who experience an FASD that is what we mean 
an FASD because there are several types of FASDs.  
Fetal alcohol syndrome is probably the best known type of FASD.  
And some other acronyms, 
some other conditions that we know are related to prenatal alcohol exposure, 
include alcohol related,  
 neurodevelopmental disorder or ARND, 
and you guys don't have to memorize these okay,
 and neurobehavioral disorder or NBD.
So both of these are really talking about the effects on the central nervous system, 
the brain.  
Then we have static encephalopathy, 
alcohol exposed,  
which is just a way of saying 
that an individual has permanent irreversible organic brain damage 
caused by that prenatal alcohol exposure. 
FAS or fetal alcohol syndrome which you're all familiar with.  
Anyone know what ARBD is though?  
Female Speaker:  Alcohol related brain damage?  
Speaker:  Very close, very close!  
Alcohol related birth defect, okay.  
So this was a term that was developed to describe those individuals, 
who had physical effects as the result of prenatal alcohol exposure.  
And by physical effects we not only mean the facial features that we see 
associated with individuals who have fetal alcohol syndrome, 
but also perhaps damage to their other internal organ systems 
like their kidneys, or their liver, or their heart, 
or even their muscular skeletal system,
 those sorts of things okay.    
FAE which is fetal alcohol effect, 
how many of heard about that term, it's been around awhile?    
No?  
Okay don't worry about that one actually, because it is falling into disuse.   
That term was coined about 20 years ago 
as a way to describe individuals who had some of the effects
 that we see with individuals with FAS 
but not enough to warrant a diagnosis of fetal alcohol syndrome.  
What they found though was that FAE   
wasn't taken very seriously by service providers, 
by educators, or even perhaps by family members themselves
 because it doesn't sound very serious does it, fetal alcohol effects?
And so what they wanted when they developed the term Fetal Alcohol Spectrum Disorders
 was a way of describing those effects 
in a way that was all encompassing 
and really spoke to the lived experience of these individuals.  
So you probably won't really see FAE around very much longer.  
And then the last one you see is PFAS which is Partial Fetal Alcohol Syndrome 
and this is a diagnosis for individuals who have some
 but not all of the characteristics we see in an individual who has FAS, 
and I am go into what that means in just a second.  
Any questions so far?  
Okay, 
so, just to sum up.  
Fetal Alcohol Spectrum Disorders, 
individuals who have an FASD 
have more than one of the features associated with FAS.  
So normally or typically we would be talking about the central nervous system dysfunction, 
with effects on the brain, 
but they don't have sufficient features for Fetal Alcohol Syndrome, 
because a diagnosis of Fetal Alcohol Syndrome 
actually requires that the individual have certain physical features, 
mostly facial features.  
[Coughing.]  
All individuals though who have an FASD
 have been exposed to alcohol in utero 
and so most of these individuals are going to have secondary
 behavioral and cognitive effects as a result.  
So when we're talking about the characteristics of Fetal Alcohol Syndrome, 
what I'm talking about when I say facial characteristics 
or facial dysmorphia, 
 there are certain things that we look at someone 
and we say their facial structure didn't develop in a typical fashion. 
So we see that they have a smooth philtrum; 
so that groove between the nose and upper lip, that's your philtrum, 
and individuals who have Fetal Alcohol Syndrome 
they are lacking or that groove there is diminished.  
They also have a thin upper lip or a thin vermilion border, 
the technical term for it, 
and I just like the way that slides off the tongue, 
but, so they have a very thin upper lip.  
And then they also have small palpebral fissures, 
and the palpebral fissures is the horizontal opening of the eye where the eye lashes are, 
so from the inner tear duct to your outer tear duct.  
In individuals with Fetal Alcohol Syndrome
 that fissure or that opening
 is at least two to three standard deviations smaller 
than a typical individual of the same age and growth.  
These things are formed because when that face was forming the mid-line, 
so you guys all know you have a midline right, 
that runs down the middle of the body 
and the two sides of the body come together and join, right?  
