1
|
Sun J, Ocay DD, Halpin M, Lobo K, Frohman DFT, Donado C, Brownstein CA, Genetti CA, Madden A, Berde CB. Clinical Characterization of Pediatric Erythromelalgia: A Single-Center Case Series. Children (Basel) 2023; 10:1282. [PMID: 37628281 PMCID: PMC10453121 DOI: 10.3390/children10081282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/18/2023] [Accepted: 07/21/2023] [Indexed: 08/27/2023]
Abstract
Erythromelalgia is a descriptive term for severe burning pain and erythema in the distal extremities relieved by cold and exacerbated by heat. Pediatric case series to date are relatively small. We extracted and analyzed medical record data for 42 pediatric patients to describe clinical characteristics, associated conditions, and responses to treatments. Informed consent was obtained according to an IRB-approved protocol that included gene discovery. Three patients had confirmed Nav1.7 sodium channelopathies, with six additional patients under investigation with novel gene candidates. There was a female predominance (2.5:1), and the median onset age was 12 years (IQR = 3-14). Patients saw a median of three specialists (IQR = 2-3) for a diagnosis. The majority (90%) reported bilateral symptoms. Cooling methods usually provided partial relief, while heat and exercise exacerbated pain. No medication appeared to be consistently effective; commonly prescribed medications included sodium channel blockers (n = 37), topical analgesics (n = 26), gabapentin (n = 22), and aspirin (n = 15). Based on the currently published literature, we believe this cohort is the largest pediatric study of erythromelalgia to date. Many findings are consistent with those of previously published case series. Work is in progress to establish a prospective cohort and multi-center registry.
Collapse
Affiliation(s)
- Jenny Sun
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Don Daniel Ocay
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
| | - Meghan Halpin
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Kimberly Lobo
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Dafni F. T. Frohman
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Carolina Donado
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
| | - Catherine A. Brownstein
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Casie A. Genetti
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Anna Madden
- Manton Center for Orphan Disease Research, Division of Genetics and Genomics, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Charles B. Berde
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
2
|
Madan E, Carrié S, Donado C, Lobo K, Souris M, Laine R, Beers E, Cornelissen L, Darras BT, Koka A, Riley B, Dinakar P, Stone S, Snyder B, Graham RJ, Padua H, Sethna N, Berde C. Nusinersen for Patients With Spinal Muscular Atrophy: 1415 Doses via an Interdisciplinary Institutional Approach. Pediatr Neurol 2022; 132:33-40. [PMID: 35636280 DOI: 10.1016/j.pediatrneurol.2022.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/15/2022] [Accepted: 04/19/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Spinal deformity and prior spinal fusion pose technical challenges to lumbar puncture (LP) for nusinersen administration for patients with spinal muscular atrophy (SMA). In this retrospective study over two study phases, we evaluated (1) factors associated with difficult LP or unscheduled requirement for image guidance and (2) effectiveness of a triage pathway for selective use of image guidance and nonstandard techniques, particularly for patients with spinal instrumentation/fusion to the sacrum. METHODS With institutional review board approval, electronic health records, imaging, and administrative databases were analyzed for patients receiving nusinersen from January 2012 through September 2021. Descriptive statistics and univariate analyses were used. RESULTS From January 2012 to March 2018 (phase 1), among 82 patients with SMA, 461 of 464 (99.4%) LP attempts were successful. Univariate analyses associated difficulty with prior spinal instrumentation, higher body mass index, and severity of the spinal deformity. Based on this experience, starting in April 2018 (phase 2), 125 patients were triaged selectively for ultrasound, fluoroscopy, or Dyna computed tomography. Patients with spinal instrumentation/fusion to the sacrum were treated primarily via intrathecal ports (137 doses) or transforaminal LP (55 doses). From April 2018 through September 2021, 704 of 709 (99.3%) LPs were successful. In total from January 2012 to September 2021, 1415 doses were administered. Over 50% of LPs were performed by neurology nurse practitioners without image guidance. Safety outcomes were excellent. CONCLUSIONS A stratified approach resulted in successful intrathecal nusinersen delivery and efficient resource allocation for patients with SMA, with or without complex spinal anatomy.
