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Vol 28, No 2 (2024)

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ORIGINAL STUDY

Platelet monoamine oxidase and erythrocyte adenosine triphosphatase as biomarkers of necrotizing enterocolitis

Vinel P.K., Tsareva V.V., Baboshko P.G., Sinitskii A.I., Kozhevnikov A.S., Grunin A.V.

Abstract

BACKGROUND: The diagnostics of necrotizing enterocolitis is a complex and often ineffective issue. Biomarkers reflecting key links in the pathogenesis of the disease may serve as early predictors of development, progression, and severe course of necrotizing enterocolitis.

AIM: To assess potentials of platelet monoamine oxidase activity and erythrocyte ATPase to predict the development of necrotizing enterocolitis in premature newborns.

METHODS: The present study had two stages and included 28 children who were treated at the Chelyabinsk Regional Children’s Clinical Hospital from November 2021 to December 2022. At the first stage, premature newborns were examined; among them a group of newborns with necrotizing enterocolitis IIB–IIIA-B was identified. Venous blood was used for testings. At the second stage, specimens obtained from the intestine during surgical interventions in newborns with surgical pathology were examined additionally as well.

RESULTS: Children with necrotizing enterocolitis showed a significant decrease in the specific activity of platelet monoamine oxidase which correlated with the activity of monoamine oxidase in gut specimens. The following changes were registered: decrease in the activity of magnesium adenosine triphosphatasein erythrocytes by 50–100% of the maximum enzyme activity in the control group; decrease of sodium-potassium adenosine triphosphatase activity y 4 times from the maximum values in the control group. There was also a significant increase in the activity of calcium adenosine triphosphatase activity in erythrocytes.

CONCLUSION: The obtained data allow to suggest that platelet monoamine oxidase in preterm newborns may potentially serve as an indicator of tissue and organ immaturity, rather than a marker of inflammation and oxidative damage. Changes in erythrocyte adenosine triphosphatase activity in preterm infants with surgical stages of necrotizing enterocolitis indicate a hypoxic hypoenergetic state, accompanied by high concentrations of intracellular calcium.

The obtained data are promising for developing new methods for diagnosis/prognosis of necrotizing enterocolitis in newborns.

Russian Journal of Pediatric Surgery. 2024;28(2):124-132
pages 124-132 views

The effectiveness of video-assisted thoracoscopic sanitation of the pleural cavity in combination with local proteolytic therapy in children with acute pleural empyema

Barova N.K., Egiev I.K., Grigorova A.N., Ubilava I.A., Stryukovsky A.E., Nadgeriev V.M., Starchenko V.M.

Abstract

BACKGROUND: A positive experience of the local applicationof proteolytic enzymes for treating purulent-inflammatory processes of various localizations has motivated the researchers to study this challenging topic and to assess the effectiveness of proteolytic enzymes in combination with video thoracoscopic sanitation and ultrasonic cavitation of the lungs and pleural cavity in children with acute pleural empyema.

AIM: To assess the effectiveness of complex treatment of acute pleural empyema in children.

METHODS: In 2020–2022, 26 children, aged 1–17 (15 boys, 57.7% and 11 girls, 42.3%), were under observation. All children were operated on for video thoracoscopic sanitation of the pleural cavity and ultrasonic cavitation of the lungs and pleural cavity. Patients were divided into two groups: main group — 12 (46.2%) children who were injected proteolytic enzymes into their pleural cavity intraoperatively and at the postoperative period; control group — 14 (53.8%) children who had no any proteolytic enzyme injections. The developed technique (Method for the treatment of acute pleural empyema in children, Patent RU2770663) was used at the surgical intervention.

RESULTS: The results obtained by the identified criteria have shown that proteolytic enzymes applied perioperatively is an effective technique what was confirmed by X-ray findings: fibrinothorax regression in the main group occurred earlier than in the control group by (2±0.4) days.

CONCLUSION: Thus, we consider that proteolytic enzymes used intraoperatively and at the early postoperative period in combination with video thoracoscopic sanitation and ultrasound cavitation of the lungs and pleural cavity is a promising and effective method for treating acute pleural empyema and can be recommended for implementation into clinical practice.

