Patna HC dismisses petition seeking age extension for appointment of Assistant Professors

Patna: The Patna High Court dismissed a petition seeking an increase in the
maximum age limit for appointing assistant professors in government medical
colleges in Bihar. On Monday, the decision was reached by a division
bench comprising Chief Justice K Vinod Chandran and Justice Harish Kumar while
dismissing the writ petition filed by Dr Nishant.  

The petitioner had contested the legality of Rule 7 of the Senior
Resident/Tutor & Bihar Medical Education Service (Recruitment, Appointment,
and Promotion) Rules, 2008, which sets the maximum age limit for unreserved
candidates at 45 years, for other backward castes at 48 years, and for
scheduled castes and tribes at 50 years, for the appointment to assistant
professor positions in government medical colleges in Bihar, reports the Times of India.

Dr Nishant’s counsel, Kumar Kaushik, argued that the state’s age limit
should match that set by the National Medical Commission (NMC), India’s
regulatory body for the medical profession and education. The NMC has
established the maximum age limit for appointing assistant professors in
medical colleges at 70 years. However, the court upheld the existing
rules and dismissed the petition.

Also Read:Assam Govt revises upper age limit for doctors in medical colleges to 45 years

The age limit has been a persistent problem for many doctors. In a move that will bring relief to thousands of doctors wanting to start their careers in the field of medical education, the National Medical Commission (NMC) might soon do away with the age limit of 45 years prescribed for the initial appointment of the Senior Residents. The Postgraduate Medical Education Board (PGMEB) of NMC examined the cases of the non-medical postgraduate students with MSC (Medical) degrees and decided to recommend to NMC abolishing the age limit of 45 years prescribed for the Senior Residents in the Teachers Eligibility Qualifications in Medical Institutions Regulations, 2022.

Recently, the Assam government increased the upper age limit for government doctors appointed across state-run medical colleges to 45 years for entry-level senior residents, tutors, demonstrators, registrars, resident surgeons and resident physician posts.
Also Read:NMC to abolish age limit of 45 years prescribed for senior residents

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TAVI shows Promising Results in High-Risk Aortic Regurgitation Patients in Revolutionary Study

USA: In a groundbreaking development for cardiovascular medicine, the results of the ALIGN-AR study have sparked hope for patients suffering from high-risk symptomatic native aortic regurgitation. The prospective, multicentre, single-arm study focused on Transcatheter Aortic Valve Implantation (TAVI) as a potential solution for this challenging condition.

The study showed that using a dedicated transcatheter heart valve for patients with symptomatic moderate-to-severe or severe aortic regurgitation (AR) at high risk of complications or mortality after surgical aortic valve replacement (SAVR), is safe and effective for treating AR.

“For Trilogy TAVI, the 30-day composite primary safety endpoint of > 40.5% was achieved,” the researchers reported in The Lancet. “2. 8% of patients who underwent Trilogy TAVI had passed at the 1-year follow-up.”

For patients with native aortic regurgitation, surgery remains the only recommended intervention. A transcatheter therapy to treat patients at high risk for complications and mortality with SAVR represents an unmet need. Commercial transcatheter heart valves in pure aortic regurgitation are hampered by unacceptable embolization and paravalvular regurgitation rates. For these patients, the Trilogy transcatheter heart valve presents a treatment option.

Torsten P Vahl, Columbia University Irving Medical Center, New York, NY, USA, and colleagues report outcomes with TAVI in patients with pure aortic regurgitation using this dedicated transcatheter heart valve.

For this purpose, the researchers conducted the ALIGN-AR trial, a prospective, multicentre, single-arm study. Symptomatic patients (aged ≥18 years) with moderate-to-severe or severe aortic regurgitation at high risk for mortality and complications after SAVI were recruited at 20 US sites for treatment with the Trilogy transcatheter heart valve.

The 30-day composite primary safety endpoint was compared for non-inferiority with a prespecified performance goal of 40·5%. The primary efficacy endpoint was 1-year all-cause mortality compared to non-inferiority with a performance goal of 25%.

346 patients were screened between 2018 and 2022. 166 patients were excluded, and 180 patients with symptomatic aortic regurgitation deemed high risk by the heart team and independent screening committee assessments, were enrolled. The patients’ mean age was 75·5 years, and 53% were male.

