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ABSTRACT: Background: Little is known about the risk factors and outcome of unsuspected pulmonary embolism (UPE) in cancer patients. Objectives: To assess the risk factors and outcome of UPE in cancer patients. Methods: The charts of 66 patients diagnosed with UPE were reviewed. Two control groups were selected: 132 cancer patients without pulmonary embolism (PE) and 65 cancer patients with clinically suspected PE. Variables associated with UPE were identified by multivariable analysis. Six-month survival and recurrent venous thromboembolism were compared by use of Cox proportional analysis. Results: Twenty-seven (40.9%) patients with UPE had symptoms suggesting PE. Adenocarcinoma (odds ratio [OR] 4.45; 95% confidence interval [CI] 1.98-9.97), advanced age (OR 1.18; 95% CI 1.02-1.38), recent chemotherapy (OR 4.62; 95% CI 2.26-9.44), performance status > 2 (OR 7.31; 95% CI 1.90-28.15) and previous venous thromboembolism (OR 4.47; 95% CI 1.16-17.13) were associated with UPE. When adjusted for tumor stage and performance status, 6-month mortality did not differ between patients with UPE and patients without PE (hazard ratio 1.40; 95% CI 0.53-3.66; P = 0.50). Patients with UPE were more likely to have central venous catheters and chemotherapy and less likely to have proximal clots than patients with clinically suspected PE. Recurrent venous thromboembolism occurred in 6.1% and 7.7% of patients with UPE and symptomatic PE, respectively. Conclusion: UPE is not associated with an increased risk of death. Patients with clinically suspected PE and those with UPE have similar risks of recurrent venous thromboembolism.
Journal of Thrombosis and Haemostasis 07/2012; 10(10):2032-8. · 5.73 Impact Factor
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ABSTRACT: L’évaluation de la gravité des patients atteints d’embolie pulmonaire (EP) est une étape cruciale qui permet de guider leur
prise en charge. Plusieurs facteurs pronostiques ont été identifiés; ils permettent de stratifier le risque de mortalité ou
de complications précoces. L’EP grave est définie par l’existence d’une hypotension artérielle ou de signes périphériques
de choc. Sa mortalité supérieure à 25 % justifie une prise en charge thérapeutique urgente et agressive associant inotropes
et fibrinolytiques. En l’absence d’état de choc, une dysfonction ventriculaire droite sur l’échocardiographie et une valeur
élevée de troponine ou de brain natriuretic peptide (BNP) sont associées à un accroissement du risque de mortalité. Une surveillance étroite de ces patients est alors recommandée,
et l’utilité d’une intensification thérapeutique par des fibrinolytiques est en cours d’évaluation. Enfin, les malades stables
hémodynamiquement et sans dysfonction cardiaque droite sont à faible risque de mortalité et pourraient, pour certains, être
traités en ambulatoire. Des scores combinant ces facteurs pronostiques ont été développés.
Risk stratification of patients with pulmonary embolism represents an important step and may help to guide initial therapeutic
management. Pulmonary embolism can be stratified into several levels of risk of early death or complications based on the
presence of several risk factors. High-risk pulmonary embolism is defined by shock or peripheral signs of hypoperfusion. It
is a life-threatening emergency with high short-term mortality (> 25%) requiring specific therapeutic strategy with inotropic
agents and fibrinolysis. In patients with normotensive pulmonary embolism, the presence of right ventricular dysfunction on
echocardiography and/or myocardial injury, as attested by elevated levels of biomarkers, is associated with an intermediate
risk of early death. These patients need close monitoring, while evaluation of fibrinolysis efficacy is currently underway.
Patients with normotensive pulmonary embolism and without right ventricular dysfunction or myocardial injury have low risk
of death. These patients may be candidates for home treatment. Several scores combining these risk factors have been described.
Mots clésEmbolie pulmonaire–Pronostic–Échocardiographie–BNP–Troponine
KeywordsPulmonary embolism–Prognosis–Echocardiography–BNP–Troponin
Réanimation 04/2012; 20(2):112-117.
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ABSTRACT: Magnetic resonance imaging (MRI) has not been validated as an alternative diagnostic test to computed tomography angiography (CTA) in patients with suspicion of a pulmonary embolism (PE).