Russian Journal of Pediatric Surgery. 2024;28(2):133-142
pages 133-142 views

Anesthetic support for laser vision correction in children

Roitberg G.E., Aznauryan I.E., Strunin O.V., Smirnov I.V., Balasanyan V.O., Agagulyan S.G., Kondratova N.V., Lazarev V.V.

Abstract

BACKGROUND: Currently, more and more laser surgeries are performed in pediatric ophthalmology. Expansion of indications for laser vision correction in children entails the increase in the number of patients and poses new specific tasks for pediatric anesthesiology. Solution of these problems is currently at the stage of active clinical search.

AIM: To propose a safe, reproducible and controllable method of anesthesiological support at pediatric ophthalmic surgeries which would ensure complete immobility of the eyeball during the intervention and patient’s rapid awakening after the surgery.

METHODS: A retrospective trial has been conducted. From October 2016 to May 2022, in the hospital of Joint Stock Company "Medicine" (clinic of Academician Roitberg) specialists from Yasny Vzor Children's Eye Clinics of Professor Igor Aznauryan operated on 429 children with ophthalmosurgical pathology. Laser vision correction was performed in children with refractive errors (astigmatism, hyperopia, congenital stable high myopia) complicated by anisometropia and/or amblyopia. The composite endpoint was surgeon's satisfaction with eye position during the main intervention and at the time of patient's awakening at the end of surgical stage. The surgeon's satisfaction was assessed with a 10-point scale, where 1 means no centration achieved and 10 means complete immobility during the correction. Awakening was the time from the end of surgical procedure until the removal of laryngeal mask after restoration of spontaneous breathing and signs of consciousness.

RESULTS: All 429 patients included in the trial completed it. Awakening came quickly and lasted, on average, 13.3 min (95% confidence interval, 12.1–14.6 min). At the early postoperative period, pain syndrome was in significant and amounted to 1–3 points by the Face, Legs, Activity, Cry, Consolability Scale and to 1–2 points by the Visual Analogue Scale. Additional anesthesia (Ibuprofen) was required in less than 10% of patients. Nausea, vomiting, and muscle pain were not observed in the postoperative period.

CONCLUSION: The proposed technique is adequate for ensuring the eyeball immobility and for acceptable wake-up time up to 9–10 points by the Aldreth scale.

Russian Journal of Pediatric Surgery. 2024;28(2):151-157
pages 151-157 views

Serum osteocalcin concentration in children with craniosynostosis

Shcherbakov A.V., Stashko Y.F., Kim S.A., Danilin V.E., Letyagin G.V., Amelina E.V.

Abstract

BACKGROUND: The present study is an actual one because up to now there are no standards for craniosynostosis diagnostics and no simple and safe techniques for it. Osteocalcin concentration in the blood serum is an important marker of bone metabolism, that is why this parameter was chosen as a potential laboratory marker of craniosynostosis.

AIM: To determine osteocalcin concentrations in the blood serum of children with various forms of craniosynostosis.

METHODS: 94 children with craniosynostosis who were treated in the pediatric neurosurgical department of the Federal Center for Neurosurgery of the Ministry of Health of the Russian Federation (Novosibirsk, Russia) from November 2018 to March 2022 were included in the trail. Inclusion criteria were: age up to 6 complete years, children with syndromic and non-syndromic forms of craniosynostosis. The obtained findings were analyzed in two age groups: up to 6 months and over 6 months because of different reference values.

RESULTS: 8 children out of 60, aged 6 months-6 years, had the increased osteocalcin concentration in the serum (13.3%).

CONCLUSION: No correlation has been revealed between craniosynostosis and increased serum osteocalcin concentrations in children under 6 years of age.

Russian Journal of Pediatric Surgery. 2024;28(2):143-150
pages 143-150 views

Assessment of the nephroprotective efficacy of steroid therapy by analyzing concentrations of new markers of the renal damage at the extracorporeal remote shock wave lithotripsy in children

Zorkin S.N., Nikulin O.D., Semikina E.L., Tsygin A.N., Snowskaya M.A., Milovanova A.M., Shakhnovsky D.S., Bayazitov R.R.

Abstract

BACKGROUND: for several decades, the remote shock wave lithotripsy was a leading technique for surgical management of concretions in the upper urinary tract. The key reason for its wide spread was minimal invasion combined with high efficiency. However, it has been proven that after each lithotripsy session the acute kidney injury develops. Currently, there is no any curative strategy aimed to protect the renal parenchyma from pathological impacts of shock wave energy.

