An NPR article written by Blake Farmer explores a university’s way to improve end of life care for nursing students. The new technology they are using are actors portraying death and verbal cues that students usually do not hear with robot simulations. They also use actors to emulate dying patient’s family members. Nurses often have to confront patients and their family members with bad news, so by using actors as an education tool, hopefully students focus on how to communicate bad news with more empathy and compassion. The NPR article mentioned studies were conducted that conclude many nurses feel unprepared to give end-of life care. Because I am a nursing student who will probably give end of life or palliative care, I am curious to know where the educational gaps are for end of life care in nursing?

In 2011, the Department of Health Administration and Nursing at the Virginia Commonwealth University Medical Center sought to find gaps in end of life care in continuing education. They surveyed 2,530  nurses from the Oncology Nursing Society among four states, who had been interviewed before in 1990 where the nurses were asked open ended questions about gaps in education for end of life care. The second most current survey asked fewer open ended questions. For example, they ranked end of life core practices from 1-12 of how important they are in nursing practices. Each nurse was mailed a survey and emailed a survey that was identical to the mailed one. Out of 2,530 surveys, only 714 were deemed acceptable to use in analysis, therefore limiting the sample size.  Surveys were conducted and found that “twenty-five percent of the respondents do not believe they are adequately prepared to effectively care for a dying patient”( White 2011). Symptom management and how to talk to patients and family members was rated one on the top competency inadequacies. Symptom management among what comprises palliative care, and communication about death and dying are some core companies under ‘end of life care’.

This study tries to find the educational gaps in end of life care education by surveys to a limited population that are all made up of oncology nurses.This study did not break down ages or experience levels, and instead gave the average age and experience number.  The average age for people conducted in this survey is 48.5 years, and the average number of years since becoming a nurse was 21.3 years. These statistics make sense, because they were re-conducting a survey done to the same population a decade later. The population of nurses in this study were of all different ages and experience levels, which contributed to different rankings of importance for the top three core competencies. For example, nurses in an older generation were more likely to select the meaning of palliative care more important than symptom management. Because the surveys were only conducted on nurses who had already been practicing, the study did not address the educational gap in end of life care for student nurses, as the NPR article suggests. The findings of the study explained there may be educational gaps in work learning settings, because the nurses that said they are confident in their end of life abilities may have been educated outside the workplace, such as conferences. However where the nurses received education on this subject was not measured, so it would be hard to conclude where the gaps in education are, based on these limitations. This study gave a view into where there might be gaps in education for oncology nurses already practicing based on age and speciality level, however because of the small sample population and how specific this study is, it does not represent where educational gaps might take place in the nursing field.

Works cited:

White, K. R., & Coyne, P. J. (2011). Nurses’ Perceptions of Educational Gaps in Delivering End-of-Life Care. Oncology Nursing Forum, 38(6), 711–717. doi:10.1188/11.onf.711-717

https://www.npr.org/2019/01/19/686830475/morphine-and-a-side-of-grief-counseling-nurses-learn-how-to-handle-death

In the United States today, more and more people are becoming obese and are at high risk for heart disease and other illnesses. A lot of the media has even claimed obesity to be an epidemic. Food companies such as Coca Cola perpetuate problems relating to obesity and heart disease. Their distracting pseudo agenda promotes helping Americans consume less overall calories and live healthier lives by providing research money in studies, when in fact, their underlying objective is their quest to make a profit. In 2015 Coca Cola created a nonprofit called the Global Energy Balance and funded research surrounding obesity. Research created by Coca Cola and other large companies for their own agenda are deeply detrimental to American people’s lives because research that is posed as unbiased leads Americans into believing that their products are a healthy choice. This topic is interesting to me because as a consumer, I am constantly seeing studies enacted that suggest what to eat, what is healthy, and what is not. So how do companies like Coca Cola exacerbate problems such as obesity in the United States?

As new evidence plasters headlines indicating a link between sugary drinks and obesity linked diseases, the companies must fight back. Companies such as Coca Cola invest their money into creating low-calorie, zero sugar, “better for you” soft drinks. Zero sugar soft drinks still include artificial sweeteners so the product will retain the same flavor without the calories and negative impacts of traditional sweeteners. In a study done by the USDA economic research service, sugar intake is decreasing but artificial sweetener consumption steadily increases. The study concluded there is a positive correlation between the rise in obesity and usage of artificial sweeteners.  