Based on the study, the following findings were made:

  • 95% of patients achieved technical success.
  • At 30 days, 2% of deaths, 1% of disabling strokes, and 1% of non-disabling strokes occurred.
  • Using standard Valve Academic Research Consortium-2 definitions, the primary safety endpoint was achieved, with events occurring in 27% of patients and new pacemaker implantation in 24% of patients.
  • The primary efficacy endpoint was achieved, with mortality in 7·8% of patients at one year.

“The observed short-term hemodynamic and clinical outcomes are promising as are signs of left ventricular remodeling, but long-term follow-up is necessary,” the researchers wrote.

As advancements in technology and procedural techniques continue to evolve, TAVI holds promise as a transformative treatment modality for patients with high-risk symptomatic native aortic regurgitation. The ALIGN-AR study serves as a beacon of hope for patients and clinicians, heralding a new era in managing this complex cardiovascular condition.

Reference:

Transcatheter Aortic Valve Implantation in Patients With High-Risk Symptomatic Native Aortic Regurgitation (ALIGN-AR): A Prospective, Multicenter, Single-Arm Study. Lancet 2024; Mar 26:[Epub ahead of print].

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COVID-19 Severity Heightened in Patients with Diabetes: Study Reveals Troubling Connection

China: The correlation between COVID-19 infection severity and pre-existing health conditions has been a focal point of scientific inquiry since the onset of the pandemic. Among the various comorbidities, diabetes has emerged as a significant risk factor, exacerbating the severity of the viral illness, according to a recent study published in the Journal of Health, Population and Nutrition.

The researchers reported that CT imaging reveals the influence of blood glucose levels on the severity of COVID-19.

The study revealed a significant correlation between blood glucose control and CT severity score (CTSS); the higher the blood glucose is, the more severe the lung manifestation. Also, the CTSS can be used to predict and evaluate COVID-19’s clinical severity.

Previous studies have shown that patients with diabetes exhibit more severe conditions concerning the clinical course and chest imaging and are more likely to develop critical COVID-19 compared with normal-infected individuals. Furthermore, those with poor blood glucose control have a worse prognosis.

Against the above background, Jin Wang from the Yan’an Hospital Affiliated with Kunming Medical University in Kunming, Yunnan, China, and colleagues aimed to analyze the correlation between blood glucose control and the severity of COVID-19 infection in diabetes patients.

For this purpose, the researchers retrospectively collected imaging and clinical data of 146 patients with diabetes combined with COVID-19 who visited the hospital between 2022 and 2023.

The patients were categorized into two groups based on an assessment of their blood glucose control: the good blood glucose control group and the poor blood glucose control group. The two groups were compared for the clinical data, computed tomography (CT) appearance and score, and the severity of COVID-19 infection, with the COVID-19 severity being the dependent variable to analyze other influencing factors.

The study led to the following findings:

· The group with poor blood glucose control showed a higher lobar involvement degree and total CT severity score than the group with good blood glucose control (13.30 ± 5.25 versus 10.38 ± 4.84).

· The two groups exhibited no statistically significant differences in blood lymphocyte, leukocyte, pleural effusion, C-reaction protein, consolidation, ground glass opacity, or crazy-paving signs.

· Logistic regression analysis showed that the total CTSS significantly influences the clinical severity of patients (odds ratio 1.585). In contrast, fasting plasma glucose and blood glucose control are not independent factors influencing clinical severity.

· The area under the curve (AUC) of CTSS prediction of critical COVID-19 was 0.895 with sensitivity of 79.3% and specificity of 88.1% when the threshold value is 12.

In conclusion, chest CT imaging is a reliable testing method for evaluating COVID-19; the higher the blood glucose level is, the more severe the clinical manifestation and the more evident the lung inflammation. This indicates that clinical patients should receive a CT scan upon admission to evaluate their initial condition, and there should be a thorough analysis of imaging appearances.

“Targeted treatment should be administered, and education and publicity activities should be implemented aiming to popularise the necessity of controlling their blood glucose among patients with diabetes and encouraging them to make an active effort to keep healthy and follow appropriate diets, thus improving their quality of life,” the researchers wrote.