To evaluate performance of current MRI technology in diagnosing PE, in reference to a 64-detector CTA. Patients/methods: Prospective investigation including 300 patients with a suspected PE, referred for CTA after assessment of clinical probability and D-dimer testing. MRI protocol included unenhanced, perfusion and angiographic sequences. MRI results were interpreted by two independent readers, to evaluate inter-reader agreement. Sensitivity and specificity were evaluated globally and according to PE location and to clinical probability category.
Of 300 enrolled patients, 274 were analyzed and 103 (37.5%) had a PE diagnosed by CTA. For patients with conclusive MRI results (72% for reader 1, 70% for reader 2), sensitivity and specificity were 84.5% (95% confidence interval [CI], 74.9-91.4%) and 99.1% (95% CI, 95.1-100.0%), respectively, for reader 1, and 78.7% (95% CI, 68.2-87.1%) and 100% (95% CI, 96.7-100.0%) for reader 2. After exclusion of inconclusive MRI results for both readers, inter-reader agreement was excellent (kappa value: 0.93, 95% CI: 0.88-0.99). Sensitivity was better for proximal (97.7-100%) than for segmental (68.0-91.7%) and sub-segmental (21.4-33.3%) PE (P < 0.0001). Sensitivity was similar for both readers within each clinical probability category.
Current MRI technology demonstrates high specificity and high sensitivity for proximal PE, but still limited sensitivity for distal PE and 30% of inconclusive results. Although a positive result can aid in clinical decision making, MRI cannot be used as a stand-alone test to exclude PE.
Journal of Thrombosis and Haemostasis 02/2012; 10(5):743-50. · 5.73 Impact Factor
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ABSTRACT: INTRODUCTION: Pulmonary arterial hypertension (PAH) is a rare condition characterized by sustained elevation in pulmonary arterial resistance leading to right heart failure. BACKGROUND: PAH afflicts predominantly women. Echocardiography is the initial investigation of choice for non-invasive detection of PAH but right-heart catheterization is necessary to confirm the diagnosis. Conventional treatment includes non-specific drugs (warfarin, diuretics, oxygen). The endothelin-1 receptor antagonist bosentan, the phosphodiesterase-5 inhibitor sildenafil, and prostanoids have been shown to improve symptoms, exercise capacity and haemodynamics. Intravenous prostacyclin is the first-line treatment for the most severely affected patients. Despite the most modern treatment, the overall mortality rate of pregnant women with severe PAH remains high. Therefore, pregnancy is contraindicated in women with PAH and an effective method of contraception is recommended in women of childbearing age. Therapeutic abortion should be offered, particularly when early deterioration occurs. If this option is not accepted, intravenous prostacyclin should be considered promptly. VIEWPOINTS AND CONCLUSION: Recent advances in the management of PAH have markedly improved prognosis and have resulted in more women of childbearing age considering pregnancy. A multidisciplinary approach should give new insights into cardiopulmonary, obstetric and anaesthetic management during pregnancy, delivery and the postpartum period.
Revue des Maladies Respiratoires 10/2010; 27(8):e79-87. · 0.59 Impact Factor
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ABSTRACT: The respective abundance of circulating endothelial cells and endothelial progenitor cells may reflect the balance between vascular injury and repair. As pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) can share features of pulmonary remodelling, we postulated that the two disorders might be associated with different types of pulmonary endothelial dysfunction. We studied 25 consecutive patients undergoing cardiac catheterisation for suspected pulmonary hypertension. Nine patients had PAH, nine had CTEPH, and seven had normal pulmonary arterial pressure and served as controls. Circulating endothelial cells were isolated with CD146-coated beads. CD34(+)CD133(+) cell and endothelial progenitor cell numbers were respectively determined by flow cytometry and cell culture, in peripheral vein and pulmonary artery blood. Plasma levels of soluble vascular endothelial growth factor (VEGF), soluble E-selectin and soluble vascular cell adhesion molecule (sVCAM) were measured by ELISA. No difference in progenitor counts or VEGF levels was found across the three groups. Compared to controls, circulating endothelial cell numbers were significantly increased in PAH but not in CTEPH, in keeping with the elevated soluble E-selectin and sVCAM levels found in PAH alone. In conclusion, PAH, in contrast to CTEPH, is associated with markers of vascular injury (circulating endothelial cells, soluble E-selectin and sVCAM) but not with markers of remodelling (endothelial progenitor cells, CD34(+)CD133(+) cells and VEGF).