AIM: to evaluate Prednisolone nephroprotective efficacy after analysing dynamic levels of biomarkers of kidney damage during the remote shock wave lithotripsy in children.

METHODS: 108 children with urolithiasis after a session of remote shock wave lithotripsy were enrolled in the study. All patients were divided into two groups of 54 participants in each. Participants from the control group were treated according to the standard protocol. Participants from the studied group, in addition to the traditional therapy, were prescribed Prednisolone orally at dosage 0.5 mg/kg once a day for 2 days before the session of external shock wave lithotripsy and 2 hours before the surgery. Urine and blood samples were taken from all patients: before surgery, 45 minutes and 24 hours after it. Biomarker concentration was assessed in all samples.

RESULTS: The biomarker concentration in the urine differed statistically significantly in patients of the studied group and of the control one. The most pronounced changes were noted 45 minutes after the surgery. A statistically significant concentration increase of all studied biomarkers was revealed in patients from the control group. In children from the studied group, concentration of kidney damage molecule 1 did not change, and lipocalin concentration associated with neutrophil gelatinase, tissue inhibitor of metalloproteinase 2 and hepatic forms of fatty acid binding protein increased statistically significantly less than in patients of the control group. Interleukin 18 concentration in the blood serum of patients from the control group increased statistically significantly, while in patients from the studied group - statistically insignificantly.

CONCLUSION: A statistically significant decrease in the concentration of studied biomarkers, and, consequently, less degree of renal damage in the studied group, can promote implementation of the glucocorticoid therapy as a medical support during the external shock wave lithotripsy in children.

Russian Journal of Pediatric Surgery. 2024;28(2):158-169
pages 158-169 views

To the question of analgesia support of children in traumatologists’ outpatient practice

Vybornov D.Y., Nekrutov A.V., Semenov N.Y., Khmelnitsky K.Y., Ilyin A.O.

Abstract

BACKGROUND: The problem of adequate anesthesia in children with injuries at the prehospital stage do exists due to the lack of a universal approach to the assessment of pain syndrome intensity as well as to age restrictions for a number of medical preparations , and to difficulties in communication with young children.

AIM: To improve the quality of specialized outpatient emergency medical care for children with traumatic injuries.

METHODS: The present survey was conducted for one month, and 113 orthopedic traumatologists from children's trauma centers and emergency traumatologic and orthopedics departments of medical organizations subordinated to the Moscow Healthcare Department participated in it. Each participant was offered a questionnaire having 24 thematic sections on analgesics application in their outpatient practice at various stages of prehospital care for children with mild and moderate traumatic injuries. At the same time, in a number of sections, several answers could be selected by a participant.

RESULTS: The obtained results demonstrated that there is no any unified systematic approach to the pain management after mild and moderate injuries in children. Analgesia techniques at the outpatient stage are paid not enough attention. Many doctors are ready to give a detailed consultation on how to relief pain at home, but in some cases, parents themselves decide on how to do it, though they do not have necessary knowledge.

CONCLUSION: To develop indications for anesthesia support requires the implementation of specialized pain assessment scales differentiated by age groups, development of methodological recommendations and standards for analgesics application at the prehospital stage with comprehensive information on existing forms and age-related features of effective and safe medical preparations of recent generations.

Russian Journal of Pediatric Surgery. 2024;28(2):170-183
pages 170-183 views

SCIENTIFIC REVIEWS

Traumatic brain injury in infants and little children (a literature review)

Mamatkulov A.D., Zaitzeva E.S., Semenova Z.B., Ahadov T.A.

Abstract

One of the acute problems of emergency neurosurgery is craniocerebral injury in children. Acuteness of the problem is determined by the disease frequency, high percentage of disability and mortality. Issues of medical and social research, diagnostics and treatment of craniocerebral trauma have not lost their relevance. Preventive measures, such as improved parental control and increased safety in the home surrounding, are being developed. Domestic and foreign literature sources on craniocerebral trauma in infants and young children for the last 15 years have been analysed . The search was done using keywords: “craniocerebral trauma”, “skull fractures” in such search engines as Google Scholar, eLibrary, PubMed and Medline. 243 sources were analysed, from which 45 articles were selected (21 domestic publications). These papers focused on specific aspects of traumatic brain injury in patients of different age categories. Infants and young children represent a specific group of traumatic brain injury victims due to specific anatomic and physiologic features. Better understanding of injury nature in infants and young children is necessary in order to improve traumatic brain injury prevention, diagnostics and treatment.