Figure 1: This graph shows the correlation between sugar intake daily, the percent of people using artificial sweeteners and the percentage of adults with obesity from 1980-2013. This correlation was further validated by The Growing Up Today Study done by the University of Texas Health and Science Center involving almost 12,000 adolescent boys showed long term weight gain with diet soda.

Not only do companies such as Coca Cola say they create better products that will not negatively affect a person’s health, but they pay researchers to say the same. Coca Cola supports the idea of living a healthy and active life, and that calorie counting is not as important. An article from the New York Times described new research that conveyed the following: “Last week, the Pennington Biomedical Research Center in Louisiana announced the findings of a large new study on exercise in children that determined that lack of physical activity ”is the biggest predictor of childhood obesity around the world.” The news release contained a disclosure: ”This research was funded by The Coca Cola Company.” This example is certainly not an individual case. Consumers are being fed supply information with evidence from research studies, that big companies have funded. Food giants much like Coca Cola are shaping consumers minds about what choices in the supermarket are healthy. People rely on the common idea that companies value the public’s health. Whereas the harsh reality is that these companies’ bottom line is earning a profit. For example, if Coca Cola stated that Coke is actually harmful, it would negatively affect their profit. It is much more cost effective to add “zero sugar” on a label even though it does not improve the nutrition of that product. Nevertheless, there continues to be a rise in obesity rates and chronic disease relating to obesity rates in the United States.

It is not a coincidence that food corporations are gaining profit and obesity rates are still inclining. Money is the underlying theme in the bridge between what consumers hear is good for them, and what these companies want them to hear. Food corporations are not concerned with the “obesity epidemic.” The data concludes that large companies have more of a priority in continuing to sell product, rather than reducing the risk of chronic disease in consumers.

References:

https://www.niddk.nih.gov/health-information/health-statistics/overweight-obesity

https://well.blogs.nytimes.com/2015/08/09/coca-cola-funds-scientists-who-shift-blame-for-obesity-away-from-bad-diets/

https://www.psychologytoday.com/us/blog/heal-the-mind-heal-the-body/201711/new-diet-ideas-the-artificial-sweeteners-controversy

In neonatal intensive care units (NICU) across the country, premature babies in need of constant monitoring are attached to wires and electrodes that take vital signs of the baby. Electrocardiograms are attached to the chest, while tiny devices that measure blood oxygen saturation, SpO2 are wrapped around the feet. These crucial measurements often come with hassle. It is hard to cuddle babies and do simple tasks like change a diaper, without interfering with the wire systems. It is also invasive for the baby.  The tape adhesives for the electrodes irritate the skin, and some babies in the NICU develop scars later in life. An article recently came out with a study that demonstrates a new technology that surpasses the wires and invasive nature of adhesions to infants. Science Magazine produced a research article summary called “Binodal, wireless epidermal electronic systems with in-sensor analytics for neonatal intensive care” about a study that created a wireless and  pad that gently adheres to the skin’s surface that continuously transmits accurate vital sign data called ECG EES and PPG EES. I am interested in this study because as a nursing student, this technology could develop to a wide variety of patients and change patient care for the better. So now I wonder in what ways will EES pads benefit infants in the NICU?

There are a couple ways the innovation of the ECG EES will be beneficial to infants and infant care units. One of the beneficial properties is how gentle the pad is on neonate’s skin. For patients being admitted to the NICU, one would not think some of the most damage a neonate can suffer is from abrasion of the skin. Removing sticky electrodes on the skin’s surface can cause up to “15% of a neonate’s total skin surface area can be traumatized daily”(Chung et al, 6). Infants in the NICU are at high risk for damage, “by age 7, more than 90% of children born preterm (<30 weeks gestation) and previously cared for in the NICU exhibit residual scars secondary to monitoring probes, adhesives, and invasive medical interventions”(Chung et al, 6).  Before testing it on a skin’s surface, research teams tested the adhesion pad in a variety of ways to find what aspects of mechanical stress the pad would be undertaking. The reason to test for mechanical stresses is to show how the EES devices “ decrease risks for skin injury relative to existing clinical standards”( Chung et al, 6). They tested EES pads that included microfluidic and did not include microfluid. “..Microfluidic chambers provide mechanical isolation between interconnected components and the skin” ( Chung et al, 2). Shear and normal stress was tested between the ECG EES and the skin, and as shown in the image below, the test with the ECG EES containing microfluid are less than the skin’s threshold of sensation : ~20kPa. This means that when stress is applied to the ECG EES pads that contain microfluidic chambers, the stress won’t affect the infant’s skin.

