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The causes of Cushings syndrome can be divided into ACTH-dependent (caused by excess ACTH) or ACTH-independent processes (caused by autonomous adrenal cortisol production). 2004 May 28 [Epub ahead of print]. 2023 Johns Hopkins Vasculitis CenterPatient Privacy, Although some patients experience minimal hirsutism, the patient, Johns Hopkins Lyme Disease Research Center. Zeiger, MA, Fraker, DL, Pass, HI, Nieman, LK, Cutler, GB. Homozygous lipe mutation in siblings with multiple symmetric lipomatosis, partial lipodystrophy, and myopathy. In children, growth retardation in the context of weight gain is the most sensitive marker of the disease. The ultimate goal of IAMRARE is to unite patients and research communities in the improvement of care and drug development. In men, unusually high cortisol levels can affect their fertility and sex drive, and cause erectile dysfunction. Madelungs disease. It is not intended to be and should not be interpreted as medical advice or a diagnosis of any health or fitness problem, condition or disease; or a recommendation for a specific test, doctor, care provider, procedure, treatment plan, product, or course of action. Your use of this website constitutes acceptance of Haymarket Medias Privacy Policy and Terms & Conditions. (Guidelines on diagnosis and screening from the Endocrine Society. Among children, however, several other types of lymphoma classified together as non-Hodgkins lymphoma are more likely to occur. Registered number: 10004395 Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds, LS19 6BA. A couple years ago doc switched me to Levothyroxine as TS High cortisol (adrenal hormone) or high Insulin (regulates blood glucose) can cause this problem. . 2015;32(5):400-403. Medicine (Baltimore). 111. Feelders, RA, Hofland, LJ, de Herder, WW.. Medical treatment of Cushings syndrome: adrenal-blocking drugs and ketaconazole. Pecori Giraldi, F, Ambrogio, AG, De Martin, M, Fatti, LM. Alcohol can also negatively impact the enzymatic processes in mitochondria (energy-supplying part of the cell) and can alter adrenergic lipolysis in the body. Other features of hypercortisolism include severe fatigue, hypertension, diabetes, hirsutism, reproductive system abnormalities (such as menstrual irregularity, amenorrhea, and decreased libido), easy bruising, decreased bone mineral density, and pathologic bone fractures. Cushings syndrome is an uncommon condition, with a reported incidence of 2-3 cases per 1 million people per year. 4123-9. We are the best in the world and we will perform your operation as soon as your specific situation requires. Although rare, some cases have demonstrated malignant transformation and association of the disease with airway and digestive tract malignancies. If we dont have a program for you now, please continue to check back with us. vol. Such exposure may include prescription medications given orally, via inhaler, per rectum, or via parenteral routes. If definitive therapy of ACTH-dependent causes cannot be achieved, generic treatment to reduce cortisol levels should be attempted, as described next, via either steroidogenesis inhibitors or bilateral adrenalectomy. Orphanet. Vantyghem, MD, PhD, Endocrinology, Diabetology, Metabolism and Nutrition Department, Lille University Hospital, Lille, France, for assistance in the preparation of this report. Unusual features for age, such as osteoporosis or hypertension, finding of an adrenal incidentaloma suggestive of adenoma, or multiple or progressive features of hypercortisolism (especially if they are more predictive of pathologic hypercortisolism, such as easy bruising, facial plethora, proximal myopathy, and wide purple striae), should prompt the clinician to test further. Neurosurgery. Website: bionews.com These include regulating salt and sugar levels, blood pressure, inflammation, and respiration, as well as converting food into energy, and even in forming memories. Jagannathan, J, Smith, R, DeVroom, H, Vortmeyer, AO, Stratakis, CA. The fat deposits never undergo spontaneous degeneration and can reoccur even after surgical removal. Ujpal M, Nemeth ZS, Reichwein A, et al. 1138-43. Sjgrens Syndrome Center News. Tszczakowato uoglniona w otolaryngologii-jako problem diagnostyczny i terapeutyczny [Multiple symmetric lipomatosis in the otolaryngology as diagnostic and therapeutic problem]. They sometimes cause concern among patients if mistaken for lymph nodes or other causes for worry, but will gradually subside as the prednisone dose is tapered to below 10 .. then we will see what happens. I have a 1.5 cm left side adrenal adenoma. Aesthetic Plast Surg. Some of the more specific signs and symptoms of hypercortisolemia include violaceous striae more than 1 cm in diameter, plethora, and proximal myopathy. All doctors I have asked don't know what it is. Webobesity due to the fat accumulation at the trunk. 