Case report
Development of concomitant diseases in COVID-19 critically ill patients
Desarrollo de enfermedades concomitantes en pacientes críticos con COVID-19
G. Puiga,
, M. Giménez-Milàa,b, E. Campistola, V. Cañoa, J. Valcarcelc, M.J. Colominaa,b
Corresponding author
a Departamento de Anestesia y Cuidados Críticos, Hospital Universitario de Bellvitge, Universidad de Barcelona, Barcelona, Spain
b Grupo de Fisiopatología Perioperatoria y Dolor, Instituto de Investigación Biomèdica de Bellvitge, Barcelona, Spain
c Departamento de Radiología, Hospital Universitario de Bellvitge, Universidad de Barcelona, Barcelona, Spain
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(B) Coronal maximum intensity projection (MIP) reconstruction of contrast-enhanced abdominal CT, showing a filling defect in the proximal/middle portion of the splenic artery, suggestive of thrombosis (yellow arrow). (C) Coronal MIP reconstructions from contrast-enhanced abdominal CT showing filling defects in the aorta at the iliac bifurcation (yellow arrow) and in the left common iliac arteries (long green arrow). (D) MPR reconstruction of contrast-enhanced abdominal CT coronal slice showing a large triangular hypodense area in the spleen, consistent with splenic infarction (yellow arrow).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "O. Comino-Trinidad, A. Calvo, A. Ojeda, J. Mercadal, L. Cornellas, C. Ferrando" "autores" => array:6 [ 0 => array:2 [ "nombre" => "O." "apellidos" => "Comino-Trinidad" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Calvo" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Ojeda" ] 3 => array:2 [ "nombre" => "J." 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Puig, M. Giménez-Milà, E. Campistol, V. Caño, J. Valcarcel, M.J. Colomina" "autores" => array:6 [ 0 => array:4 [ "nombre" => "G." "apellidos" => "Puig" "email" => array:1 [ 0 => "gpuig@bellvitgehospital.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Giménez-Milà" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Campistol" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "V." 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"apellidos" => "Colomina" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Departamento de Anestesia y Cuidados Críticos, Hospital Universitario de Bellvitge, Universidad de Barcelona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Grupo de Fisiopatología Perioperatoria y Dolor, Instituto de Investigación Biomèdica de Bellvitge, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Radiología, Hospital Universitario de Bellvitge, Universidad de Barcelona, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Desarrollo de enfermedades concomitantes en pacientes críticos con COVID-19" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 500 "Ancho" => 1250 "Tamanyo" => 58315 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Bronchial arteriography. Hypertrophy of bronchial arteries (right intercostobronchial trunk and right branch of the bronchial trunk) (A). Uneventful embolization of these branches (B).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The treatment of respiratory failure, inflammatory response and hypercoagulability are the main therapeutic challenges in patients with COVID-19 admitted to critical care units (CCU). The basic principles of critical care must be taken into consideration<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> when deciding the best approach to the different acute and serious problems of patients with COVID-19. Due to its complexity and severity, it is not surprising that these patients may develop other concomitant diseases typical of CCU patients, such as thromboembolic events,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> acute kidney injury, or secondary infections such as necrotizing pneumonia or acalculous cholecystitis.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a> The overall mortality rate of 31% described in Spanish series is higher in patients with these complications.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> We describe 2 cases of complications that occurred in critically ill patients admitted for COVID-19.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case 1</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 65-year-old man admitted to the hospital after 10 days of fever, cough, and dyspnoea. His medical history was significant for: allergy to aspirin and NSAIDs, former smoker, and high blood pressure under treatment with enalapril. The chest X-ray on admission showed bilateral interstitial infiltrates. After SARS-CoV-2 was detected by polymerase chain reaction (PCR), treatment with hydroxychloroquine, lopinavir/ritonavir, amoxicillin-clavulanate, and interferon beta was started. On the fourth day of admission, he presented clinical worsening with tachypnoea of up to 45 breaths per minute and SaO<span class="elsevierStyleInf">2</span> 80% despite non-invasive mechanical ventilation (NIMV) with a high fraction of inspired oxygen. Orotracheal intubation was performed without complications in the CCU. Following this, and after recruitment manoeuvres, it was decided to ventilate in the prone position. Treatment with a single dose of tocilizumab and dexamethasone for 10 days was started in the CCU.