Russian Journal of Pediatric Surgery. 2024;28(2):184-193
pages 184-193 views

Treatment of pectus excavatum in children with the vacuum bell: a literature review

Shominova A.O., Mitupov Z.B., Razumovskij A.Y., Nurik V.I., Gincu G.S., Pavlov A.A.

Abstract

Pectus excavatum is the most common type of chest deformation with the sunken sternum and adjacent parts of the ribs. In recent decades, approach to the management of this pathology has changed, in many respects due to Eckhart Kloba’s invention a vacuum bell in 1992, which can be used both intraoperatively and as a non-invasive monotherapy.

Literary sources were searched in PubMed, Web of Science, Scopus, Google Scholar, and Elibrary databases. The following keywords were used for search in the English literature: «pectus excavatum», «funnel chest», «vacuum bell», «vacuum chest wall lifter», «suction cup», «minimally invasive repair of pectus excavatum (MIRPE)», «intraoperative vacuum bell». In Russian-language literature sources, the key words were: “воронкообразная деформация грудной клетки», «консервативное лечение», «вакуумный колокол». More than 50 publications on this topic have been analyzed.

Patients of different age groups with pectus excavatum of varying severity were taken in the study. The effectiveness of treatment was mainly assessed by computed tomography measurements of deformity depth and the Haller index before and after treatment. Excellent correction results were achieved in 13.5–80% of patients with the vacuum bell. The authors have made an attempt to define how patient’s age, duration of treatment, pathology severity, and deformity type correlate with the effectiveness of vacuum bell treatment. The vacuum bell can also be used as a non-invasive lift of the sternum during Nuss thoracoplasty surgery.

Currently, there is no any unified tactics for the conservative management of patients with pectus excavatum, namely, unified indications, period of conservative treatment, and optimal patient’s age for vacuum bell application. In the available literature, there is no any criterion that could predict the success of conservative treatment; there are no follow-up data for more than 2 years. A more precise assessment of vacuum bell effectiveness in the treatment of patients with pectus excavatum should be confirmed in longer studies with a larger number of cases.

Russian Journal of Pediatric Surgery. 2024;28(2):194-205
pages 194-205 views

Transfusion therapy with allogeneic blood components in children of cardiosurgical units

Zyuzin V.S.

Abstract

The article discusses features of allogeneic blood component transfusion in newborns and infants. This work is primarily addressed to specialists of "non–transfusiological" profile, such as neonatologists, anesthesiologists, intensive care specialists, pediatricians, hematologists and pediatric surgeons. Specific anatomical and physiological structure of child's organism, especially at its neonatologic period, specifies different approaches to the clinical application of donor blood components. However, description of transfusion therapy in children is found only in a small proportion of clinical recommendations, and its legislative level is regulated with an order of the Ministry of Health and the Government decree. Last documents are of administrative nature, and do not help much clinicians in specific decision-making situation. At the same time, transfusion with allogeneic blood is associated with significant complications. The overall prevalence of posttransfusion reactions in children is higher than in adults, and is associated with higher mortality rates. This is especially true for pediatric cardiac surgery. Application of donated blood after cardiopulmonary bypass surgery is associated with postoperative complications such as thrombosis, stroke, acute kidney injury, prolonged mechanical ventilation and death. The authors emphasize the necessity of scientific substantiation of each transfusion with evidence-based medicine. Indications for hemotransfusion have to rely not only on the concentration of hemoglobin and hematocrit, but also on additional physiological triggers. In order to minimize undesirable transfusion reactions and complications, modern technologies should be used to improve the quality of blood components. Attention is focused on modern components of donated blood. The review is aimed to summarize and structure current data on transfusion therapy in pediatric patients. The authors analyse domestic and foreign clinical recommendations and publications. Restrictive and liberal strategies of transfusion therapy are compared. Specific criteria for indications, algorithms for prescription, speed and volume of donor blood component infusion in pediatric units were revealed.