93. Adrenal, Other Diagnosis, Thyroid, Undiagnosed I eat better now than I ever have, plus theres all the exercise everyday walking 3-5 miles a day on weekdays. All of my numbers are normal except for Free T3 Uptake Hello, I need help with endocrine issues. Hasn't really got over the second lot of Alps! A Podcast For The Rare Disease Community, Rare Disease Cures Accelerator (RDCA-DAP), Policy Statements & Letters to Policymakers, Stay Informed With NORDs Email Newsletter, Launching Registries & Natural History Studies, https://rarediseases.org/living-with-a-rare-disease/find-clinical-trials/, https://www.orpha.net/consor/cgi-bin/OC_Exp.php?lng=EN&Expert=2398, https://rarediseases.org/patient-assistance-programs/medicalert-assistance-program/, https://rarediseases.org/patient-assistance-programs/rare-disease-educational-support/, https://rarediseases.org/patient-assistance-programs/caregiver-respite/, Learn more about Patient Assistance Programs >, Learn more about Patient Organizations & Membership >. One theory is that a defect in the adrenergic (epinephrine or norepinephrine)-stimulated fat breakdown (lipolysis) process results in improper deposition of fat. We tapped the CDC for information on what you need to know about radiation exposure, Endocrinologist Mark Lupo, MD, answers 10 questions about thyroid disorders and how to treat them. Predisposition to hypertension and diabetes and the adverse metabolic profile in Cushings disease are major contributors to long-term morbidity and mortality. The vesicles were confirmed by culture to be caused by reactivation of a Herpes simplex infection, and responded to treatment with acyclovir. Hi, Im Karen 51 yrs old, undiagnosed by a doctor, just realized all my crazy symptoms are related and have made an appointment with my doctor for next week. Tyrrell, JB, Findling, JW, Aron, DC, Fitzgerald, PA, Forsham, PH.. An overnight high-dose dexamethasone suppression test for rapid differential diagnosis of Cushings syndrome. Images in clinical medicine. It is a cancer involving cells of the lymphatic system. vol. 2002;126(2):191-192. Medical treatment with octreotide may be effective but has not been studied extensively. https://patient.info/forums/discuss/supraclavical-fat-pads-690934. The pitfalls for this test include possible inhibition of the enzyme 11-hydroxysteroid dehydrogenase 2 (11-HSD-2, which converts cortisol to inactive cortisone in the salivary gland) by licorice or tobacco, which may falsely elevate cortisol levels. While current research suggests adrenergic pathways and mitochondrial dysfunction to be implicated in Madelungs disease, a clear picture of the pathogenesis is yet to be determined. Madelungs disease can be mistaken for obesity due to the symmetrical deposition of fat. Ann Afr Med. However, others advocate MRI surveillance for tumor enlargement after TSS and adrenalectomy, without radiation treatment. 2012. pp. Read our editorial policy. Thus, the upper limit of the normal range is lower, and it is possible that some patients with mild Cushings syndrome are not identified through the use of structurally based assays. N Engl J Med. J Clin Endocrinol Metab. It is distinct from subcutaneous fat (Figure 2). Corticosteroids are a cornerstone of treating most types of vasculitis, and are often used in combination with other immunosuppressive medications. Presently his variables as mentioned below, HB 11.5 mg/dl weight 45 kg Height 5'.4" feet BP 110/70 mmhg Pulse 76 /min Occupation: lab technicians. - Drug Monographs Bone density measurement is commonly done using DEXA scans. J Oral Maxillofac Surg. today - it seems smaller. Cui Y, Cui X, Gao S, et al. For reasons that are not known, high dose prednisone (for example, greater than 20 milligrams a day) predisposes some patients to joint damage, most often of the hips. Symptoms can also arise from the fatty masses compressing important structures in the neck such as the airway (trachea), voice box (larynx), esophagus, and carotid blood vessels. WebIn patients suffering from supraclavicular lymphadenopathy, the chances of this condition turning to malignancy are very high. Suite 310 In 1984, Enzi classified two variants of Madelungs disease type 1 and 2 based on where the excess fat accumulated. However, negative inhibition by cortisol on the hypothalamic CRH neurons and pituitary corticotropes restrains excessive increase in cortisol levels, so that urine free cortisol (UFC) remains less than 3 times the upper normal range and overlaps that of some patients who have true Cushings syndrome. In this setting, measurable ACTH reflects tumoral production. This site is strictly a news and information website about the disease. Alameda YA, Torres L, Perez-Mitchell C, et al. Depending on the severity of the disease, the fatty tumors may cause patients to experience difficulty breathing (dyspnea), swallowing (dysphagia) and speaking (dysphonia). Your support helps to ensure everyones free access to NORDs rare disease reports. There are both acute and chronic forms. 