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient improved after 24<span class="elsevierStyleHsp" style=""></span>h in the prone position, and was extubated 5 days after admission. He was treated with high-flow nasal cannula (HFNC) until the seventh day, when he gradually developed tachypnoea together with intense abdominal pain with guarding in the right upper quadrant. He was re-intubated due to clinical and blood gas worsening with PaO<span class="elsevierStyleInf">2</span> 65<span class="elsevierStyleHsp" style=""></span>mmHg and PaCO<span class="elsevierStyleInf">2</span> 30<span class="elsevierStyleHsp" style=""></span>mmHg. Biliary pathology was suspected, so an urgent CT scan was performed, which showed acalculous cholecystitis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), massive bilateral PE and ischaemic colitis. The patient developed septic shock, probably of biliary origin, with growth of <span class="elsevierStyleItalic">Enterobacter aerogenes</span> in peripheral blood cultures, and required infusion of norepinephrine at 0.3<span class="elsevierStyleHsp" style=""></span>mcg/kg/min. The infection was controlled by ultrasound-guided percutaneous cholecystostomy and ertapenem 1<span class="elsevierStyleHsp" style=""></span>g/24<span class="elsevierStyleHsp" style=""></span>h. He also received an anticoagulant (enoxaparin 1<span class="elsevierStyleHsp" style=""></span>mg/kg/12<span class="elsevierStyleHsp" style=""></span>h) for PE. Fourteen days after admission, and after improvement of inflammatory parameters and withdrawal of norepinephrine, he was extubated with PaO<span class="elsevierStyleInf">2</span>/FiO<span class="elsevierStyleInf">2</span> >250; HFNC therapy was maintained. The patient had significant muscle weakness. On the 17th day of admission, he presented lower gastrointestinal bleeding in the form of haematochezia and haemodynamic instability, for which he was re-intubated and norepinephrine infusion 0.2<span class="elsevierStyleHsp" style=""></span>mcg/kg/min was restarted. An urgent CT scan showed ischaemic colitis with no active bleeding or perforation. On the 19th day of admission a tracheotomy was performed. After weaning procedures, he was disconnected from mechanical ventilation on the 34th day of admission. The patient is still in the CCU, receiving conventional oxygen therapy through the tracheostomy and intensive physiotherapy sessions.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 2</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 57-year-old man weighing 68<span class="elsevierStyleHsp" style=""></span>kg with a history of active alcoholism, former smoker, laryngectomy in 2016 for supraglottic carcinoma with no evidence of disease, and treated for tuberculosis 15 years earlier. He came to our hospital 6 days after the onset of symptoms consisting of fever peaks and dyspnoea at rest. A chest X-ray performed on admission showed bilateral alveolar infiltrates. SARS-CoV-2 tests were positive, so treatment was started with hydroxychloroquine, lopinavir/ritonavir, amoxicillin-clavulanate, anti-inflammatory therapy with methylprednisolone for 3 days, tocilizumab (2 doses) and tacrolimus. On the ward, he presented delirium, possibly due to alcohol withdrawal. On the sixth day of admission, haemoptysis was observed in the tracheal aspirate, causing tachypnoea and desaturation, so piperacillin-tazobactam was started. Chest X-ray and CT angiography revealed possible right lower lobe (RLL) pulmonary cavitation and PE (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">On the seventh day, he was admitted to the CCU with hypotension and hypoxaemia. He was sedated with remifentanil and propofol in order to start mechanical ventilation, as well as norepinephrine at 0.25<span class="elsevierStyleHsp" style=""></span>mcg/kg/min.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment with enoxaparin 40<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h was started after weighing up bleeding versus thrombotic risk due to PE. Bronchoalveolar aspirate (BAA) samples were taken for culture, being positive for <span class="elsevierStyleItalic">Staphylococcus aureus</span> and <span class="elsevierStyleItalic">Proteus mirabilis</span>, culture and auramine–rhodamine stain were negative for TB, and nasopharyngeal swab was negative for methicillin-resistant <span class="elsevierStyleItalic">S. aureus</span> (MRSA). Serum galactomannans were slightly positive, but fungal colonies were never isolated in respiratory specimen. Haemoptysis episodes persisted for 48<span class="elsevierStyleHsp" style=""></span>h, so in consensus with the vascular and interventional radiologist diagnostic arteriography was performed.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The image showed hypertrophy of the bronchial arteries with pathological vascularization of the RLL (right intercostobronchial trunk and right branch of the bronchial trunk), so these were embolised without incident (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Haemoptysis improved and the patient was disconnected from mechanical ventilation 2 days later. He also developed acute kidney injury stage 2 with hypernatremia and hypokalaemia that progressively improved. Eight days after admission to the UCC, he was discharged to the Semicritical Pulmonology Care Unit.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Critically ill patients with COVID-19 are likely to present various concomitant pathologies that need to be diagnosed and treated early.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Acalculous cholecystitis is a typical complication of major surgery and trauma in critically ill patients.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> Prolonged fasting, arterial hypotension, and parenteral nutrition, which would predispose to an alteration of gallbladder motility and the formation of bile stasis have been described as risk factors. Mortality in these cases is up to 50%, and has a worse prognosis than calculous cholecystitis,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> mainly due to diagnostic difficulty and the population it usually affects. It requires a high diagnostic suspicion for which a specific diagnostic imaging test, either an ultrasound or an abdominal CT, is indicated. In the case described here, it was essential that the patient was conscious.