One of the reasons the application of this study is so important in the world of medicine, is how new technology will benefit the patients. Because they have designed devices with compassion that leads to better care for the infants, healthier babies will be the outcome.  The neonates benefit from non invasive wireless data collector pads because they will physically be healthier by not getting their skin ripped off and be will given more skin to skin contact as a result of ECG EES. Having skin to skin contact, or being able to cuddle a baby stabilizes the infant more quickly. Below is an image of the EES device being put to use so a mother can hold the infant without a jumble of wires.

Another important aspect of these wireless devices are the accuracy of what they measure. The devices were tested against the gold standard of measurements, or clinical standard  readings. For example, the heart rate, respiratory rate and temperature were measured and compared. The accuracy is obviously seen in the images below. After doing extensive lab testing for these products, volunteer adult participants vital signs were measured using normal gold standard operations and ECG EES devices.

They used this data to show the validity of the ECG EES technology on healthy adult volunteers to be further advanced to clinical trials. They then did the same test on healthy neonates, and measured vital signs against gold standards, mechanical force applied to skin, and compatibility when submerged in water. This further exemplifies the robustness of this study because as it goes through each stage of testing, the results are still safe and accurate. An important consideration for this developing technology is expense. While the ECG EES devices are as accurate and safer for infants compared to regular electrode monitoring, advancements in technology can get expensive and may reach to only better funded hospitals. However, the article argues once fully developed, the cost will become less than $20.00 USD, and therefore become common in US hospitals. Because the devices are also reusable, there will be greater potential to distribute in developing countries. That being said, large companies who may buy the technology can charge more and it may not get distributed to those in need.

This research went through years of lab testing and is in the middle of clinical trials. This technology not only has the capability of helping infants in the NICU become healthier by taking away the harmful adhesives and allowing more skin to skin contact, but also by helping nurses with constant monitoring of temperature, ECG, and heart rate. ECG EES devices are reusable, which will benefit the waste hospitals produce and can be implemented in other units of a hospital setting. It may be a new learning curve to apply these devices to NICU units, but in the end it will be favorable.

Resources:

Chung, Ha Uk. “Binodal, Wireless Epidermal Electronic Systems With In-Sensor Analytics For Neonatal Intensive Care”. Science.Sciencemag.Org, 2019, http://science.sciencemag.org/content/sci/363/6430/eaau0780.full.pdf. Accessed 1 Mar 2019.

The American Journal of Public Health recently published a study about the effects of sugar-sweetened beverage tax in Berkeley, Oakland, and San Francisco, California. The study targeted two neighborhoods in each of these three cities with the highest amount of African American and Hispanic residents according to the 2010 Census data (Lee et al.). The study mostly looked at the Berkeley neighborhoods and used the others for comparison. The results between the Berkeley group and the comparison group are significantly different. Based on this study, would a sugar-sweetened beverage tax overall reduce the consumption of sugar-sweetened beverages?

In a cross-sectional design, this study looked at sugar-sweetened beverage consumption rates in demographically diverse neighborhoods before the sugar-sweetened beverage tax and three years after. The study was done by having data collectors stand near “heavily foot-trafficked” intersections and adults filling out a fifteen question survey that asked how many times a day a person drank sugar-sweetened beverages, and the results were converted to frequencies. Results showed a decrease in consumed sugar-sweetened beverages by 52.5% in Berkeley, however the study states that “there were no significant consumption changes in the comparison group” (Lee et al.). So while the questionnaires being answered by adults  in Berkeley were decreasing their sugar-sweetened beverage consumption and increasing their water intake significantly, other neighborhoods in different cities that experienced the same tax, did not see as a significant change in reducing consumption of sugar-sweetened beverages.