Well there was alcohol exposure at that point 
and so that midline didn't form the way it was supposed to 
and as a result you get these facial features.  
You notice they all occur along this midline.  
And we think that or evidence shows that 
these outward facial features 
may be representative of problems going on behind the face
 in the brain and that perhaps
 the midline of the brain perhaps didn't form the way it should either.  
Does that make sense?  
That's okay you can say no, I wouldn't mind.  
Individuals with FASDs also have growth restrictions; 
they are smaller and weigh less than their peers.  
And they're going to have central nervous system dysfunction.    
So their central nervous system of their brain 
doesn't work the way they should, in one or more areas.  
And these areas include cognitive deficits, 
so these can look like learning disabilities.  
So these individuals have problems with the way that they learn.  
0:09:56.383,1193:02:47.295
Fetal Alcohol Spectrum Disorders 
Competency IV:  Biological Effects of Alcohol on Fetus 
Friday, January 20th, 2012
So we're not talking necessarily about academic learning disabilities,
 we're talking about problems with the way that a person is able to store 
information for later retrieval.  
They have memory problems; 
one of the areas we know can be affected by fetal alcohol exposure  
is the hippocampus 
and the hippocampus plays a major role in the short term memory. 
If you have problems with your short term memory 
 it stands to reason then that you're perhaps going to have problems
 pulling those short term memories and making them long term memories, right, 
which is essentially what learning is, 
making that long term learning about how to do something. 
They have often executive functioning deficits.   
Who has heard of executive functioning?  
Several people.    
Executive functioning is how we organize our information.  
It's like the executive at the top office
 that's taking all the information and making something out of it.  
Individuals with executive functioning deficits, 
they have problems with planning, 
they have problems with understanding consequences or cause and effect.  
They have problems with their concentration in general 
because in order to concentrate you have to be able to
 filter out what is important information
 and focus in on what you need to be doing now, 
and that's an executive functioning skill.  
They can also have motor functioning deficits.  
So they may be prone to clumsiness 
because their motor skills or coordination 
isn't perhaps where it should be, okay.  
So their brain or the central nervous system perhaps has trouble communicating  
to their muscular skeletal system 
so they don't quite know where they're putting their feet sometimes if that makes sense. 
Balance problems can be an issue 
and some individuals even experience tremors.  
They can have attention and hyperactive issues.  
So they can appear overactive, or have difficulty completing tasks,
 or trouble with transitions.  
So they may have trouble moving from one task to another 
or perhaps one environment to another.  
And then they may have social skills deficits.  
Especially a lack of stranger fear, 
and they may appear immature for their age.  
One thing that we say quite commonly about individuals who have an FASD 
is that their chronological age doesn't match their developmental age.  
So in some areas of their development 
they are perhaps operating several years below their chronological age 
and of course that can cause problems with a variety of social issues right.  
So how does this happen? 
[Coughing.]   
Alright and for the purposes of this discussion
 I'm going to assume you're all over the age of 21, okay?  
[Class laughing.]  
And so as a woman we take a drink of alcohol 
and that alcohol goes into our stomach right, 
because that's where we process everything, 
and from there that absorption of that alcohol comes very rapidly.  
For women peak blood alcohol level occurs about an hour after consumption.  
And the absorption rate though does depend on several factors; 
I'm sure we're all familiar that if you've eaten a meal 
the alcohol affects you less quickly right, than if you had an empty stomach.  
Body mass also appears to be a factor 
and so
 a 90 pound woman who hasn't eaten 
is probably going to be affected more quickly than a 150 pound woman who has had a meal.  
I think that's - you all get that right?  Okay.  
There are some gender differences though.  
Women actually attain greater blood alcohol concentrations than men, 
and that's because of the way that women process alcohol verses the way that men process alcohol.  
So women tend to process that alcohol a lot more quickly from their stomach, like I said.  
Men tend to process some of that alcohol from that upper intestine as well, 
and so it's going to reach their blood alcohol,
 I'm sorry; it's going to read their blood system a lot less quickly.  