Reference:

Lu, D., Liu, Y., Ma, P. et al. Severity of COVID-19 infection in patients with COVID-19 combined with diabetes. J Health Popul Nutr 43, 55 (2024). https://doi.org/10.1186/s41043-024-00548-w

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Mediterranean diet linked to improved pain and quality of life in fibromyalgia patients: Study

Mediterranean diet linked to improved pain and quality of life in fibromyalgia patients suggests a study published in Pain Therapy.

Fibromyalgia is a form of chronic pain that affects a large number of women. It can start at any age and last a lifetime, with no cure. The Mediterranean diet is said to have an anti-inflammatory effect. Therefore, this study was conducted to investigate the possible beneficial effects of a personalized Mediterranean diet in patients with fibromyalgia. Outpatients with fibromyalgia were recruited and invited to participate in the study, including clinical, nutritional, and dietary assessments. Patients received a personalized Mediterranean diet (DIET group) or a generally balanced diet (NODIET group) to be followed for 8 weeks. All tests were carried out at baseline and repeated after 4 and 8 weeks. Results: In total, 100 subjects were included, 84 of whom completed the study. Most of the patients showed incorrect habits in terms of food choices, timing of meals and composition of nutrients. The DIET group showed an improvement in most of the fibromyalgia parameters, including disability scores, fatigue, and anxiety. The habit of eating inflammatory foods and/or eating meals with the wrong nutritional content would increase the negative status of patients with fibromyalgia. With this study, we confirm that proper attention to feeding habits would improve the quality of life of such patients.

Reference:

Casini, I., Ladisa, V., Clemente, L. et al. A Personalized Mediterranean Diet Improves Pain and Quality of Life in Patients with Fibromyalgia. Pain Ther (2024). https://doi.org/10.1007/s40122-024-00598-2

Keywords:

Mediterranean diet, improved, pain, quality of life, fibromyalgia, patients, Casini, I., Ladisa, V., Clemente, L, Pain therapy

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Aspirin’s Efficacy in Primary Prevention Examined: Study Shows Varied Impact on Adults with Elevated Lipoprotein(a)

USA: A recent study published in the American Journal of Preventive Cardiology has suggested the benefits of aspirin in primary prevention could be dependent on lipoprotein(a) [Lp(a)] levels of a person.

The study found a significantly lower atherosclerotic cardiovascular disease (ASCVD) mortality in adults without clinical ASCVD with elevated Lp(a). Given the high prevalence of predominantly genetically determined elevated Lp(a), the findings may have public and clinical health implications for aspirin utilization in primary prevention.

Analyzing more than 2900 people with a median follow-up of 26 years, the researchers found that regular aspirin use in those aged 40 to 70 years cut the risk of ASCVD mortality in half among those with Lp(a) levels of 50 mg/dL or more but had no benefit among those with reduced Lp(a).

Lipoprotein(a) is an atherogenic and prothrombotic lipoprotein associated with ASCVD. Alexander C. Razavi, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, and colleagues aimed to assess the association between regular aspirin use and ASCVD mortality among individuals with versus without elevated Lp(a) in a nationally representative US cohort.

Eligible participants were aged 40–70 years without clinical ASCVD, reported on aspirin use, and had Lp(a) measurements from the Third National Health and Nutrition Examination Survey (NHANES III, 1988–1994), the only cycle of this nationally representative US cohort to measure Lp(a).

Regular aspirin use was defined as aspirin intake ≥30 times in the previous month. Over a median 26-year follow-up, using NHANES III linked mortality records and weighted Cox proportional hazards regression, the association between regular use of aspirin and ASCVD mortality was observed in those with and without elevated Lp(a) (≥50 versus <50 mg/dL).

The study revealed the following findings:

  • Among 2,990 persons meeting inclusion criteria (∼73 million US adults), the mean age was 50 years; 53% were female, and 7% reported regular aspirin use.
  • The median Lp(a) was 14 mg/dL, and the proportion with elevated Lp(a) was similar among those with versus without regular aspirin use (15.1% versus 21.9%).
  • Among individuals with elevated Lp(a), the incidence of ASCVD mortality per 1,000 person-years was lower for those with versus without regular aspirin use (1.2 versus 3.9).
  • In multivariable modeling, regular aspirin use was associated with a 52% lower risk of ASCVD mortality among individuals with elevated Lp(a) (HR=0.48) but not for those without elevated Lp(a) (HR=1.01).

