Hospitals have reached breaking point: Rate of COVID patients being admitted is dropping because beds are full and mild cases are being turned away as US reports a third of the world's new infections and families beg for ICU space on social media
New data suggests that a smaller percentage of patients with COVID-19 are being admitted to hospitals because the nation's healthcare systems are being overwhelmed by the staggering number of new infections - as the United States reported a third of new global coronavirus cases on Friday.
While total hospitalizations from the virus have reached new highs in the US with 101,276 people receiving professional medical care as of Friday, two sets of data show that the percentage of those who are admitted to the hospital once testing positive is decreasing.
This is not due to increased testing resulting in more milder cases of COVID-19 being identified, according to The Atlantic, as while testing in November increased by a third compared to the previous month, new cases also doubled meaning more people are getting sick.
Instead, it comes as hospitals are being forced to tighten their restrictions on who is admitted, suggesting that some patients who may have been hospitalized for treatment during the spring and summer wave are now being turned away as deaths from the virus also increase.
On Friday, 2,595 deaths were reported in the US, pushing the 7-day average up to 1,917 deaths per day. It marked the end of the deadliest week of the pandemic since mid-April.
As of Friday, 279,966 Americans have died from coronavirus and 14.4 million cases have been confirmed since the start of the pandemic.
Hospitals are under such strain that in Pennsylvania, one son was forced to beg on social media to find an ICU bed for his mother as her condition worsened.
While hospitalizations hit record highs in the US, the average percentage of infected people who are hospitalized with COVID is dropping. It comes as overwhelmed hospitals are facing major bed shortages are are forced to enforce stricter guidelines on who can be admitted, even as deaths across the nation increase pushing the 7-day average went up to 1,917 deaths per day
Healthcare workers in Houston, Texas, comforts a patient on Friday as the virus rages across the US. New data suggests that hospitals around the country are admitting a smaller percentage less coronavirus patients as they are overwhelmed by cases
Hospitals are being forced to tighten their restrictions on who is admitted, suggesting that some patients who may have been hospitalized for treatment during the spring and summer wave are now being turned away as deaths from the virus also increase. Pictured, a healthcare worker checks a patient's I.V. line in the COVID-19 intensive care unit in Texas
On Friday, 2,595 deaths were reported in the US, pushing the 7-day average went up to 1,917 deaths per day
Some hospitals in Texas have had to ask patients to wait in the emergency room for beds to open up as capacity reaches its limits, with one region warning they may have to start asking people to wait in their cars to avoid overcrowding.
'This morning we had 23 people waiting in the emergency rooms for admissions,' Laredo Health Authority Dr. Victor Treviño said Monday.
'If this trend continues, for safety reasons and the contagious nature of the virus, these hospitals may need to start asking patients, after they triage, to wait in their vehicles to avoid overcrowding in the emergency rooms.'
And in South Dakota, one network of hospitals sent 150 people home with oxygen tanks to keep beds open for sicker patients.
According to the Atlantic, as coronavirus cases surged across the Midwest in October, a smaller percentage of those cases made it to hospital.
About 9.5 percent of COVID-19 cases across the country were being admitted to hospital throughout August and September but by the end of October, this had dropped to 8 percent as the nation broke past a daily record of 66,000 new cases.
It amounted to a 16 percent drop in the proportion of patients admitted in September.
Yet as new daily cases climbed even further – with an average of 100,000 Americans testing positive for COVID-19 almost every day in November – the percentage hospitalized decreased even further.
Throughout last month, an average of 7.4 percent of coronavirus cases were admitted to hospitals last month. While only a .6 percent decrease, it amounts a difference of hundreds of Americans.
Ashish Jha, the dean of the Brown University School of Public Health, found similar data when comparing the number of people hospitalized with the cases confirmed the week earlier.
He found that for weeks through the summer, about 3.5 percent of the number of cases reported a week earlier were hospitalized with COVID-19, but that number is dropping as cases rose in November.
'This is a real thing. It's not an artifact. It's not data problems,' Jha said.
Data from the Centers for Disease Control also showed a dip in hospitalizations over the past two weeks
Hospitalizations are still at record highs, as shown, but a lower percentage of COVID-19 patients are being admitted
If the death rate increases to 1.9%, the US could be reporting over 3,000 daily deaths by mid-December
Given the strain on healthcare systems and waits for beds, the data suggests that hundreds of Americans who tested positive with COVID-19 last month may not have been hospitalized when they would have been if infected and showing symptoms in previous months.