In addition 
 because women have a higher fat content to their bodies
 and because alcohol is what we call hydrophilic,
 it likes to go where there is water, 
it's going to concentrate in those cells with a higher water content. 
One of those areas with a high water content is of course your bloodstream.  
So because of those things and women actually have a lower 
binge drinking definition than men do.  
I'm not sure I included that slide today but it doesn't look like I did.   
Who knows what binge drinking is?  
I'm sure you all have a variety of definitions of that.  
Female Student:  Drinking a large amount of alcohol in one sitting?  
Speaker:  Yep, pretty much, that's pretty much it.  
There is a specific definition in research for alcohol use,
 and that is, for women 4 or more standard drinks 
in any one occasion, and an occasion is 2 to 3 hours generally.  
For men it's 5 or more in any one occasion.  
And a standard drink is what, any ideas?  
Female Student:  1 ounce of liquor, 12 ounce beer, 4 ounces of wine.  
Speaker:  5 ounces of wine; 
One, 12 ounce wine or beer cooler, 
and 1.5 ounces of liquor like tequila or any of the harder stuff.  
If you go to a restaurant these days 
and I'm going to bring up the example of wine because I like wine 
and you know they give you these huge glasses right?  
You could probably fit two or three standard drinks in one of those glasses 
so if you have two glasses of wine
 filled pretty near to the top, 
that's a binge drinking episode!  
And you probably didn't even realize it right?  
I bring this up because one of the other things we like to talk a little bit about is prevention.  
So I hope that gives you a little bit of awareness next time you're out 
and having a beer or wine to think about how much you're actually drinking, 
okay, because it's probably more than you think it is.  
Alright, so like I said alcohol is hydrophilic, it's very soluble in water.  
Cells are 98% water right?  
And alcohol very easily crosses those cell membranes
 because the molecular structure of alcohol 
is very similar to other things that the cell needs like water, like sugars.  
So the cell doesn't know this is something that is not good 
and needs to keep out so it can very easily cross that cell membrane.  
This has a major impact on the developing fetus as a result, 
because the placenta can only act as a selective barrier.  
So it's only sort of designed to allow things through that it knows are okay 
and it keeps other things out.  
So it keep out certain viruses, not all, 
it can -- you know, let nutrients in and wastes out and those sorts of things.  
But because of that molecular structure of alcohol
 it doesn't know that it is something to keep out, 
so it can very, very easily cross that placenta.  
And if it crosses that placenta  
the alcohol concentration that embryo and fetus is exactly the same as the mother, 
but the fetus is that much smaller. 
So relatively the impact of that alcohol is probably going to be much higher, 
does that make sense?  
Female Student:  So is there a difference if the child is young, say you're only 4 weeks pregnant
and you have some alcohol, is there more of a chance of fetal alcohol syndrome or less?  
Speaker:  That's a really good question.  
Female Student:  Or is it kind of hard to say? [Chuckling.]    
Speaker:  That is hard to say 
and that's actually the reason the Surgeon General recommends 
to avoid alcohol if you're pregnant or planning to become pregnant, 
because we just don't know what the effects are going to be for any one individual,
 or any one fetus, 
because there are so many different variables that can play into that.  
There is you know, the general metabolism, 
have you eaten at the time, how much did you drink, 
do you drink regularly, do you not drink regularly, 
how efficient is your body at processing alcohol, 
a variety of genetic factors that seem to have a role in this.  
So it's much better to avoid than try to figure out those individual things.  
Okay so how does this impact the central nervous system?  
You have this handout, 
it's black and white sorry, but you can see it in color up here on the board.  
This chart basically shows 
the entire fetal period through 38 weeks which is considered full term.  
And you will see at the front here on the left hand side 
we have prior to implantation, and then implantation onwards.  
Now there are estimated to be about 
95 to 100 billion neurons in the human cortex, the human brain.  
And so the generation rates of those new neurons 
in that developing fetus is about 250,000 per minute over this 9 month span.  
Female Student:  Can you say that again?  
Speaker:  So there's 250,000 new neurons formed, 
every minute, for the entire gestational time period or 9 months, 40 weeks.  
That's a lot of brain cells!  
