Letter to the Editor
Risk factors associated with hernias on peritoneal dialysis
Factores de riesgo asociados a hernias en diálisis peritoneal
Aránzazu Sastre
, Jose González-Arregoces, Igor Romainoik, Santiago Mariño, Cristina Lucas, Elena Monfá, Ana Aguilera, Benjamin de León, George Stefan, Mario A. Prieto
Corresponding author
Servicio de Nefrología, Complejo Asistencial Universitario de León, León, Spain
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Prieto" "autores" => array:10 [ 0 => array:4 [ "nombre" => "Aránzazu" "apellidos" => "Sastre" "email" => array:1 [ 0 => "aranchasastre@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Jose" "apellidos" => "González-Arregoces" ] 2 => array:2 [ "nombre" => "Igor" "apellidos" => "Romainoik" ] 3 => array:2 [ "nombre" => "Santiago" "apellidos" => "Mariño" ] 4 => array:2 [ "nombre" => "Cristina" "apellidos" => "Lucas" ] 5 => array:2 [ "nombre" => "Elena" "apellidos" => "Monfá" ] 6 => array:2 [ "nombre" => "Ana" "apellidos" => "Aguilera" ] 7 => array:2 [ "nombre" => "Benjamin" "apellidos" => "de León" ] 8 => array:2 [ "nombre" => "George" "apellidos" => "Stefan" ] 9 => array:2 [ "nombre" => "Mario A." "apellidos" => "Prieto" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Nefrología, Complejo Asistencial Universitario de León, León, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Factores de riesgo asociados a hernias en diálisis peritoneal" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Dialysis fluid in the peritoneal cavity increases intraperitoneal pressure (IPP).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> This increase in pressure may lead to complications in the abdominal wall, particularly hernias. It may also contribute to the failure of ultrafiltration, and it may be cause of abandonment of the technique.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The aim of the study was to assess the frequency of hernias, identify the risk factors for the development of hernia and to determine whether or not they lead to failure of the dialysis technique.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We studied prevalent patients on peritoneal dialysis at day 01 August 2015 in the Complejo Asistencial Universitario de Leon, in Leon, Spain. We analysed the variables: age; gender; type; time on dialysis; presence of polycystic kidney disease; history of abdominal surgery; diagnosis and repair of hernia before starting dialysis; anthropometric parameters (body mass index (BMI), fat tissue index (FTI) and lean tissue index (LTI) measured by bioimpedance); daytime/sc volume; nocturnal/sc volume; residual volume; and IPP and ultrafiltration measured by a peritoneal equilibration test. We compared the group of patient with hernias with the group without hernias. Continuous variables were expressed as mean and standard deviation; in the case of discrete variables, absolute frequencies and percentages are provided. The association between qualitative variables was evaluated with the chi-square test and quantitative variables using Student's 2-tailed <span class="elsevierStyleItalic">t</span>-test. For the comparisons, the tests were considered to be significant when <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05. SPSS® statistical software for Windows was used.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We analysed 44 patients, 27 males (61.4%), 17 females (38.6%), 28 on continuous ambulatory peritoneal dialysis (CAPD) (63.6%), the average time on dialysis 27.63<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>19.1 months, 3 PKD (6.8%), 22 had a history of abdominal surgery (50%) and 8 (18.8%) had a hernia repair prior to starting dialysis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">There were 8 hernias (18.8%), 3 umbilical and 5 inguinal, 7 in males (87.5%), 50% on CAPD. In 6 patients, the prescription was changed to automated peritoneal dialysis (APD) with a dry day, one patient remained on CAPD with reduction of volume/sc; with these prescription changes, 6 (75%) patients remained asymptomatic and without complications such as incarceration or strangulation. One hernia (12.5%) was repaired surgically with mesh implant, and the patient was switched temporarily to haemodialysis due to the presence of persistent pain.</p><p id="par0030" class="elsevierStylePara elsevierViewall">There were no differences between patients with hernias or without hernias in the variables age, dialysis modality, BMI, FTI, LTI, time on dialysis, volume/sc, ultrafiltration and IPP. In contrast, there was greater residual volume in the patients with hernias: 467<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>61.8 compared to 360.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>116<span class="elsevierStyleHsp" style=""></span>ml (<span class="elsevierStyleItalic">p</span> 0.017). There were more subjects with PKD and more with hernias and previous abdominal surgery in the group with hernias (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). 100% of the group with hernias had IPP<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>13<span class="elsevierStyleHsp" style=""></span>cm/H<span class="elsevierStyleInf">2</span>O.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">We analysed the 34 patients who had IPP<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>13<span class="elsevierStyleHsp" style=""></span>cm/H<span class="elsevierStyleInf">2</span>O and compared them to those with lower IPP. Time on dialysis was 31.47<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>18 vs 14.55<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15 months (<span class="elsevierStyleItalic">p</span> 0.012), BMI 27.68<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4 vs 21.62<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>46<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span> (<span class="elsevierStyleItalic">p</span> 0.001), FTI 13.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5 vs 7.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4 (<span class="elsevierStyleItalic">p</span> 0.02), daytime/sc infusion volume 1103.12<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>132 vs 875<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>349<span class="elsevierStyleHsp" style=""></span>ml/m<span class="elsevierStyleSup">2</span> (<span class="elsevierStyleItalic">p</span> 0.003) and residual volume 411.11<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>94 vs 275.14<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>125<span class="elsevierStyleHsp" style=""></span>ml (<span class="elsevierStyleItalic">p</span> 0.001). We found no significant differences in the rest of the variables, including ultrafiltration.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Frequency of hernias vary in the range of 12–37% in different studies,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> similar to that found in our series, and there is no reason why a hernia should influence the continuing success or failure of the technique.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> No patient in our series has had to abandon the technique so far, although it has been needed to increase the use of cycler with dry day.</p><p id="par0045" class="elsevierStylePara elsevierViewall">As in other studies, neither IPP or infusion volume appear to predict the development of abdominal hernias.