Russian Journal of Pediatric Surgery. 2024;28(2):206-214
pages 206-214 views

CASE REPORTS

Robot-assisted Heller myotomy in the treatment of achalasia in children

Kozlov Y.A., Poloyan S.S., Sapukhin E.V., Strashinsky A.S., Makarochkina M.V., Marchuk A. ., Rozhanski A.P., Byrgazov A.A., Muravev S.A., Narkevich A.N.

Abstract

BACKGROUND: Esophageal achalasia in children is a rare disease. Heller myotomy combined with Dor fundoplication remains the treatment of choice for this disease. Surgical interventions include open, laparoscopic and robotic approaches. This article describes the first experience of Heller robot-assisted myotome in a child. It also presents a literature review on this topic.

CLINICAL CASE DESCRIPTION: The authors present retrospective data of a 10-year-old adolescent boy who was operated on for esophageal achalasia with the robot-assisted approach. The patient was admitted to the surgical department of Irkutsk State Regional Children's Clinical Hospital in satisfactory condition with complaints of dysphagia, frequent regurgitation after meals, and delayed weight gain. The diagnosis of cardia achalasia was put after contrast examination of the esophagus and after endoscopic examination of the upper gastrointestinal tract and after esophageal manometry. Heller robot-assisted myotomy was performed with surgical robot Versius (manufactured by CMR, UK). Patient's weight was 30 kg. His age was 10 years. This disease lasted for 3 years. Robot-assisted Heller myotomy was done in a minimally invasive manner without conversion to an open surgery. Total myotomy length was 7 cm; duration of surgical intervention — 125 minutes; duration of patient's stay in the hospital — 4 days; duration of follow-up — 4 months. In the late follow-up, no significant complications, like symptom recurrence or reflux, were seen.

CONCLUSION: Robotic-assisted Heller myotomy for esophageal achalasia in children is safe and effective technique. It is also good alternative to open and laparoscopic surgeries.

Russian Journal of Pediatric Surgery. 2024;28(2):215-223
pages 215-223 views

Meso-Rex bypass in a 7-month-old child with prehepatic portal hypertension

Zadvernyuk A.S., Kulikova N.V., Nurik V.I., Razumovskiy A.Y., Knyazeva N.A.

Abstract

BACKGROUND: The prehepatic form of portal hypertension is the most common cause of portal hypertension in children. Nowadays mesoportal shunting is the most optimal therapy for such pathology. In the world literature, there are only few publications describing application of such surgical technique in children of the first year of life.

CLINICAL CASE DESCRIPTION: The article describes a case of a 7-month old child with prehepatic portal hypertension who had mesoportal bypass surgery. A month before the surgery, the child had an episode of gastrointestinal bleeding which was treated conservatively. Additional diagnostics before surgery included liver and spleen ultrasound examination, transarterial mesenteric portography, and esophagogastroduodenoscopy. The child was discharged home on the 6th postoperative day. For three months after the surgery, he received antiplatelet therapy and proton pump inhibitors. In 3-months, follow-up ultrasound showed satisfactory blood flow through the shunt. Patient’s weight gain had also a positive trend.

CONCLUSION: Mesoportal bypass surgery is technically achievable in children of the first year of life. In our opinion, patient’s age has a positive impact on creating a functioning mesoportal shunt: the younger the patient, the greater the likelihood of favorable outcome.

Russian Journal of Pediatric Surgery. 2024;28(2):224-230
pages 224-230 views

Jadassohn's nevus in a newborn: surgical treatment or conservative tactics

Karyakina I.A., Rekhviashvili M.G., Bazina I.G., Bogatyreva N.N., Propletkina K.D.

Abstract

BACKGROUND: Jadassohn's nevus (seborrheic nevus, nevus of the sebaceous glands) is a hamartoma which is mainly localized on the scalp and face skin. At birth, it looks like a barely noticeable light yellow plaque which significantly increases at the puberty period under androgenic stimulation. The histological picture of Jadasson's nevus is characterized by changes in the epidermis in the form of acanthosis, papillomatosis, hyperkeratosis, and a large number of hyperplastic sebaceous glands. Pluripotent epithelial cells, which are part of the hamartoma, may provoke the growth of secondary benign and malignant tumors. This nevus may be manifested by Schimmelpenning–Feuerstein–Mims syndrome which can damage the nervous system and eyes. Currently, there are no uniform recommendations for the management of patients with Jadassohn's nevus.