Medical experts have warned for months of the danger if hospitals are faced with more coronavirus patients than they can treat. If the lack of beds in hospitals becomes critical, it would lead to further deaths of patients who may have lived if there had been more space.
Medical units across the country have worked to avoid this happening but recent surges in cases have been more extreme.
'If, in fact, there's a scenario that's very severe, it is conceivable that will happen,' Anthony Fauci, the nation's top infectious-disease doctor, warned in March during the first wave of the country's outbreak.
'We're doing everything we can to not allow that worst-case scenario to happen.'
During the spring and summer surges in cases, while state-level healthcare systems struggled with more local outbreaks, the fear was never realized on a national level.
States such as New York introduced field hospitals, patients were transferred to other states and medical workers from other parts of the country were brought in to help.
Yet the recent data suggests that the problem is currently nationwide, meaning Americans infected with the coronavirus now could be more vulnerable as the healthcare available to them in previous months is now being overwhelmed.
'The assumption we will always have a hospital bed for [you] is a false one.' Dan Johnson, a critical-care doctor, told the Atlantic in November.
That discovery was made earlier this week by a son in Pennsylvania as he desperately searched for an ICU bed for his mother.
'My Mom is not doing very well and is maxed out at Hanover Hospitals capabilities,' Shawn Rider wrote to Facebook. 'We are looking for a hospital that has an EMCO machine and a bed so Hanover can transfer her to you.
'I'm sorry to be blunt but FB is the faster way to get out. Hanover Hospital is making calls, but I can't move forward without giving it my best shot.
'Mom … please continue to fight,' he added.
Rider was contacted by a doctor in York hospital who was able to successfully transfer his mother, according to a post the next day.
Shawn Rider was forced to use a Facebook post to find an ICU bed for his mother in Pennsylvania
He was later contacted by a doctor from another hospital and she was transferred
Friday was country's third worst day of the pandemic with 2,607 people dying, hospitalizations hitting a record 101,000 and new projections showing that there could be almost 539,000 deaths by April. The U.S. also hit a record high of 227,885 new cases in 24 hours.
The data means that more Americans died from coronavirus this week than heart disease, lung cancer or chronic obstructive pulmonary disease.
A total of 11,820 died from COVID-19 over the past week, according to the Institute for Health Metrics and Evaluation (IHME). By comparison 10,724 died from ischemic heart disease; 3,965 from tracheal, bronchus and lung cancer; and 3,766 from chronic obstructive pulmonary disease.
Professor Marty Makary slammed the FDA for meeting to review the Pfizer vaccine on December 10 even though it had already gained approval in the U.K. on Wednesday
The University of Washington's IHME estimates that the death toll could reach 538,893 in the U.S. by April without greater attention to social distancing and mask-wearing. With a rapid vaccine rollout, the prediction is that the number could drop slightly to 527,000. If universal mask-wearing was practiced, that figure is projected to be even lower, with 472,000 deaths by April.
The renewed fears for the nation's hospitals comes as a professor at Johns Hopkins slammed the Food and Drug Administration for continuing to hold off their approval of the COVID-19 vaccine - dubbing the agency's progress 'Operation Turtle Speed'.
In an op-ed for The Dispatch, professor Marty Makary said there needed to be more urgency in approving the vaccine.
He criticized the agency for waiting, as he saw it, to meet to review the Pfizer vaccine on December 10 even though it had already gained approval in the U.K. on Wednesday. 'FDA regulators are wasting precious time in greenlighting a COVID vaccine as more than 2,000 Americans are dying each day and the pandemic continues to starve American society,' Makary wrote in the scathing op-ed.
Britain on Wednesday became the first country in the world to approve the jab, after regulators gave it the green light in the wake of evidence showing it was up to 95 per cent effective and safe.
It prompted a major international row, with both the EU and the United States lashing out at the speed at which it was approved.
Donald Trump's top medic Dr Anthony Fauci accused the UK drug regulator of failing to adequately scrutinize data from manufacturers.