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,4</span></a> A positive association has however been described with being elderly, polycystic kidney disease, BMI,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> prolonged time on peritoneal dialysis<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> and previous hernias.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> There is a negative association with being female.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">We were unable to demonstrate any association with age or a lower LTI, perhaps because of the small sample size.</p><p id="par0055" class="elsevierStylePara elsevierViewall">We can conclude that 18.8% of our patients developed an abdominal hernia as a complication; nevertheless 100% were able to continue with their dialysis technique.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The risk factors in our series were: being male; polycystic kidney disease; having had previous hernias; previous abdominal surgery; and greater residual volume.</p><p id="par0065" class="elsevierStylePara elsevierViewall">IPP<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>13<span class="elsevierStyleHsp" style=""></span>cm/H<span class="elsevierStyleInf">2</span>O was associated with more time on dialysis, higher BMI, FTI and daytime volume/sc and greater residual volume.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Since 100% of these complications occur with IPP<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>13<span class="elsevierStyleHsp" style=""></span>cm/H<span class="elsevierStyleInf">2</span>O, we recommend adjusting the dialysis prescription to not exceed these limits, especially in patients with the risk factors described.</p><p id="par0075" class="elsevierStylePara elsevierViewall">We believe that our finding of residual volume being a risk factor for hernias is a new observation; the tolerated pressure limit could be reduced to 13<span class="elsevierStyleHsp" style=""></span>cm/H<span class="elsevierStyleInf">2</span>O in patients at high risk of developing mechanical problems affecting the abdominal wall.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sastre A, González-Arregoces J, Romainoik I, Mariño S, Lucas C, Monfá E, et al. Factores de riesgo asociados a hernias en diálisis peritoneal. Nefrologia. 2016;36:567–568.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">FTI: fat tissue index; BMI: body mass index; LTI: lean tissue index; IPP: intraperitoneal pressure; PLKD: polycystic liver and kidney disease.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Data are expressed as mean plus standard deviation.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Hernia \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">No hernia \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> Value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment with dialysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25.9 (13.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28.01 (20.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57 (19.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63.6 (17.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.6 (2.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.2 (5.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FTI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.6 (4.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.4 (5.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LTI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.7 (3.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.14 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Daytime/sc infusion volume \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1048.3 (58.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1051.9 (242.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nocturnal/sc infusion volume \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1068.6 (56) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1146.3 (142.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IPP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.37 (1.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.83 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Residual volume \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">467 (61) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">360.9 (116) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.02 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ultrafiltration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">619 (239) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">458.5 (250) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gender, female/male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.5/87.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44.4/55.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PLKD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Previous surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47.2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.04 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Previous hernia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.02 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1299529.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Comparison between patients with and without hernias.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intraperitoneal pressure in PD patients: relationship to intraperitoneal volume, body size and PD-related complications" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. 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| 2023 November | 280 | 32 | 312 |
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| 2023 September | 204 | 34 | 238 |
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| 2023 April | 83 | 20 | 103 |
| 2023 March | 104 | 28 | 132 |
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| 2020 August | 83 | 11 | 94 |
| 2020 July | 66 | 19 | 85 |
| 2020 June | 95 | 25 | 120 |
| 2020 May | 97 | 12 | 109 |
| 2020 April | 92 | 27 | 119 |
| 2020 March | 115 | 22 | 137 |
| 2020 February | 96 | 24 | 120 |
| 2020 January | 100 | 27 | 127 |
| 2019 December | 104 | 35 | 139 |
| 2019 November | 91 | 24 | 115 |
| 2019 October | 114 | 17 | 131 |
| 2019 September | 133 | 20 | 153 |
| 2019 August | 110 | 22 | 132 |
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| 2019 April | 145 | 33 | 178 |
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| 2018 October | 183 | 26 | 209 |
| 2018 September | 105 | 16 | 121 |
| 2018 August | 104 | 15 | 119 |
| 2018 July | 124 | 14 | 138 |
| 2018 June | 72 | 13 | 85 |
| 2018 May | 99 | 13 | 112 |
| 2018 April | 88 | 9 | 97 |
| 2018 March | 55 | 8 | 63 |
| 2018 February | 49 | 9 | 58 |
| 2018 January | 68 | 6 | 74 |
| 2017 December | 88 | 8 | 96 |
| 2017 November | 56 | 12 | 68 |
| 2017 October | 37 | 3 | 40 |
| 2017 September | 51 | 23 | 74 |
| 2017 August | 38 | 34 | 72 |
| 2017 July | 36 | 47 | 83 |
| 2017 June | 31 | 10 | 41 |
| 2017 May | 30 | 11 | 41 |
| 2017 April | 36 | 7 | 43 |
| 2017 March | 27 | 26 | 53 |
| 2017 February | 31 | 19 | 50 |
| 2017 January | 40 | 18 | 58 |
| 2016 December | 16 | 3 | 19 |
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