Now alcohol can affect the creation of those neurons at any point.  
So you will see here that there are different organ systems 
in development at different periods during gestation.  
So one of the first systems that starts development is the systems that become the heart.  
We have the upper and lower limbs.  
We have the facial features so lip, ears, eyes, teeth, palate, and the genitalia.  
But the one organ system that is in continuous development the entire way through the pregnancy
 is the central nervous system.  
This is why we see most of the effects of prenatal alcohol exposure
 on the central nervous system.
Because it stands to reason, right,
 that if there is alcohol exposure when something is in development 
that's the organ system that is going to be affected.  
The organ system that is most likely to be affected 
because of that rate of development is the central nervous system.  
Remember those facial features 
that we see in individuals with Fetal Alcohol Syndrome?  
Those facial features have been found to occur   
if there is alcohol exposure in a very narrow window of gestation, 
and that's days 19 to 21.
It's a 3 day window around about here. 
[On screen: pointing:  4]  
When does a woman find out she's pregnant, generally? 
Female Student:  About a month.   
Speaker:  It's usually generally around about here.   
[On screen: pointing: 4, 5]  
It can be earlier if she's planning pregnancy right, 
but and with the new pregnancy tests but generally it's about this mark.  
So it's actually possible for a woman to be out having a good weekend 
not knowing that she's pregnant 
perhaps you know have two or three drinks, or three or four beers or whatever, 
and because she doesn't know she's pregnant and should be avoiding alcohol, 
she has perhaps already exposed that developing embryo to that alcohol.  
And if it occurs in that window that's when we see those physical facial features 
that we associate with FAS, does that make sense?  
Female Student:  Yes.  
Speaker:  What I'm driving at there is this.  
This is a prevention message, 
if you're sexually active and not using contraception 
please do not drink alcohol because you may be pregnant and not know it.  
For guys in this room 
you're part of that equation 
because last time I checked there were 2 involved at conception!  
So if you don't know she's using contraception 
and you know that she's been drinking, 
contraception becomes your responsibility, okay.  
Alright, any questions on this?  
[Coughing.]  Excuse me.  
Okay, 
alright so 
when we talk about alcohol disrupting the development of the central nervous system, 
one of the first and earliest things that it can disrupt is what we call neurogenesis 
or the development of those neurons, remember the 250,000 every minute.  
So that generation neuro-generation occurs very rapidly 
in the developing embryo and fetus.  
And alcohol exposure during that process 
is naturally going to affect some numbers 
because if it's going to disrupt neurogenesis you're going to have fewer neurons.  
And if you have fewer neurons in certain areas of the brain 
then that area of the brain isn't probably not going to work as well as it should, 
right, because you don't have enough there.  
And as a result that can cause certain cognitive and behavioral problems.  
[Coughing.]  
It can also disrupt the typical growth and differentiation of neurons.
So newly formed neurons go through a process of maturation or differentiation, 
so they have to become the type of neuron required 
for the lifespan of that particular person, alright.  
And they can become and that's off the bottom here of the PowerPoint  
but they can become a neuron, astrocyte, 
and I'm sorry I can never get quite out that last one
 I'm not going to try to stumble over that today!  [Laughing.] 
So each one of these processes is vulnerable to the effects of alcohol exposure, 
or ethanol exposure.  
So again if you have that process disrupted 
and the cell doesn't become what it's supposed to become, 
that's going to cause problems later on for the proper functioning of that brain, 
right, that makes sense.  
Also one of the major parts of central nervous system development 
is the growth of the brain or the expansion of the brain 
starting very early on in development.  
It kind of looks like an onion if you see it sort of ballooning out a little bit.  
That process is called migration.  
So what happens is these neurons get signals saying
 you are supposed to do this in this location, 
and if you go to that location that is where you're going to be for the rest of your life 
okay, and you're going to do this particular job there.  
And the neuron pretty much follows those signals 
and migrates to where they're supposed to be.  
If there is alcohol exposure during that point, 
that neuron is going to get the wrong signals essentially,   
and so it may stop much earlier than it's supposed to, 
and end up the wrong part of the brain for its particular function. 