The University of Washington's IHME estimates that the death toll could reach 538,893 in the U.S. by April without greater attention to social distancing and mask-wearing. With a rapid vaccine rollout, the prediction is that the number could drop slightly to 527,000. If universal mask-wearing was practiced, that figure is projected to be even lower, with 472,000 deaths by April
A medical staff member cleans a patient in the COVID-19 ICU at the United Memorial Medical Center in Houston
Medical staff members observe the examination of a patient in the Houston hospital on Friday
A COVID patient FaceTimes her family from the United Memorial Medical Center on Friday
But Makary asserted that the FDA's review could be done 'within 24 to 48 hours without cutting any corners.'
'They just need to work harder,' he added.
'Contrary to popular belief, the FDA process is not hands-on — it does not interview vaccine trial patients or look under a microscope at the immune cells.
'It's doing a statistical analysis and looking at data.
'For the vaccine trial, the data set is small and straightforward.
'If my research team, normally tasked with analyzing data on millions of patients, was asked to review the smaller Pfizer vaccine study of 43,000 patients, it would take about one hour.'
Makary credited the European Medications Agency for using rolling reviews, reviewing data in the real time for the sake for efficiency. He implored the FDA to begin doing that as well.
'Today, as the career FDA staff sit on the Pfizer and Moderna vaccine applications, we health care workers continue to work in highly infected ICUs and testing centers,' he said.
'Vulnerable seniors grow lonelier, and more American families fall behind financially. During a health emergency, the FDA should be convening a single, day-long meeting immediately when the data is submitted, in the same way American businesses have emergency board meetings when a crisis occurs.
'The FDA has a moral and civil obligation to review the data with a sense of urgency. It's not too late—the FDA could call an emergency meeting today.'
Dr. Anthony Fauci said that the average healthy American may not get the vaccine until April - by which time the IHME predicts nearly 539,000 people would have died.
'We have a number of conflating events occurring. We have the surge that we know has gone on before the Thanksgiving holiday -- that very steep inflection of cases that has led to the record numbers,' he said on a CNN Town Hall with Anderson Cooper.
Fauci said the US was yet to see the effects of any Thanksgiving holiday-related surge.
'That may peak two to three weeks from now, and they will cusp at the Christmas holiday. We are really very concerned if you take the Thanksgiving surge, the Christmas surge. By the time you get to December and the beginning of January, we very well could see the numbers you just mentioned.'
Dr. Fauci added that the number of fatalies could be lower if people wore masks and practised social distancing.
'So we all need to pull together to do that because as I've said so many times, help is on the way. Vaccines are imminent. We will be starting to get vaccine doses in people's arms by the middle and end of December, and then more in January.'
'FDA regulators are wasting precious time in greenlighting a COVID vaccine as more than 2,000 Americans are dying each day and the pandemic continues to starve American society,' Makary declared in the scathing op-ed
'For the vaccine trial, the data set is small and straightforward,' he claimed. 'If my research team, normally tasked with analyzing data on millions of patients, was asked to review the smaller Pfizer vaccine study of 43,000 patients, it would take about one hour'
In California, a rapidly-escalating crisis was unfolding and six San Francisco Bay Area regions on Friday issued a new stay-at-home order as the number of virus cases surged and hospitals filled.
Gavin Newsom, the governor of California, said on Thursday that the area was exempt from his regional lockdown.
But the local health officials overrode him and decided to pre-emptively enforce a lockdown, to stem what they see as a tsunami of new cases coming their way.
'We cannot wait until after we have driven off the cliff to pull the emergency [brake],' said Santa Clara County Health Officer Sara Cody.
The changes will take effect for most of the area at 10pm on Sunday and last through January 4.
The counties have not yet reached Newsom's threshold, announced a day earlier requiring such an order when 85 per cent of ICU beds at regional hospitals are full, but officials said the hospital system will be overwhelmed before the end of December when Newsom's order would apply.
'We don't think we can wait for the state's new restrictions to go into effect later this month. This is an emergency,' said Contra Costa Health Officer Chris Farnitano.
A patient is wheeled into a hospital in Manhattan on Friday
New York City is suffering a surge in COVID-19 cases, in similar scenes playing out across the country
Nurses in Worcester, Massachusetts tend to patients at the UMass Memorial Hospital on Friday
A nurse cares for a Covid-19 positive patient at UMass Memorial Hospital in Worcester, Massachusetts
The order came the same day the state recorded another daily record number of cases, with 22,018, and hospitalizations topped 9,000 for first time.