European Respiratory Journal 04/2010; 36(6):1284-93. · 5.89 Impact Factor
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ABSTRACT: Little is known about residual abnormalities after pulmonary embolism (PE).
To assess risk factors and the clinical significance of perfusion defects in patients with PE.
Consecutive patients receiving at least 3 months of anticoagulant for an acute PE were included in a prospective cohort study. Ventilation/perfusion lung scan, echocardiography, 6-min walk test, thrombophilia and hemostatic variables were performed 6-12 months after PE. Perfusion defect was defined as a perfusion defect in at least two segments.
Seventy-three out of 254 patients (29%) had perfusion defects during follow-up (median 12 months) and were more likely to have dyspnea, had a higher systolic pulmonary arterial pressure [39 mmHg (SD) (12) vs. 31 mmHg (8); P < 0.001] and walked a shorter distance during the 6-min walk test [374 m (122) vs. 427 m (99); P = 0.004]. Age [odds ratio (OR) 1.35; 95% confidence interval (CI), 1.11-1.63], the time interval between symptom onset and diagnosis (OR, 1.17; 95% CI, 1.04-1.31), pulmonary vascular obstruction at the onset of PE (OR, 1.34; 95% CI, 1.16-1.55) and previous venous thromboembolism (OR 2.06; 95% CI, 1.03-4.11) were independent predictors of perfusion defect after treatment of acute PE. Total tissue factor pathway inhibitor concentration was associated with perfusion defects.
Perfusion defects are associated with an increase in pulmonary artery pressure (PAP) and functional limitation. Age, longer times between symptom onset and diagnosis, initial pulmonary vascular obstruction and previous venous thromboembolism were associated with perfusion defects.
Journal of Thrombosis and Haemostasis 03/2010; 8(6):1248-55. · 5.73 Impact Factor
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ABSTRACT: A joint Task Force of the ESC and of the ERS has developed guidelines on the diagnosis and treatment of pulmonary hypertension (PH) to provide updated information on the management of patients with this condition.
The term pulmonary hypertension (PH) describes a group of devastating and life-limiting diseases, defined by mean pulmonary artery pressure >25 mmHg at rest. The diagnosis of PH requires a series of investigations intended to confirm the diagnosis, clarify the clinical group and the specific aetiology and an algorithm for this is proposed. Several drugs are currently approved to try to correct endothelial dysfunction. They lead to a significant improvement in the prognosis of patients who are in NYHA functional class II, III or IV. The evaluation of the severity of PH has a pivotal role in the choice of initial treatment and evaluation of the response to therapy in individual patients.
These guidelines should be widely disseminated and implemented in order to improve the management of patients with PH.
These guidelines summarise recent advances in the understanding and management of PH.
Revue des Maladies Respiratoires 02/2010; 27(2):141-50. · 0.59 Impact Factor
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European Respiratory Review 09/2009; 18(113):137-47.
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ABSTRACT: Pulmonary embolism (PE) is common and potentially serious. Three stages are described: mild PE, moderate PE (associated with an ultrasound right ventricular dysfunction) and severe PE (associated with a shock). In the first category, the prognosis is highly favourable (mortality under 5%) and the initial phase of anticoagulant treatment is well documented and codified: the treatment is based on heparin therapy (non fractionated or derivatives) and oral anticoagulants. In the severe forms, fibrinolysis is indicated in addition to the heparin therapy, given the very high mortality (up to 50%). However, the optimum care of moderate PE (intermediate mortality between 10 and 15%) remains uncertain, due to the inability to demonstrate a benefits-risk ratio in favour of fibrinolysis. In addition, this entity is still poorly defined. Although cardiac ultrasound data is useful, other parameters, such as pro-BNP, provide a better identification of these forms of intermediate prognosis. Although the evaluation of the new oral and injectable anticoagulants is promising, it mainly concerns mild PE. In addition, trials are currently under way in patients with a gloomier prognosis. The purpose is to validate or invalidate the indication of classic treatments (fibrinolysis) or new treatments (optional caval filters).