Collapse
Affiliation(s)
- Elena Madan
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sabrina Carrié
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Carolina Donado
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kimberly Lobo
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Michelle Souris
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Regina Laine
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elizabeth Beers
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Laura Cornelissen
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Basil T Darras
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Anjali Koka
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Bobbie Riley
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Pradeep Dinakar
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Scellig Stone
- Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian Snyder
- Department of Orthopaedic Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Robert J Graham
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Horacio Padua
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Navil Sethna
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Charles Berde
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
3
|
Cornelissen L, Underwood E, Gabard-Durnam LJ, Soto M, Tao A, Lobo K, Hensch TK, Berde CB. Tactile sensitivity and motor coordination in infancy: Effect of age, prior surgery, anaesthesia & critical illness. PLoS One 2022; 17:e0279705. [PMID: 36584108 PMCID: PMC9803162 DOI: 10.1371/journal.pone.0279705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 12/13/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Tactile sensitivity in the infant period is poorly characterized, particularly among children with prior surgery, anaesthesia or critical illness. The study aims were to investigate tactile sensitivity of the foot and the associated coordination of lower limb motor movement in typically developing infants with and without prior hospital experience, and to develop feasible bedside sensory testing protocols. MATERIALS AND METHODS A prospective, longitudinal study in 69 infants at 2 and 4 months-old, with and without prior hospital admission. Mechanical stimuli were applied to the foot at graded innocuous and noxious intensities. Primary outcome measures were tactile and nociceptive threshold (lowest force required to evoke any leg movement, or brisk leg withdrawal, respectively), and specific motor flexion threshold (ankle-, knee-, hip-flexion). Secondary analysis investigated (i) single vs multiple trials reliability, and (ii) the effect of age and prior surgery, anaesthesia, or critical illness on mechanical threshold. RESULTS Magnitude of evoked motor activity increased with stimulus intensity. Single trials had excellent reliability for knee and hip flexion at age 1-3m and 4-7m (ICC range: 0.8 to 0.98, p >0.05). Nociceptive threshold varied as a function of age. Tactile sensitivity was independent of age, number of surgeries, general anaesthesia and ICU stay. CONCLUSIONS This brief sensory testing protocol may reliably measure tactile and nociceptive reactivity in human infants. Age predicts nociceptive threshold which likely reflects ongoing maturation of spinal and supraspinal circuits. Prior hospital experience has a negligible global effect on sensory processing demonstrating the resilience of the CNS in adverse environments.
Collapse
Affiliation(s)
- Laura Cornelissen
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children’s Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Ellen Underwood
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children’s Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Laurel J. Gabard-Durnam
- Center for Cognitive and Brain Health, Northeastern University, Boston, Massachusetts, United States of America
| | - Melissa Soto
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children’s Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Alice Tao
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children’s Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kimberly Lobo
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children’s Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Takao K. Hensch
- Harvard Medical School, Boston, Massachusetts, United States of America
- F.M. Kirby Neurobiology Center, Department of Neurology, Boston Children’s Hospital, Boston, MA, United States of America
| | - Charles B. Berde
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children’s Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| |
Collapse
|
4
|
Bagley L, Kordun A, Sinnott S, Lobo K, Cravero J. Food allergy history and reaction to propofol administration in a large pediatric population. Paediatr Anaesth 2021; 31:570-577. [PMID: 33529424 DOI: 10.1111/pan.14147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 01/23/2021] [Accepted: 01/26/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Anaphylaxis to propofol is rare; however, providers face a clinical quandary as medication warnings still exist regarding propofol administration to egg-, soy-, and peanut-allergic patients. AIMS The primary aim evaluated the rate of allergic reactions during propofol-containing anesthesia in patients listed allergic to egg, soy, or peanut compared with nonallergic patients who received propofol. The secondary aim evaluated the relationship between food allergy history and allergy testing data. METHODS A retrospective chart review conducted between May 2012 and October 2018 identified pediatric patients listed allergic to egg, soy, and/or peanut, who received propofol. Allergy testing and results are presented. Evidence of allergic reaction to propofol during anesthesia was evaluated, and compared with a large nonallergic cohort who received propofol. RESULTS Of the 232 392 anesthetics administered, 177 360 (76%) included propofol and 11308 (6%) involved a patient listed allergic to at least 1 index food. A large number of patients had no food allergy testing (n = 6153) or negative testing (n = 2198). Of the 3435 patients listed egg-allergic, 976 tested positive; 750 tested negative; and 1709 had no testing. Of the 2011 patients listed soy-allergic, 322 tested positive; 585 tested negative; and 1104 had no testing. Additionally, 5862 patients were listed peanut-allergic; 1659 tested positive; 863 tested negative and 3340 had no testing. One record of proven propofol anaphylaxis occurred; it was in a patient without a history of food allergies. There were 6 other cases of suspected allergy to propofol. One had a peanut and tree nut allergy and was lost to follow-up; one had no testing available, while 4 patients had positive propofol allergy testing and positive allergy tests to other medications. The rate of proven propofol anaphylaxis during anesthesia in the nonallergic cohort was 0.06/10 000, and the rate in egg- and soy-allergic patients was 0/5446. One patient with a listed peanut allergy had a possible reaction to propofol. CONCLUSIONS In the listed food-allergic cohort, the majority had no allergy testing or negative testing. We found no evidence of a relationship between food allergy history and perioperative propofol reaction. We suggest multiply allergic and atopic patients may have a similar likelihood of propofol reaction as with other medications.