The study done used excellent data collecting techniques by using cross-sectional questions repeated from 2014 to 2017, so they had a lot of information and data to process. In the article it states that pretax consumption was compared to  an average of post tax consumption, and checked for robustness in unweighted models and modified-inverse probability weighted models. They also used results in the Berkley study and compared it to Mexico’s tax on sugar-sweetened beverages. The results in Mexico’s tax showed the tax affected lower SES households than higher SES households. The Berkeley study used this example from Mexico to use as evidence in concluding lower income households could be more responsive to the tax. Lower income households have disproportionate rates of cardiometabolic disease which are affected by intake of sugar-sweetened beverages. That is not to say high income people do not have cardiometabolic diseases, but are generally more educated and have better access to healthy options, therefore reducing the rates of such diseases.

The study concludes persistent declines of consumed sugar-sweetened beverages as a result of the tax could significantly reduce obesity and affiliated diseases, especially in populations with high initial sugar-sweetened beverage consumption. The study targeted neighborhoods with high diversity populations, but never clearly connected those neighborhoods with lower SES status. Although the study inferred that the tax would affect lower income households and a more diverse population more, the study never explained that the two are connected. They Berkeley study discussed implications should be to implement the tax in other places because consumed sugar-sweetened beverages lowered by half of beverages consumed daily of=ver three years. However, these results were only seen in the Berkeley neighborhoods, and not in the compared neighborhoods.The broader implications suggest that the tax would lower obesity and cardiometabolic disease rates in other areas, especially low SES areas, and that the tax an effective policy option to increase public health.

This conclusion, no matter how robust the study is, continues to be problematic. The study demonstrates success in Berkeley, but failure in other cities. No changes in the comparison group with the same demographic surveyed and  the same tax should not suggest a success, or continuing policy change. The study suggests that a sugar-sweetened beverage tax is an effective way to improve public health, relating to obesity. Consumption of sugar beverages may decrease in lower income households, but that would not increase the public health of higher income households who might not be affected by the tax because they can afford to drink sugar-sweetened beverages with physical income, and better healthcare. Discussions also only accounted for adults, and according to the CDC, obesity  by sugar-sweetened beverage consumption affects young adolescents more than adults. The Berkeley study does not demonstrate effective results in the change of sugar-sweetened beverages relating to the decrease of sugar-sweetened beverages consumed in larger areas.

References:

“Sugar Sweetened Beverage Intake”. Centers For Disease Control And Prevention, 2019, https://www.cdc.gov/nutrition/data-statistics/sugar-sweetened-beverages-intake.html.

Lee, Matthew M. et al. “Sugar-Sweetened Beverage Consumption 3 Years After The Berkeley, California, Sugar-Sweetened Beverage Tax”. American Journal Of Public Health, 2019, pp. e1-e3. American Public Health Association, doi:10.2105/ajph.2019.304971. Accessed 24 Feb 2019.

An article featured in The Guardian “Which countries are the most (and least) committed to reducing Inequality?” written by Niamh McIntyre discusses country spending in relation to inequality. Oxfam and the Development Finance International researched and analyzed 18 indicators across 3 policy areas in 152 different countries to rank countries’ inequality levels. The countries are ranked according to the budget they spend on each policy area. The three policies the research focused on are taxation, social spending in areas including health, welfare and education, and labor rights. The United States is ranked out 23rd overall on the Oxford inequality index. The U.S spends 73% of its budget on social spending including social security, welfare and health (Desilver 2017), and has the highest corporate taxation rate out of high income countries. Why is the U.S on a low ranking for reducing inequality if it spends the most in two out of three policy areas? This analysis looks at high ranked countries on the Oxfam scale and highlights spending on policy areas between the United States and other countries showing inequalities despite the United States being a high income country.

Taxation is one of the policy areas that Oxfam measured, and corporate tax is a big component in how counties are ranked. Progressive structure and incidence on tax is also used. This metric is influenced by the Gini coefficient, which measures income distribution among a country. Corporate tax is a direct tax imposed on the income or capital of a corporation. Generally, countries are not seen to raise corporation tax, they have been declining. “The G20 average has declined 40% in 1990 to 28.7% in 2015” (McIntyre). Lowering corporation tax is seen as a disadvantage concerning countries’ inequality level. However, the United States has the largest corporate tax out of all major economies. Its corporation tax is at 39%, the highest percent corporation tax for high income countries. Sweden imposes 22% for corporation tax. Compared to the United States’ 23rd rank,  Sweden is ranked 1st for the lowest income inequality on the Oxfam level. This means Sweden has the lowest inequality rate out of 152 countries around the world. Yet, Sweden is ranked 8th in progressive structure and incidence on tax. This metric is influenced by their different policies . Comparatively, the United States may have a worse ranking not because of corporate tax imposed, but because of other factors such as falling wages. Countries with a lower GDP than the United States nevertheless rank higher, not because they impose a higher corporate tax as the article suggests, but because these countries tend to have a more progressive minimum wages. (McIntyre).