Revue de Pneumologie Clinique 01/2009; 64(6):298-304. · 0.24 Impact Factor
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Revue des Maladies Respiratoires 12/2008; 25(9):1193. · 0.59 Impact Factor
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F Couturaud,
G Pernod,
C Pison,
P Mismetti, O Sanchez,
G Meyer,
F Parent,
P Girard,
G Simonneau,
L Drouet, [......],
K Provost,
N Vilmans,
X Gosset,
A Bura-Rivière,
G Meach,
K Lacut,
J-L Bosson,
K Guillot,
D Mottier,
C Leroyer
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ABSTRACT: After stopping a 3 to 6 months course of oral anticoagulation for a first episode of idiopathic venous thromboembolism (VTE), the risk of recurrent VTE is high (10% per year). In this setting, international guidelines recommend at least 6 months treatment. However, this recommendation is not satisfactory for the following reasons: (1) no randomized trial has compared 6 months to extended duration (2 years) anticoagulation; and (2), even though the frequency of recurrent VTE is similar after pulmonary embolism (PE) and deep vein thrombosis (DVT), the fatality rate of recurrent VTE after PE is higher than that after DVT.
A French multicentre double blind randomized trial. The main objective is to demonstrate, after a first episode of symptomatic idiopathic PE treated for 6 months using a vitamin K antagonist, that extended anticoagulation for 18 months (INR between 2 and 3) is associated with an increased benefit / risk ratio (recurrent VTE and severe anticoagulant-related bleeding) compared to placebo. The double blind evaluation is ensured using by active warfarin and placebo, and blinded INR. The protocol was approved by the ethics board of the Brest Hospital on the 7th of March 2006. For an alpha risk of 5% and a beta risk of 20%, the estimated sample size is 374 patients.
This study has the potential to: (1) demonstrate that the benefit / risk ratio of extended anticoagulation for 18 months is higher than that observed with placebo in patients with a first episode of idiopathic PE initially treated for 6 months, during and after the treatment period; and (2) to validate or invalidate the contribution of isotope lung scans, lower limb Doppler ultrasound and D-Dimer at 6 months of treatment as predictors of recurrent VTE (medico-economic analysis included).
Revue des Maladies Respiratoires 10/2008; 25(7):885-93. · 0.59 Impact Factor
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ABSTRACT: The diagnostic value of indirect computed tomographic venography (CTV), following thoracic computed tomographic angiography (CTA), has not been specifically evaluated in postpartum patients with suspected pulmonary embolism.
To assess the diagnostic value of CTV in postpartum venous thromboembolism.
We reviewed all CTA and CTV procedures performed during the last 7 years in our institution for suspected pulmonary embolism during the postpartum period. We focused on the quality of CTA, the rates of positive CTA and isolated positive CTV findings, and alternative diagnoses provided by CTV.
Fifty-five CTA and 33 CTV procedures were performed for suspected pulmonary embolism in 47 patients referred between 24 h and 2 months after Cesarean (34 patients) or vaginal (13 patients) delivery. Of the 33 patients who had both CTA and CTV, seven had positive CTA findings and four had isolated positive CTV findings. Thus, the absolute increase in the venous thromboembolism detection rate following CTV was 12.1% [95% confidence interval (CI) 4.0-29.1]. Subcapsular hematoma of the liver or spleen was found on CTV in another two patients without venous thromboembolism. Consequently, CTV had a direct impact on clinical management in six of 33 patients (18%).
Our results suggest that postpartum patients with suspected pulmonary embolism have a significant rate of pelvic vein thrombosis and that the use of CTV leads to a 31% relative increase in the detection rate of venous thromboembolism as compared to CTA alone in these patients.
Journal of Thrombosis and Haemostasis 09/2008; 6(9):1478-81. · 5.73 Impact Factor
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ABSTRACT: The investigation of pulmonary arterial hypertension (PAH) requires a rigorous aetiological assessment in which imaging modalities play an important role.