As of Friday, California has 1,286,557 confirmed cases of COVID-19, resulting in 19,582 deaths.
The number of COVID-related deaths increased by 0.7 per cent from the prior day total of 19,437.
This week's Thursday-to-Friday jump is one of the largest day-over-day case count increases of the pandemic. Only two others are higher, one in August and the one from Tuesday to Wednesday of this week.
The number of hospitalizations due to confirmed and suspected COVID-19 cases in California reached a total of 9,948 on Friday - an increase of 246 from the prior day total.
The number of ICU patients due to confirmed and suspected COVID-19 cases in California reached a total of 2,248, an increase of 101 from the prior day total.
The state's current test positivity rate is now 7.3 per cent, up from 7 per cent just 24 hours earlier. That's very close to where it was during the pandemic's late July peak, at 7.5 per cent despite the fact that the number of tests is up 10 per cent since then. That usually decreases the positivity rate.
California Governor Gavin Newsom (above) announced Thursday he will plunge regions of the state into lockdown within a matter of days, banning outdoor dining for hard-hit restaurants
A key concern is that the state may struggle to staff its medical facilities.
While the spring surge was more limited in scope, with some parts of California being hit harder than others.
That allowed more room for shifting resources and bringing in medical professionals from areas that could spare them.
The current surge is not only larger than the spring one but also much more widespread, leaving fewer areas with nurses and doctors to spare.
Los Angeles County was placed under even stricter rules than those set by the state on Wednesday as Mayor Eric Garcetti announced an order closing non-essential businesses, banning all travel including walking and prohibiting social gatherings outside a single household.
On Friday, Garcetti gave an astonishingly grim forecast of the death toll, telling a press conference: 'We are facing a decade of homicides'.
He warned his county is on track to surpass 11,000 deaths by the end of the year, with more than 500,000 cases.
Garcetti urged people to 'control' the spread and stay home for Christmas.
The decision by the six Bay Area counties means that restaurants will have to close to indoor and outdoor dining, and bars and wineries must close, along with hair and nail salons and playgrounds.
Retail stores and shopping centers can operate with just 20 per cent customer capacity. Gatherings of any size with people outside of your household are banned.
Berkeley Health Officer Lisa Hernandez said people should not meet in person with anyone they don't live with, 'even in a small group, and even outdoors with precautions.'
'If you have a social bubble, it is now popped,' Hernandez said.
'Do not let this be the last holiday with your family.'
Shoppers at Costco in Santa Clarita fill their trolleys on Friday, ahead of Monday's lockdown
Food is loaded on Friday as drivers in their vehicles wait in line on arrival at a 'Let's Feed LA County' food distribution
A street blocked off for outdoor dining is mostly empty on Friday in Sausalito, California
Chandeliers hangs above a space where outdoor dining had been set up at Flemings Prime Steakhouse in Woodland Hills
The new stay-at-home order will cut sharply into the most profitable shopping season and threaten financial ruin for businesses already struggling after 10 months of on-again, off-again restrictions and slow sales because of the pandemic.
The five Bay Area counties, along with San Mateo County, were the first region in the country to order a lockdown on March 17 when the area of seven million people had fewer than 280 cases and just three deaths.
Officials said it was much easier to implement such an order regionally, since the Bay Area counties are so closely connected.
In Santa Clara County, the most populated in the region and home to two million residents and the headquarters of Apple and Google, officials previously banned all high school, collegiate and professional sports and imposed a quarantine for people traveling to the region from areas more than 150 miles away after officials began seeing an uptick in cases following Thanksgiving Day.
Compliance officers fanned out throughout the county on Thanksgiving Day and continue to visit business to make sure they follow capacity rules and other precautions.
All the counties, except for Marin, are in the most restrictive purple tier in the state's pandemic blueprint for the economy, forcing most non-essential indoor activities to stop.
Public health officials have long warned that the toll from Thanksgiving gatherings could start to swamp hospitals by Christmas.
While the spring surge was more limited in scope, with some parts of California being hit harder than others.
That allowed more room for shifting resources and bringing in medical professionals from areas that could spare them.
The current surge is not only larger than the spring one but also much more widespread, leaving fewer areas with nurses and doctors to spare.