Alcohol, oops, can also disrupt the nerve growth factor - 
so the thing telling it how far to go and when to stop - those things.   
And it can also effect what we call the chemical substrates 
or other cells called glial cells  
and glial cells are where the neuron kind of travels along on top of. 
Simplifying a lot of stuff there but you get the general idea.  
Once it reaches its destination that neuron has to form a synapse 
and alcohol disrupts that too.  
Are you starting to a see a pattern here?  
And if it can't form the synapse properly
 how is that going to effect the communication
 between the neurons and other parts of the central nervous system?  
They are not going to be working as well as they should, right?  
And then apoptosis or programmed cell death;
 alcohol can cause cells to die off prematurely.    
There are certain times when it's appropriate for cells to die, 
let's think of a, skin is a good example, 
you know skin cells die and replaced right 
and you just kind of slough them off.  
Well neurons generally don't die or are replaced   
but we also know that these neurons sometimes go through apoptosis 
because we create more neurons and more connections than we really need.
So during the first year of life we go through a kind of pruning process 
where the brain goes through -- I have too many redundant cells   
and processes here and you need to stop, you need to stop, you need to stop.
Well alcohol can tell those cells to stop and to die when they're not supposed to, 
and again that will affect the functioning of that particular brain right?    
And then finally alcohol can affect the development of those neurotransmitter receptors.    
You know at the end of those synapses 
the way that the brain nerve cells should communicate 
is through certain chemicals right?  
They send those signals backwards and forwards.  
Alcohol can disrupt the neurotransmitter itself 
and disrupt the receptors here as well.  
So if there is continuous exposure to alcohol through gestation, 
you can see how significantly 
a person's central nervous system can be affected.  
And then lastly plasticity; 
so nerve cells have a pretty limited capacity for plasticity,   
which is the cells ability to repair themselves and regenerate those connections.
Mature neurons are less able to regenerate their function   
and prenatal alcohol exposure decreases that ability even further.
Does that make sense?  
So what does this actually look like in a lived experience, 
about what is going on during development,
 but when working with these individuals what can this look like?  
Well firstly it's going to be different from person to person.  
No two individuals with an FASD are going to be effected in quite the same way 
because of what we talked about earlier,   
how much alcohol they are exposed to, when that exposure occurred, 
their genetics, their mother's genetics,
 a whole variety of factors including what we call the postnatal environment.
So have they been able to access services, 
did they get good health care after they were born, 
those kinds of things, seem to have a big impact as well.  
Individuals with Fetal Alcohol Syndrome may have a low IQ,
may not; it's really dependent on certain individual things.  
Individuals that have an FASD other than FAS 
often have an IQ at or just below what we call the normal range.
So if that is the case will be eligible for many of the Special Education Services; 
something to be aware of.  
Many of these individuals have attention, memory and hyperactivity problems,    
because those are the parts of the brain affected by the prenatal alcohol exposure.
They can have learning impairments, 
so that's not just related to academics,
 it can also include language and their understanding of language, their language acquisition,  
okay; how they are able to interpret what people are saying to them 
and then act on those instructions or what someone have said. 
So they can have speech, and language, and communication issues.  
What this often will look like in FASD individuals, especially as they sort of reach the teenage or adult years, 
is they may look like they are completely understanding everything that you said 
and in fact they are able to repeat it verbatim back to you.
What happens though  
is they are not have a phonetic connection with those words 
 and the meaning of those words and what that actually requires for them to implement.
Does that make sense?  
What might that look like in the classroom?  
If you've given someone an instruction 
and they can repeat it back to you and then they go off and do something else?  
What can that look like, or how would you interpret that?  
Disobedience?  
Female Student:  Generally.  
Could be like they said go out and get a pen and didn't, might be someone disobeying.  
Speaker:  Uh huh.  
Not paying attention, not following instructions, 
those sorts of things; something to be aware of.  
It can also impact visual spatial skills, 
who knows what visual spatial skills are?  