“Regular aspirin use was associated with a 52% lower risk of ASCVD mortality among adults without clinical ASCVD who had elevated Lp(a),” the researchers wrote. “These findings suggest that Lp(a) measurement may help identify individuals who benefit from aspirin therapy for primary prevention.”

Reference:

Razavi, A. C., Richardson, L. C., Coronado, F., Dzaye, O., Bhatia, H. S., Mehta, A., Quyyumi, A. A., Vaccarino, V., Budoff, M. J., Nasir, K., Tsimikas, S., Whelton, S. P., Blaha, M. J., Blumenthal, R. S., & Sperling, L. S. (2024). Aspirin Use for Primary Prevention Among US Adults With and Without Elevated Lipoprotein(a). American Journal of Preventive Cardiology, 100674. https://doi.org/10.1016/j.ajpc.2024.100674

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Tazarotene and Imiquimod Offer Similar Efficacy in Treating Plane Warts

Researchers have found that tazarotene 0.1% gel and imiquimod 5% cream offer similar efficacy in treating plane warts, according to a three-arm randomized controlled trial. Both treatments demonstrated significant improvements compared to baseline and placebo, but tazarotene may offer additional advantages, such as a safer profile regarding dyspigmentation and cost savings. The study was published in the journal Clinical and Experimental Dermatology by Hagar N. and colleagues.

Plane warts, particularly when multiple and recurrent, can be challenging to treat and may negatively impact a patient’s quality of life. For lesions located in cosmetically sensitive areas, topical treatments are often preferred to minimize potential sequelae. This study aimed to compare the efficacy and tolerability of tazarotene 0.1% gel and imiquimod 5% cream in treating plane warts.

In this parallel three-arm randomized controlled trial, 60 patients were assigned to one of three groups: imiquimod, tazarotene, or placebo. Patients applied the corresponding treatment once daily at night for up to 12 weeks. The primary outcomes measured were the percentage of respondents with complete clearance and the type and frequency of side effects in each group.

The key findings of the study were as follows:

  • Complete clearance was achieved in 50% of patients, while 15% experienced partial response and 35% showed no response.

  • Complete clearance was achieved in 40% of patients, with another 40% experiencing partial response and 20% showing no response.

  • There was no significant difference in treatment efficacy between the imiquimod and tazarotene groups (P=0.190).

  • Both active treatments provided significant improvement over baseline and the placebo group (P=0.001).

  • However, tazarotene 0.1% gel may offer advantages such as a safer profile regarding dyspigmentation and a lower cost.

Both treatments were generally well-tolerated, with no significant safety concerns reported. Side effects, including local irritation and inflammation, were manageable and did not differ significantly between the groups.

Tazarotene 0.1% gel appears to offer equivalent efficacy to imiquimod 5% cream in treating plane warts. Moreover, it provides maintained efficacy without recurrence, a safer profile regarding dyspigmentation, and an advantageous cost benefit. These findings suggest that tazarotene could be a preferred option for treating plane warts, particularly in cosmetically significant areas.

Reference:

Nofal, H., Omran, F., ElKholy, B., Nofal, S., & Nofal, A. (2024). Tazarotene is as effective and tolerable as imiquimod in the treatment of verruca plana, a comparative randomized clinical trial. Clinical and Experimental Dermatology. https://doi.org/10.1093/ced/llae133

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Ketogenic diet may help restore metabolic health in psychiatric symptoms: Study

The ketogenic diet may help restore metabolic health in psychiatric symptoms suggests a study published in the Psychiatry Research.

The ketogenic diet (KD, also known as metabolic therapy) has been successful in the treatment of obesity, type 2 diabetes, and epilepsy. More recently, this treatment has shown promise in the treatment of psychiatric illness. We conducted a 4–month pilot study to investigate the effects of a KD on individuals with schizophrenia or bipolar disorder with existing metabolic abnormalities. Twenty–three participants were enrolled in a single–arm trial. Results showcased improvements in metabolic health, with no participants meeting metabolic syndrome criteria by study conclusion. Adherent individuals experienced significant reduction in weight (12 %), BMI (12 %), waist circumference (13 %), and visceral adipose tissue (36 %). Observed biomarker enhancements in this population include a 27 % decrease in HOMA–IR, and a 25 % drop in triglyceride levels. In psychiatric measurements, participants with schizophrenia showed a 32 % reduction in Brief Psychiatric Rating Scale scores. Overall Clinical Global Impression (CGI) severity improved by an average of 31 %, and the proportion of participants that started with elevated symptomatology improved at least 1–point on CGI (79 %). Psychiatric outcomes across the cohort encompassed increased life satisfaction (17 %) and enhanced sleep quality (19 %). This pilot trial underscores the potential advantages of adjunctive ketogenic dietary treatment in individuals grappling with serious mental illness.