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Necrotizing pneumonia, which was diagnosed in the second patient, is a rare form of adult pneumonia, with a prevalence of less than 1%. Among the risk factors described are alcoholism, diabetes mellitus, or corticosteroid therapy.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Many pathogens have been described as causative agents, one of the most frequent being <span class="elsevierStyleItalic">S. aureus</span>. Other aetiological agents are anaerobic bacteria, mycobacteria or fungi, especially in immunosuppressed patients. In our case, haemoptysis, which can sometimes be massive, was the first symptom that helped guide the diagnosis and choose radiological and microbiological diagnostic tests. The usual treatment is empirical antibiotic therapy that is later directed according to the culture results, reserving surgery or bronchial artery embolization for severe cases that do not respond to medical treatment, or when anticoagulation is indicated, which was the case in our patient.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">COVID-19 patients are known to present a wide array of dysfunctions in various organs, such as the lungs, heart, liver, kidney, and as new research is showing, the vascular endothelium.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The benefit of a multidisciplinary approach is shown in the 2 cases presented here.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Seriously ill patients admitted for SARS-CoV-2 pneumonia may suffer other pathologies that require early diagnosis and treatment, and a multidisciplinary approach is highly beneficial.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors have not received any type of funding for this article.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of interests</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors of this article have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1450926" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1323066" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1450927" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1323065" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case 1" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Case 2" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-05-08" "fechaAceptado" => "2020-09-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1323066" "palabras" => array:4 [ 0 => "COVID-19" 1 => "Acalculous cholecystitis" 2 => "Intraarterial embolisation" 3 => "Necrotising pneumonia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1323065" "palabras" => array:4 [ 0 => "COVID-19" 1 => "Colecistitis acalculosa" 2 => "Embolización intraarterial" 3 => "Neumonía necrotizante" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">It may be necessary a consideration about the best approach to the acute concomitant problems that critical COVID-19 patients can develop. They require a rapid diagnosis and an early treatment by a multidisciplinary team. As a result, we would like to describe two clinical cases a patient with diagnosis of COVID-19 pneumonia with good respiratory evolution that, after extubation suffered an acalculous cholecystitis and a patient with COVID-19 pneumonia that suffered an overinfection with necrotising pneumonia that presented with haemoptysis and was finally treated with arterial embolisation by the interventional radiologist’s team.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Puede ser necesaria una reflexión sobre cuál es el mejor abordaje para las enfermedades agudas concomitantes que pueden desarrollar los pacientes críticos con COVID-19. Estos requieren una sospecha diagnóstica y un tratamiento precoz, basados en el trabajo de equipos multidisciplinares. Presentamos dos casos de enfermedades concomitantes en pacientes con COVID-19. Un paciente diagnosticado de COVID-19 con buena evolución respiratoria que tras extubación presentó una colecistitis acalculosa y un paciente con neumonía por COVID-19 que presentó una sobreinfección con neumonía necrotizante, cuyo primer síntoma fue hemoptisis y fue finalmente tratado con embolización arterial por radiología intervencionista.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Puig G, Giménez-Milà M, Campistol E, Caño V, Valcarcel J, Colomina MJ. Desarrollo de enfermedades concomitantes en pacientes críticos con COVID-19. Rev Esp Anestesiol Reanim. 2021;68:37–40.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 612 "Ancho" => 1750 "Tamanyo" => 143578 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest-abdomen contrast-enhanced CT angiography. Image A shows a filling defect in the right main artery (arrow). Image B shows bilateral pulmonary infiltrates and uncomplicated acute cholecystitis (arrow in image C).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 556 "Ancho" => 1250 "Tamanyo" => 91290 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Portable chest X-ray showing possible right lower lobe pulmonary cavitation (image A). Chest CT showing RLL with possible necrotizing pneumonia (image B). Both images are marked with an arrow.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 500 "Ancho" => 1250 "Tamanyo" => 58315 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Bronchial arteriography. Hypertrophy of bronchial arteries (right intercostobronchial trunk and right branch of the bronchial trunk) (A). Uneventful embolization of these branches (B).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A novel coronavirus from patients with pneumonia in China, 2019" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N. Zhu" 1 => "D. Zhang" 2 => "W. Wang" 3 => "X. Li" 4 => "B. Yang" 5 => "J. Song" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/nejmoa2001017" "Revista" => array:6 [ "tituloSerie" => "NEJM." 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