In the last month, the state imposed restrictions in 52 of the state's 58 counties, including asking people not to leave the state and implementing an overnight curfew for all but essential trips, such as getting groceries.
But it has not worked, because data shows people are ignoring the rules, Dr Mark Ghaly, the state's top public health officer, acknowledged on Thursday.
California issued a statewide order for its 39.5 million residents, 8.5 million of whom live in the Bay Area.
The state has almost double the population of New York state and 10 million more than Texas.
Texas on Friday confirmed 13,699 new cases of the virus - a 7.1 per cent increase over the past seven days.
The seven-day average of new cases has tripled since the beginning of October.
A total of 2,645 people were in ICU in the state.
The state is reporting on Friday fewer than 700 available ICU beds, the Texas Tribune reported - the least amount available since the pandemic began.
The number of Texans hospitalized with COVID-19 increased to over 9,000 this week.
According to a White House Coronavirus Task Force report, Texas is seeing an 'unsustainable increase in hospitalizations' from the virus and 'statewide mitigation must increase.'
The situation is particularly dire in West Texas, and experts worry the holidays could exacerbate an already dangerous situation.
In New York, meanwhile, Governor Andrew Cuomo urged the exhausted residents of his state to keep their guard up.
'I understand COVID fatigue - we all are tired and exhausted by this pandemic,' he wrote in his nightly email.
'But we can't give in to it. We can't let hospitalizations climb.'
The state reported over 10,000 positive cases, and 11,271, or 5.41 per cent of all tests, were positive.
There were 795 patients in ICU, Cuomo said - an increase of 12 from the previous day - and 60 new deaths from the virus.
Cuomo said that contact tracing data suggested that small indoor gatherings are a source of 70 per cent of infections, and warned New Yorkers to steer clear of the traditional celebrations.
'While I can understand why there is a desire to gather, we can't give in to it this holiday season,' he said.
'We have regulations in place for a compelling reason: to safeguard the public health, keep people out of hospitals and save lives.'
Cuomo emphasized the new guidelines by the CDC, updated on Friday, which stressed the need for people to wear masks in all non-household indoor settings.
'There is not detailed plan that we've seen anyway as to how you get the vaccine out of a container into an injection syringe into somebody's arm,' Biden said, after his team got briefed on the administration's plans
On Wednesday Joe Biden, the president-elect, amplified the bleak forecast during a roundtable with workers and small business owners hard hit by the devastating economic fallout of the pandemic.
'Christmas is going to be a lot harder. I don't want to scare anybody here, but understand the facts - we're likely to lose another 250,000 people dead between now and January. You hear me?' Biden said.
The op-ed by the Johns Hopkins' professer also comes as President-elect Joe Biden raised concerns Friday about what he said was a lack of detailed planning for end-stage distribution of the coronavirus vaccine, following discussions with current Trump administration officials.
Biden made the statement after speaking in Wilmington about a 'grim' jobs report that he also called 'dire.'
'There is no detailed plan that we've seen anyway as to how you get the vaccine out of a container into an injection syringe into somebody's arm,' Biden said.
A U.S. Food and Drug Administration (FDA) panel of outside advisers is due to meet on Dec. 10 to discuss whether to recommend emergency-use authorization of the Pfizer vaccine. Moderna's vaccine, also found to be nearly 95% effective, is expected to be reviewed a week later.
While some U.S. health officials described a rollout timeline that assumed FDA authorization would come within days of the Dec. 10 meeting, FDA officials have said it could take weeks.
Dr Stephen Hahn, FDA Commissioner, said it is still realistic to vaccinate 20 million Americans against COVID-19 this year after a 'robust discussion' at the White House this week (file)
From container to arm: Biden said he wanted to see a detailed plan which sets out how people will actually received the virus, with Pfizer's likely to be the first to be actually injected
Pfizer will only be able to ship half as many doses of its coronavirus vaccine as it promised by the end of the year. Pictured: Refrigerated trucks equipped to deliver the vaccines leave a Pfizer plant in Belgium
Fauci has said that one of the biggest problems the U.S. faces is convincing people to trust the vaccine
Pfizer, Moderna and a third producer, AstraZeneca Plc, have already started manufacturing their vaccines and say distribution could begin almost immediately after approval. AstraZeneca, however, may have to conduct an additional trial to gain U.S. approval after a dosing error led to better results in recently released data than for its planned regimen.