The chest x-ray may show non-specific signs such as cardiomegaly and dilatation of the pulmonary arteries, and also allows examination of the lung parenchyma. Echocardiography is the essential screening tool and allows evaluation of left ventricular function. Pulmonary ventilation/perfusion scanning is essential to confirm post embolic PAH. Spiral CT has become an essential examination. It allows detailed study of the lung parenchyma, the pulmonary vessels and the cardiac chambers, and also helps determine the aetiology and complete the pre-treatment assessment. Magnetic resonance imaging allows calculation of several haemodynamic parameters and morphological study of the cardiac chambers and pulmonary vessels but requires further evaluation.
The improvement in the quality of vascular images and the development of complementary MRI techniques may lead to increase of this modality in the study of PAH.
Imaging plays a fundamental role in the management of patients suffering from PAH.
Revue des Maladies Respiratoires 03/2007; 24(2):155-69. · 0.59 Impact Factor
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ABSTRACT: Most patients with suspected pulmonary embolism (PE) have a positive D-dimer test and undergo diagnostic imaging. Additional non-invasive bedside tests are required to reduce the need for further diagnostic tests.
We aimed to determine whether a combination of clinical probability assessment and alveolar dead space fraction measurement can confirm or exclude PE in patients with an abnormal D-dimer test.
We assessed clinical probability of PE and alveolar dead space fraction in 270 consecutive in- and outpatients with suspected PE and positive D-dimer. An alveolar dead space fraction < 0.15 was considered normal. PE was subsequently excluded or confirmed by venous compression ultrasonography, spiral computed tomography and a 3-month follow-up. Radiologists were unaware of the results of clinical probability and capnography.
PE was confirmed in 108 patients (40%). Capnography had a sensitivity of 68.5% (95% confidence interval [CI]: 58.9-77.1%) and a specificity of 81.5% (95% CI: 74.6-87.1%) for PE. Forty-five patients (16.6%) had both a low clinical probability and normal capnography (sensitivity: 99.1%, 95% CI: 94.9-100%) and 34 patients (12.6%) had both a high clinical probability and abnormal capnography (specificity: 100%, 95% CI: 97.7-100%).
Capnography alone does not exclude PE accurately. The combination of clinical probability and capnography accurately excludes or confirms PE and avoids further testing in up to 30% of patients.
Journal of Thrombosis and Haemostasis 07/2006; 4(7):1517-22. · 5.73 Impact Factor
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ABSTRACT: Adequate initial anticoagulant treatment is required to prevent thrombus growth and recurrence. Intravenous unfractionated heparin is being replaced by low-molecular-weight heparin as the anticoagulant of choice for initial treatment of venous thromboembolism. Vitamin K antagonists remain the only oral anticoagulant available (target international normalized ratio: 2.5). The duration of therapy should be individualized according to the risk of recurrence and the risk of bleeding. Three months of treatment is usually adequate if thrombosis was provoked by a reversible risk factor such as surgery. For patients with unprovoked ("idiopathic") thrombosis, anticoagulant treatment for at least 6 months is indicated. For patients with a recurrence of venous thromboembolism or with an irreversible risk factor such as cancer, indefinite anticoagulant therapy is recommended. Long-term treatment with low-molecular-weight heparin is usually preferable for patients with active cancer. Systemic thrombolysis is indicated for patients with massive pulmonary embolism but controversy persists for those with isolated right ventricular dysfunction.