Reference:

Shebani Sethi, Diane Wakeham, Terence Ketter, Farnaz Hooshmand, Julia Bjornstad, Blair Richards, Eric Westman, Ronald M Krauss, Laura Saslow. Ketogenic Diet Intervention on Metabolic and Psychiatric Health in Bipolar and Schizophrenia: A Pilot Trial, Psychiatry Research, Volume 335, 2024, 115866, ISSN 0165-1781, https://doi.org/10.1016/j.psychres.2024.115866.

(https://www.sciencedirect.com/science/article/pii/S0165178124001513)

Keywords:

Ketogenic diet, restore, metabolic, health, psychiatric symptoms, study, Bipolar illness; Schizoaffective disorder; Ketogenic diet metabolic therapy; Insulin resistance; Obesity; Metabolic psychiatry; Metabolic syndrome; Psychiatric disease; Clinical trial; Mental health, Shebani Sethi, Diane Wakeham, Terence Ketter, Farnaz Hooshmand, Julia Bjornstad, Blair Richards, Eric Westman, Ronald M Krauss, Laura Saslow, Psychiatry Research

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Robotic technology may potentially improve precision and accuracy in prosthetic dentistry: Study

Robotic technology may potentially improve precision and accuracy in prosthetic dentistry suggests a study published in the Journal of Prosthetic Dentistry.

With the increasing interest in using robots in dentistry and the widespread dissemination of information on this topic and its applications, a comprehensive review of robot applications in prosthodontics is needed. The purpose of this scoping review was to assess the current status of prosthodontic robotic applications, their achievements to date, and the barriers hindering their broader adoption and further advancement. The checklist for Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) was used to conduct this review. A comprehensive search methodology was developed to identify relevant studies on the use of robots in prosthodontic procedures in the PubMed, Scopus, Web of Science, and Google Scholar databases. The inclusion criteria were studies that specifically outlined the application of robots in the field of prosthodontics. Results: Eighteen relevant studies were found. Of these, 10 studies focused on assessing the effectiveness of robotic systems through in vitro testing using phantom models for tooth preparation. These studies specifically explored the processes involved in creating complete crowns and veneers. The remaining 8 studies investigated the use of robotics in tooth alignment, with a specific focus on complete dentures. Robots have the potential to improve precision and accuracy in prosthetic dentistry. However, clinical studies are needed to confirm the widespread use of robots in prosthodontics, as their clinical application is still in its early stages.

Reference:

Alqutaibi AY, Hamadallah HH, Alturki KN, Aljuhani FM, Aloufi AM, Alghauli MA. Practical applications of robots in prosthodontics for tooth preparation and denture tooth arrangement: A scoping review. J Prosthet Dent. 2024 Mar 12:S0022-3913(24)00120-3. doi: 10.1016/j.prosdent.2024.02.006. Epub ahead of print. PMID: 38480014.

Keywords:

Robotic, technology, potentially, improve, precision, accuracy, prosthetic dentistry, study, Alqutaibi AY, Hamadallah HH, Alturki KN, Aljuhani FM, Aloufi AM, Alghauli MA, Journal of Prosthetic Dentistry

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Routine Abdominal Drainage Not Beneficial in Colorectal Endometriosis Surgeries: Study

A recent study questioned the longstanding practice of using prophylactic abdominal drainage (AD) following colorectal surgery for endometriosis. The key findings were published in the recent issue of European Journal of Obstetrics and Gynecology and Reproductive Biology.

The study spanned from February 2019 to July 2023 and included a total of 215 patients who underwent a minimally invasive procedure to address endometriosis affecting the colorectal area. The research by Adrien Crestani and team employed a propensity score matched analysis to evenly distribute patient characteristics across two groups, where one group received abdominal drainage and the other group did not. This method allowed for a fair comparison of postoperative outcomes between the two sets of patients.