Female Student:  That's like telling where the door frame kind of is to your body.  
Speaker:  Yes, it's where you are in space, okay, it's part of it yeah.  
So who here has had trouble growing up or even now,
 I know I have this problem, hitting the ball with a softball or baseball bat?  
Yeah, right!  
That's a visual spatial skill; 
understanding where that ball is relative to you 
and then when you have to bring the bat back and swing it  
is a facial spatial skill and it's supposed to get better with practice
 but apparently I haven't practiced enough. 
Another visual spatial skill that is really important to be aware of in a classroom setting, 
is being able to look at a chalkboard 
and copy down what's on that chalkboard to the paper in front of you, 
that's a visual spatial skill as well.
And many of these individuals have problems in that area  
so they can't interpret what's up there and translate it down here. 
That's going to cause problems in a learning environment.  
Now many of these individuals, oops, that was clever,
 I don't know how to get myself back there [to the correct screen.]
Of course we would do this when we record it right?    
Many of these individuals can have secondary conditions, or secondary disabilities, 
and these are generally disabilities that we see in individuals who  
have not received adequate support for their primary disabilities, 
so all of those things we talked about before in the central nervous system dysfunction. 
With adequate support we can help relieve some of these things.  
So mental health problems like depression, okay,  
individuals with FASD can be more prone to those. 
Disruptive school experiences and trouble with the law 
because of behavioral issues often, okay. 
Often confinement or incarceration.
Inappropriate sexual behavior and other alcohol or drug problems.  
These are often things that those with FASD are higher risk for,  
but it's not 100% guarantee that they will go on to develop those things; 
I want to make that clear. 
Just because a person has an FASD doesn't mean they're go on and 
end up in juvenile justice or an adult correctional facility.   
It's less likely to happen if we understand what's going on for those individuals  
and we can put into place the appropriate supports. 
Which is one of the reasons I'm here today   
to teach you about these things and about how alcohol can effect someone's central nervous system, 
and development, 
and maybe give you an idea of what that might look like 
when you're working with one of these individuals, kind of a starting point.
I want to just reiterate the public health message:  
that there is no known safe amount of alcohol. 
There is no safe type of alcohol; 
and I just want to explain why this one is in here.  
There are a lot of cultural and social definitions around what alcohol is 
and different alcohol types may be safer than others.
For example, the commonly known is red wine is good for you, right?   
You should have a glass of red wine every day.
It's good for your heart!  
Well it's still alcohol, if you're pregnant, you are planning to get pregnant,  
or if you are sexually active and not using contraception, which is planning a pregnancy by the way, 
you should not be consuming alcohol. 
In addition, just to give you a little bit more broad on that,  
Russia over the summer finally moved beer from the food column to the alcohol column. 
[Class laughing.]  
In Russia beer was classified as food.  
So that's also what I mean by the social and cultural definitions about
 what alcohol is and what is classed alcohol is.  
So if you grow up thinking beer is food 
you're not going to think beer during pregnancy is bad, right?  
So those are things to be aware of too.  
And there is no safe time to drink alcohol during pregnancy, 
and I think you're pretty clear on that now.  
Alcohol can affect the development of the fetus at any point during the pregnancy.
So we really encourage you to think about your alcohol use, 
your contraception use, have those discussions with your partner, 
and make sure that you are, you know, accessing everything that you can 
in terms of helping yourself and helping your friends as well, okay.  
Any questions?  
Very quiet bunch.  
Okay, alright, so that's everything we went over today.  
We do have free to students' public workshops coming up in December 
on a Friday morning between 9 and 1, FASD Foundations and then FASD 201.  
You all are going to be going sort of into the classroom and teaching and something, right?  
The State of Alaska does require you to have FASD training before you enter the classroom, 
so if you come to one of our trainings you can get that certificate and knock that out of the way real early.  
Female Student:  How long is that good for?  Is it indefinitely?  
Speaker:  As far as I know   
and you can always come back for booster training if necessary. 
We do try to make sure we're offering our training for free to students so 
that is our goal.  
Student:  Thank you.  
[Applause.]  