Another policy area the Oxfam research focuses on is social spending which includes health, welfare, and education. The rankings seem to be more focused on education spending as a means of measuring inequality and less focused on other factors such as welfare and health. According to the rankings, “High-income countries tended to fare much worse than low-income countries on education spending” (McIntyre). The United States ranked 25th in spending on health, education and social protection.  The lowest percent the U.S spent on education is 3%. Comparatively, Sweden spends 7.9% of its budget on education and Zimbabwe spent 29% of its budget on education.

The chart below shows results from Pew Research on how the United States spends its budget. While the U.S spends most of its budget on social services at 73%, this is divided into seven categories. Although Medicare is a large part of the budget of the U.S. it might not correlate to better health for Americans.

The Oxfam measurement does not take into account policies. Therefore, on a global scale it can be difficult to find the primary cause of inequality in each category. However, the lack of budget on education contributes to the bad  inequality ranking for social spending. The graph below visually represents different countries’ budgets on education. High income countries are seen spending less on education than low income countries.

Overall rankings for inequality levels on the Oxfam list were relatively high for high income countries, except the U.S, which had a low ranking. Although the United States spends a lot of money in two out of three policy areas Oxfam is concerned with, the ranking is still low due to a number of factors. The biggest factor that contributes to the U.S.’s low ranking is spending on education. Generally, low income countries spent more of their budget on education while high income countries like the U.S did not, but what pulled other countries like Sweden to the top of the rankings were taxation policies and labour rights. Higher wages, and smarter taxation laws contributed to Sweden’s better equality and the United State’s worsening equality.

http://www.pewresearch.org/fact-tank/2017/04/04/what-does-the-federal-government-spend-your-tax-dollars-on-social-insurance-programs-mostly/

References:

https://www.theguardian.com/inequality/datablog/2017/jul/17/which-countries-most-and-least-committed-to-reducing-inequality-oxfam-dfi

http://www.pewresearch.org/fact-tank/2017/04/04/what-does-the-federal-government-spend-your-tax-dollars-on-social-insurance-programs-mostly/

https://www.npr.org/2017/08/07/541797699/fact-check-does-the-u-s-have-the-highest-corporate-tax-rate-in-the-world

As the use of new technology increases and doctors and scientists know more than ever before, healthcare practices should in theory be getting safer and more prominent. Literacy and education related to pregnancy is growing. More information on obstetric care is increasing. Obstetric care is crucial for women’s health, the World Health Organization describes that basic essential obstetric care should include “parenteral antibiotics, parenteral oxytocic drugs,  parenteral sedatives for eclampsia, manual removal of placenta and manual removal of retained products” (WHO 2000). There is a more comprehensive list, but the previous examples are essential. In April of 2017 the University of Minnesota Rural Health Research Center conducted a study on the loss of obstetric services in the United States, which disproportionately affect  rural counties. This study’s information came from the American Hospital Association, where about 6,300 hospitals spread throughout the United States reported on loss of obstetric care. Because hospitals and obstetric care services are rapidly declining, should more obstetric care be implemented in rural areas?

Compared to micropolitan area, rural counties are losing obstetric services at a much    faster rate. The number of hospitals that provide obstetric services declined by 25% in eleven years (RHRC). Rural counties are being more isolated not only because of hospital closures, but because obstetric care is not being offered to these communities, mostly in noncore areas. The findings also saw a trend that obstetric unit closure is more likely in counties with low birthweight and lower median household income. This is important to look at because it brings into question the lack of services that are essential to providing obstetric care for women. The chart below shows distribution among micropolitan and noncore rural areas. The loss of obstetric services in noncore areas are significantly higher than micropolitan areas.