CLINICAL CASE DESCRIPTION: In this article, we present our own experience of treating two children discussed pathology. The first boy had a radical surgery at the age of 16 days of life because of large dimensions of the nevus and a significant cosmetic defect. Removal of the formation at the neonatal period has prevented the development of rough postoperative scars and promoted good cosmetic outcome due to high elastic and regenerative properties of baby's skin. In the second child, Jadasson's nevus looked like a barely noticeable light yellow plaque; therefore, conservative tactics was chosen for this patient. Both children were consulted by a neurologist and an ophthalmologist who found no pathology in the nervous system and in the vision organs.

CONCLUSION: The described two clinical examples demonstrate the need for individual and multidisciplinary approaches in the management of patients with Jadasson's nevus. Active surgical tactics should be applied because of a significant cosmetic defect rather than for the prevention of malignant transformation which is met in less than 1% of cases.

Russian Journal of Pediatric Surgery. 2024;28(2):231-238
pages 231-238 views

Relapse of a false left-sided diaphragmatic hernia in a 2-year-old child complicated by strangulation and colon necrosis, cecum perforation and peritonitis

Gumerov R.A., Valitov I.O., Smirnov E.A., Kolodko S.V.

Abstract

BACKGROUND: Despite the large number of works devoted to diaphragmatic hernia (DH) in children, this problem is still one of the most pressing in pediatric surgery. Diagnostics and treatment of DH complications still remains one of the most difficult tasks for pediatric surgeons dealing with complications. The most dangerous one is strangulation of the recurrent hernia which leads to stomach and intestine necrosis. Many researchers point out that diagnostics of strangulated diaphragmatic hernia is a difficult issue. One of the reasons for late diagnosis may be physicians' insufficient knowledge on specific features of clinical course of this disease. Intensive development of video endoscopic surgery in pediatric practice contributes to the active implementation of modern technologies on DH treatment, thus leading to much better outcomes.

CLINICAL CASE DESCRIPTION: The authors present a rare clinical case: a 3-day-old child survived thoracoscopic correction of congenital Bochdalek diaphragmatic hernia. After the surgery, paroxysmal abdominal pain and vomiting appears from time to time. The child was treated by various specialists who put various diagnosis: appendicitis, intestinal colic, and gastritis. After this ineffective treatment, the 2-year old child was admitted to the hospital where strangulation of a recurrent diaphragmatic hernia complicated by colon necrosis, perforation of the cecum and peritonitis were diagnosed. The child had a comprehensive management including laparotomy, colon resection with end-to-end anastomosis, plastic surgery of the diaphragm dome, suturing of cecum perforation and sanitation of the abdominal cavity. The postoperative period was without complications. The patient was discharged on day 12 in satisfactory condition. 10 month later, at the follow-up visit, the child was found healthy, no complaints.

CONCLUSION: Strangulated diaphragmatic hernia needs close attention because this pathology can lead to serious complications. Timely diagnostics and surgical treatment of congenital DH promote complete recovery and prevent complications.

Russian Journal of Pediatric Surgery. 2024;28(2):239-244
pages 239-244 views

CLINICAL PRACTICE. GOLDEN ARCHIVE

Thoracoabdominal localization of a teratodermoid tumor in a child

Bessarabov V.I.

Abstract

BACKGROUND: A benign teratodermoid tumor of thoracoabdominal localization is a rare condition in which one half of the formation is located in the pleural cavity, and covered with the visceral pleura of the right lung lower lobe and the other half is located in the right liver lobe The incidence of teratodermoid tumors of the thoracic-abdominal location is unknown; no such publications are found in the literature .

CLINICAL CASE DESCRIPTION: This article describes a clinical case of a child with a benign teratodermoid tumor of thoraco-abdominal localization, which was detected during X-ray examination of the chest organs because of respiratory disease. It is believed that surgical intervention is the only effective treatment for this pathology. During surgery, it was found out that the tumor had a dumbbell shape; its upper part was located in the chest cavity, and the symmetrical lower part-via a congenital hole in the diaphragm — was located in the right liver lobe. Despite of such unusual location, all tumor was enucleated.

CONCLUSION: This clinical case demonstrates the only described complete surgical removal of the tumor with rare thoracoabdominal location.

Russian Journal of Pediatric Surgery. 2024;28(2):245-248
pages 245-248 views

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