Beyond regulatory hurdles, vaccinations face opposition from significant numbers of Americans who reject medical science and fear vaccines as harmful.
Similarly, many Americans still refuse to follow basic public health guidance on wearing masks and avoiding crowds.
In hopes of increasing compliance, the CDC on Wednesday added new guidelines to shorten the duration of quarantines.
The health agency said seven days with a negative COVID-19 test and 10 days without a test would suffice for individuals showing no symptoms after exposure to the virus. But it still recommends a 14-day quarantine as preferable.
Across the country on Friday, state health departments were preparing local hospitals for the first shipments of Pfizer Inc's COVID-19 vaccine, if approved.
The first shipment is expected to cover inoculations of 3.2 million people - nowhere near enough for the 21 million U.S. healthcare workers.
And government officials said initial shipments would also go to five government agencies including the Departments of Defense, State and the Veterans Health Administration.
The subsequent two weekly vaccine distributions could cover 7 to 10 million people a week, provided a second vaccine - from Moderna Inc - is authorized early in the second half of December, and Pfizer meets its distribution estimates, according to data provided by Department of Health and Human Services (HHS) and the companies.
Federal officials have not disclosed exactly how many doses will be in later shipments.
'For the time being, and the foreseeable future, the demand for vaccines is going to exceed the supply by a lot, even for the highest priority groups that are identified,' said Josh Michaud, Kaiser's associate director of global health policy.
States have the final word on how to distribute vaccines to their citizens, but federal officials have said that of some 330 million U.S. residents, healthcare workers and those in nursing homes should be considered first for vaccines.
With early supplies limited, the federal government is allocating doses based on state populations, rather than the proportion of the populations at high risk. That means some states' health workers will be better protected than others.
Alabama for instance, will receive enough vaccine for around 17% of its healthcare workers, while Illinois could cover only 13%, according to data from state officials.
The approach would initially leave out around 190,000 healthcare workers in Alabama and more than 570,000 in Illinois, according to Kaiser Family Foundation data on healthcare workers by state.
More than two million healthcare workers in California will have to wait as early vaccine supplies are doled out, based on figures provided to Reuters by state officials.
This first stage of the rollout illustrates the complexity of the government's goal to vaccinate most Americans by mid-2021.
U.S. officials maintain they will distribute 40 million doses by the end of the year - enough to inoculate 20 million people - with millions of shots shipping every week, assuming speedy approvals of both the Pfizer and Moderna vaccines.
Pfizer, which developed its vaccine with German partner BioNTech SE, told Reuters the United States will receive about half of the 50 million doses it will produce in 2020.
Moderna's vaccine could add at least another 12.5 million doses, federal officials have said.
The CDC expects about 5 million to 10 million doses to be shipped per week in the first weeks of the U.S. vaccine distribution effort.
States meanwhile are preparing for the first distribution to fall short, as hospitals across the country grapple with record numbers of COVID-19 patients and staffing shortages.
'Clinical staff are becoming infected, nurses and doctors. It's creating a workforce crunch and the beds are filling up,' said Alan Morgan, chief executive of the National Rural Health Association, an advocacy group for rural hospitals.
Arkansas's state epidemiologist Jennifer Dillaha said vaccines are urgently needed to keep up with the surge in patients.
'We want to ensure our hospital capacity as much as possible through vaccination for those healthcare workers who are at highest risk for infection,' she said.
More than half a dozen states including Alabama, California, New Mexico, and Wisconsin, told Reuters the first allocation estimates they have been given would not be near enough to cover all their healthcare workers, let alone other high-priority residents.
The size of initial allocation figures shared with Reuters ranges widely, from around 330,000 in California - the most populous U.S. state - to less than 7,000 in North Dakota, which has 50,000 healthcare workers, according to Kaiser data and figures provided to Reuters by state officials.
That means both states can vaccinate less than 20 per cent of their healthcare workforce with the first shots. New York state will receive 170,000 shots initially, enough for roughly 13 per cent of its healthcare workers.
The U.S. government expects the number of available doses to increase in January to about 60 million to 70 million.
It has made deals for 100 million doses of Pfizer's vaccine for $1.95 billion and 100 million of Moderna's for $1.5 billion, with options to buy more. It expects vaccines to be free to most Americans.
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