Collapse
Affiliation(s)
- Lisa Bagley
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna Kordun
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sean Sinnott
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kimberly Lobo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph Cravero
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
5
|
Donado C, Spagnuolo GM, Lobo K, Berde C, Dinakar P. Effect of lumbar medial branch blocks on extension-related axial chronic low back pain in a pediatric population: a retrospective chart review and prospective follow-up. Reg Anesth Pain Med 2020; 45:1019-1020. [PMID: 32393524 DOI: 10.1136/rapm-2019-101218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Carolina Donado
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Genevieve M Spagnuolo
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kimberly Lobo
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Charles Berde
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Pradeep Dinakar
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA .,Department of Anesthesiology, Perioperative & Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
6
|
Abstract
The management of pediatric pain typically consists of individualized treatment plans and interventions that have not been systematically evaluated. There is an emerging need to create systems that can support the translation of clinical discoveries, facilitate the assessment of current interventions, and improve the collection of patient-centered data beyond routine clinical information. We present the development of the pediatric pain data repository, a custom-built system developed at Boston Children’s Hospital by a multidisciplinary pain treatment service. The Repository employs a web platform to collect standardized patient-reported outcomes and integrates this with electronic medical record data. To date, we have collected information on 2577 patients and anticipate adding approximately 500 new patients per year. Major strengths of the Repository include collection of extensive longitudinal patient-reported outcomes, automated clinical data abstraction, and integration of the system into clinical workflows to support medical decision making.
Collapse
Affiliation(s)
- Carolina Donado
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kimberly Lobo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Charles B Berde
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Florence T Bourgeois
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
7
|
Cornelissen L, Bergin AM, Lobo K, Donado C, Soul JS, Berde CB. Electroencephalographic discontinuity during sevoflurane anesthesia in infants and children. Paediatr Anaesth 2017; 27:251-262. [PMID: 28177176 DOI: 10.1111/pan.13061] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Deep anesthesia in adults may be associated with electroencephalographic (EEG) suppression and higher rates of postoperative complications. Little is known about the impact of anesthetic depth on short- or long-term outcomes in pediatrics. Brain activity monitoring may complement clinical signs of anesthetic depth. This prospective observational study aimed to assess the frequency and degree of profound EEG suppression using multichannel EEG in children during sevoflurane general anesthesia. METHODS Children aged 0-40 months who required general anesthesia for elective surgery were included. Continuous EEG recordings were performed starting from when anesthesia began and until recovery. Discontinuity was defined as EEG amplitude <25 uV, lasting ≥2 s, and observed in all electrodes across the scalp. Frequency, duration, and inter-event interval of discontinuity events were measured. Relationships between discontinuity events and postnatal age, endtidal sevoflurane concentration (etSEVO), and multiple clinical parameters were analyzed. RESULTS Discontinuity events were observed in 35/68 children, with a median duration of 10 s (95%CI: 8-12) and a median of 4 events per patient (95%CI: 2-7). Children who had discontinuity events were younger (5.5 months, 95%CI: 3.6-6.5) compared to children who did not have discontinuity events (10.2 months, 95%CI: 6.1-14); (difference between medians, 4.7 months, 95%CI: 2.3-8, P = 0.0002). Younger infants exhibited a higher number of discontinuity events, and the incidence decreased with postnatal age (r68 = -0.53, P < 0.0001). The majority of discontinuity events were observed during the first 30 min of anesthesia (66.4% total events), where etSEVO was >3%. Few discontinuity events were observed during maintenance and none during emergence. Blood pressure, heart rate, tissue oxygen saturation, and endtidal CO2 partial pressure did not change during these events. CONCLUSIONS Electroencephalographic monitoring may complement clinical signs in providing information about brain homeostasis during general anesthesia. The impact of discontinuity events on immediate and long-term outcomes merits further study.
Collapse
Affiliation(s)
- Laura Cornelissen
- Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Ann M Bergin
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Kimberly Lobo
- Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Carolina Donado
- Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Janet S Soul
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Charles B Berde
- Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
8
|
Chiauzzi E, Dasmahapatra P, Lobo K, Barratt MJ. Participatory research with an online drug forum: a survey of user characteristics, information sharing, and harm reduction views. Subst Use Misuse 2013; 48:661-70. [PMID: 23750771 DOI: 10.3109/10826084.2013.800117] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Visitors to a popular online drug forum completed an online survey between November 2011 and January 2012, which covered (1) demographic characteristics, (2) substance use (including nonmedical prescription opioid use), (3) forum activity, and (4) harm reduction beliefs. The study sample (N = 897) primarily included Caucasian males in their twenties from the United States, the United Kingdom, Australia, and Canada. The practice of harm reduction was overwhelmingly endorsed by participants. Current nonmedical prescription opioid users reported more activity in forums and past substance abuse treatment. The study's implications and limitations are noted and future research is suggested.
Collapse
|