The results were adjusted to account for similar clinical backgrounds and surgical procedures and indicated that patients who had an abdominal drain inserted experienced longer hospital stays and a higher rate of postoperative complications. The statistical analysis showed a significant difference, where the individuals undergoing AD stayed longer in the hospital (p < 0.001) and encountered more complications (p = 0.03) when compared to their counterparts who did not receive a drain.

The study found no significant differences in rates of hospital readmissions, repeat surgeries or severe complications between the two groups by suggesting that the primary differences were confined to length of stay and initial postoperative recovery.

These findings are crucial as they challenge the traditional use of prophylactic abdominal drainage in colorectal surgeries for endometriosis. For years, AD has been routinely employed by surgeons with the belief that it helps by reducing the risk of complications like the infection or fluid accumulation. Also, this study suggests that the practice may be unnecessary and could potentially worsen patient outcomes.

The study adds pivotal evidence to the valuation of routine abdominal drainage in endometriosis surgery and it appears that the practice may need reevaluation in term of these findings which associate it with prolonged hospitalization and increased complications. As this retrospective study brings out detailed data, the results will need to be confirmed through further prospective trials. Overall the implications are significant and could influence future guidelines and standards of care in the treatment of endometriosis involving colorectal surgery. 

Reference:

Crestani, A., de Labrouhe, E., Le Gac, M., Kolanska, K., Ferrier, C., Touboul, C., Dabi, Y., & Darai, E. (2024). To drain or not to drain: A propensity score analysis of abdominal drainage after colorectal surgery for endometriosis. In European Journal of Obstetrics & Gynecology and Reproductive Biology. Elsevier BV. https://doi.org/10.1016/j.ejogrb.2024.04.028

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Magnetic seizure therapy in bipolar mania patients enhance cognitive outcomes: JAMA

A recent study published in the Journal of American Medical Association found Magnetic Seizure Therapy (MST) as a potential alternative to Electroconvulsive Therapy (ECT) for treating bipolar mania by potentially offering fewer cognitive side effects. Bipolar disorder is characterized by extreme mood swings including emotional highs (mania) and lows (depression) which can significantly impair the quality of life. ECT has long been recognized as an effective treatment for severe cases of mania but comes with the drawback of potential cognitive adverse effects like memory loss. So, Shan Chen and team sought for a less invasive option and focused on MST that was not previously tested for bipolar mania.

The randomized clinical trial from the Shanghai Mental Health Center was conducted between July 2017 to April 2021 and included 48 patients who underwent severe episodes of mania. The patients were divided into two groups, where one group received ECT and the other group underwent MST. Both groups participated in 8 to 10 treatment sessions over several weeks with MST being delivered at 100% device output and a frequency of 75 Hz over the vertex. The effectiveness of the treatments was primarily measured by changes in the Young Manic Rating Scale (YMRS) score and the overall response rate was defined as a more than 50% reduction in YMRS score from baseline.

The findings revealed that both MST and ECT had high response rates with efficacy of 95% in the ECT group and 86.4% in the MST group. Also, the outcomes showed no significant difference in the reduction of mania symptoms between the these two therapies by affirming the comparable efficacy of MST. The key differentiator was in the cognitive outcomes, where patients in the MST group expressed significantly better preservation of cognitive functions in language skills when compared to the patients treated with ECT.

This trial is significant as it introduces MST as a pivotal treatment option that could reduce some of the cognitive drawbacks linked with traditional ECT. The outcomes of this study highlight the safety of both treatments as there were no serious adverse effects reported in either group. Overall, the findings of this study suggest that MST could be adopted as a standard therapy for bipolar mania management in patients who are at high risk of cognitive impairment.

Reference:

Chen, S., Sheng, J., Yang, F., Qiao, Y., Wang, W., Wen, H., Yang, Q., Chen, X., & Tang, Y. (2024). Magnetic Seizure Therapy vs Modified Electroconvulsive Therapy in Patients With Bipolar Mania. In JAMA Network Open (Vol. 7, Issue 4, p. e247919). American Medical Association (AMA). https://doi.org/10.1001/jamanetworkopen.2024.7919

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