La Presse Médicale 12/2005; 34(19 Pt 2):1427-34. · 0.67 Impact Factor
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Revue des Maladies Respiratoires 01/2004; 20(6 Pt 3):S18-25. · 0.59 Impact Factor
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La Presse Médicale 06/2003; 32(17):787-8. · 0.67 Impact Factor
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ABSTRACT: MOST IMPORTANT: Pulmonary hypertension (PH) is a severe, potentially life-threatening complication of connective tissue diseases, among which scleroderma is first line. The aim of this paper was to review the literature and report our experience with this particular complication of connective tissue diseases. In our centre of pulmonary vascular diseases, connective tissue diseases represent the third cause of PH. RESULTS: Scleroderma and particularly its limited cutaneous variant, the CREST syndrome, is the most common connective tissue disease affected by pulmonary hypertension. It can be related to a specific lung parenchymal involvement (hypoxic PH), to an isolated pulmonary vascular involvement or to a cardiac dysfunction secondary to specific myocardial lesions. DIAGNOSIS: Echocardiography is an excellent examination to detect pulmonary hypertension. However, right heart catheterisation is necessary to confirm the diagnosis of pulmonary hypertension and to test vasoreactivity with a potent vasodilator such as nitric oxide (NO). REGARDING TREATMENTS: Oral calcium channel blockers are indicated in patients who are responders to acute NO tests. Treatment with continuous intravenous prostacylin is obviously an improvement, at least functionally, although it appears less effective than in primary PH. With the new subcutaneous, oral and inhaled vasodilatators (prostaglandin and endothelin receptor antagonists), a few cases of improvement of PH with intensive immunosuppressive therapy were observed, essentially during systemic lupus erythematosus and Sharp syndrome. IN PRACTICE: PH is a severe complication of connective tissue diseases. Early detection of this complication should allow an earlier and more aggressive therapeutic approach in these patients, before irreversible vascular lesions occur.
La Presse Médicale 06/2003; 32(17):789-99. · 0.67 Impact Factor
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ABSTRACT: A COMPLICATION OF CERTAIN SYSTEMIC DISEASES: Pulmonary hypertension (PH) can complicate the progression of certain systemic diseases such as sarcoidosis, histiocytosis X and some vasculites. The mechanisms at the origin of PH are varied and always require rigorous analysis in order to optimise treatment. DEPENDING ON THE DISEASE: PH associated with sarcoidosis is essentially related to specific lung parenchymal fibrosis and is poorly responder to corticosteroids. Other mechanisms may be more rarely incriminated (compressive andenopathies, mediastinal fibrosis, florid sarcoidosis concomitant to a pulmonary occlusive vascular disease...). During histiocytosis X, the ventilatory limitation of these patients does not always correlate with the severity of the respiratory failure, suggesting the existence of a pulmonary vascular disease progressing independently of the pulmonary parenchymal lesions. The pulmonary artery damage during Takayasu's arteritis and other auto-immune pulmonary arteritis may lead to potentially life-threatening complications, notably through stenosis and/or obstruction of the pulmonary arteries. Pulmonary hypertension is exceptional during Wegener's disease or periateritis nodosa. CONCLUSION: PH can complicate the progression of certain systemic diseases. The physiopathological mechanisms responsible are unclear (specific parenchymal fibrosis, isolated vascular involvement...). Globally, available treatments are disappointing.
La Presse Médicale 06/2003; 32(17):800-3. · 0.67 Impact Factor
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ABSTRACT: PURPOSE: Pulmonary hypertension is a rare but well-known life-threatening complication of connective tissue diseases. The aim of this article is to analyse the available literature and to report the experience of a pulmonary vascular diseases centre about this complication. CURRENT KNOWLEDGE AND KEY POINTS: Scleroderma and its limited variant, the CREST syndrome (calcification, Raynaud phenomenon, esophageal dysmotility, sclerodactily, telangiectasia), is the most common connective tissue disease affected by pulmonary hypertension. Dyspnea is the main symptom and is frequently severe. Echocardiography is an excellent exam to detect pulmonary hypertension. However, right heart catheterization is necessary to confirm the diagnosis of pulmonary hypertension and to test vasoreactivity with a potent vasodilator such as nitric oxide. Pulmonary hypertension is less severe in patients with connective tissue diseases perhaps because of an earlier diagnosis. A significantly lower proportion of patients presents an acute vasodilator response, suggesting an early constitution of irreversible pulmonary vascular lesions. Continuous intravenous epoprostenol therapy seems to be less effective as compared with patients with primitive pulmonary hypertension and does not improve survival. So, we observed dramatic improvement in rare cases after immunosuppressive therapy. FUTURE PROSPECTS AND PROJECTS: New treatments with oral, subcutaneous or inhaled stable prostacyclin analogs or with an endothelin receptor antagonist are currently being evaluated. The role of immunosuppressive therapy has to be defined.
La Revue de Médecine Interne 02/2002; 23(1):41-54. · 0.61 Impact Factor