This study calls for a need to asses obstetric care on a regular basis, however does not provide information about how many women now lack access to obstetric care. This study shows that hospitals and obstetric care is decreasing in rural counties, but it does not focus on other variables affecting women’s health. There are a lot of other variables and demographics that would be helpful to measure to determine what essential obstetric care services women do not have access to and are in need of. A more comprehensive study could identify the essential care that is lacking, and possibly improve obstetric care for women in rural areas.While there are micropolitan areas and urban communities, most of the United States is considered to be  rural counties. The populations of people are vastly different and it is crucial to provide access to obstetric care to all women to reduce the risk of pregnancy.

This study does a good job at representing rural counties in the United States because there are approximately 3,000 counties in the United States, so this is a representative sample of counties. It also highlights not only hospitals that have been shut down in rural communities and therefore do not offer obstetric care but count for closures of just obstetric units. The data from this study overall show that there is a need to extend obstetric care in rural counties even though women demographics were not included in this study.

References:

http://rhrc.umn.edu/wp-content/files_mf/1491501904UMRHRCOBclosuresPolicyBrief.pdf

https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm

https://www.acsh.org/news/2017/10/25/infant-mortality-25-higher-rural-areas-12031

https://www.cdc.gov/nchs/products/databriefs/db285.htm

http://www.nzdl.org/gsdlmod?e=d-00000-00—off-0cdl–00-0—-0-10-0—0—0direct-10—4——-0-1l–11-en-50—20-about—00-0-1-00-0–4—-0-0-11-10-0utfZz-8-00&cl=CL1.177&d=HASHdf54d1ccac38838ac10c04.2&gt=1

Much like their counterpart big tobacco, giant food corporations such as Coca Cola and Nestle perpetuate problems relating to obesity and heart disease. But, why does this happen? Their distracted agenda is to help Americans consume less and live healthier lives by providing research money in studies, when in fact, their underlying objective is their quest to make a profit. This is deeply detrimental to American people’s lives because food corporations’ agendas lead Americans into believing that their products are a healthy choice.  

While most Americans know that smoking cigarettes increases risk for cancer, big tobacco companies are getting better at hiding the fact that they still are selling carcinogens in new styles and flavors. Juul is a great example of a hazardous product that is popular among young adults. The same is happening with the food industry. As new evidence plasters headlines indicating a link between sugary drinks and obesity linked diseases, the companies must fight back. Companies such as Coca Cola invest their money into creating low-calorie, zero sugar, “better for you” soft drinks, and put more time into funding research that concludes “Americans should be more concerned with exercise than diet to maintain health” (Reilly). This is a big theme among company giants. They supply information to people with evidence from research studies, that they (big companies) have funded. Large companies like Coca Cola support the individual idea that “it’s your fault if you’re obese, not soda’s”. They also promote living a healthy active life while exercising, but diet is not as important. Because companies such as Nestle own a lot of other companies like Gerber baby food and Powerbar, they have a lot of impact on consumer choices.  Food giants support the idea of living a healthy and active life, and that calorie counting is not as important. This image shows a couple major companies that own most used products in everyday life.

Food giants are shaping consumer’s minds about what choices in the supermarket are healthy. People rely on the common idea that companies value the public’s health. Whereas the harsh reality is that these companies’ bottom line is earning a profit. For example, if Coca Cola stated that Coke is actually harmful, it would negatively affect their profit. It is much more cost effective to add “zero sugar” on a label even though it does not improve the nutrition of that product. Nevertheless, there continues to be a rise in obesity rates and chronic disease relating to obesity rates in the United States. This graph shows the rising obesity rates in the United States for men and women starting in 1960. The trend continues to grow, despite the new healthy soda and nutritious cookies that are out on the market.

It is not a coincidence that food corporations are gaining profit and obesity rates are still inclining. Money is the underlying theme in the bridge between what consumers hear is good for them, and what these companies want them to hear. Food corporations are not concerned with the “obesity epidemic”. The data concludes that large companies have more of a priority in continuing to sell product, rather than reducing the risk of chronic disease in consumers.

References:

https://www.niddk.nih.gov/health-information/health-statistics/overweight-obesity

https://www.insidephilanthropy.com/home/2018/1/5/food-companies-manipulation-of-nutrition-research-takes-root-abroad

https://www.huffingtonpost.com/2012/04/27/consumer-brands-owned-ten-companies-graphic_n_1458812.htmlh

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