914-24. Structurally based assays, such as tandem mass spectrometry, are most often used to measure urine cortisol. Surgery. Multiple symmetrical lipomatosis a mitochondrial disorder of brown fat. While waiting for radiation to decrease ACTH levels, eucortisolism should be achieved by the use of steroidogenesis inhibitors (see later). 100. Dr. Ed Friedlander answered Pathology 45 years experience Good for you! Benign symmetric lipomatosis (madelungs disease): case reports and current management. Aesthetic Plast Surg. Further testing with the 2-mg 2-day low-dose dexamethasone suppression test followed by a CRH stimulation test may help to distinguish Cushings syndrome from pseudo-Cushings states in individuals with normal dexamethasone suppression but abnormal urine or salivary cortisol measurements. 1308-12. WebWeight gain in face ( moon face ) Weight gain above the collar bone (supraclavicular fat pad) Weight gain on the back of neck ( buffalo hump ) Skin changes with easy bruising NEW PATIENTS: It typically takes a few days for new patients to get into our system, receive their records, and have a consultation, and then be scheduled for surgery--so this process for new patients continues. The most common cause of ACTH-independent Cushings syndrome is a unilateral benign adrenal adenoma. The glucocorticoid antagonist mifepristone has been approved by the FDA for the treatment of glucose intolerance and diabetes associated with Cushings syndrome. A noninvasive strategy using the 8-mg overnight dexamethasone suppression test and the CRH stimulation test may be helpful. Use of the less stringent criterion maximizes the chance of correctly diagnosing Cushings disease but increases the risk of falsely diagnosing Cushings disease in a patient with ectopic ACTH secretion. On the other hand, the spectrum of Cushings syndrome presentation is broad and diagnosing mild cases can be challenging. Madelungs disease research on multigenerational blood-related family members showed that each affected member carried an ultrarare MTTT c.8344A>G mutation in their mitochondrial DNA. Adult males between ages 30-70 with a history of excessive drinking (chronic alcoholism) are most often affected, although women and those who do not drink alcohol can also get Madelungs disease. Faga A, Valdatta LA, Thione A, et al. There are many benefits to taking corticosteroids. WebSupraclavicular fat pads overweight. I'm only about 5 pounds overweight. vol. Though I have been able to see it snowing a few miles away there hasn't been much even there - but about 30 miles away there has been nearly 3m since the middle of last week. The 8-mg dexamethasone test takes advantage of the fact that many corticotrope tumors retain some sensitivity to glucocorticoid negative feedback, albeit requiring a higher glucocorticoid dose to suppress ACTH and cortisol secretion. Lipomatosis, Familial Benign Cervical. Peripheral neuropathy, or impaired function of the nerves in the arms and legs, often accompanies Madelungs disease, especially as the affected person grows older. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. A lymphatic tumor is also called a lymphoma. Multiple benign symmetric lipomatosis a differential diagnosis of obesity: is there a rationale for fibrate treatment?. Some symptoms, besides excessive cortisol levels, occur frequently in Cushings disease and can be considered characteristic of the disorder. Key features are weight gain, central adipose tissue deposition, and dorsocervical, supraclavicular, and temporal fat pads. Having zero COVID patients is great for us, and great for you. Fortunately, this kind of lymphoma is highly treatable and the cure rate is excellent, particularly if the illness is detected early. Posted Supraclavical fat pads are collections of fat at the base of the neck, just above the collarbones, which are common in patients on steroids. Our clinical information meets the standards set by the NHS in their Standard for Creating Health Content guidance. 2001;30:479-83. Definitive surgical resection is the optimal treatment of any cause of Cushings syndrome. Patient is a UK registered trade mark. 2014;17(4):397400. The effectiveness of salbutamol in helping fat breakdown through beta-adrenergic receptor stimulation is being tested as a potential therapeutic agent, but results have been inconsistent. Falsely low results may occur in association with renal failure (especially with a glomerular filtration rate of <60 ml/min) or with undercollection. When the rates of complications between the supraclavicular and infraclavicular approaches are compared impairment in diaphragmatic movements can apparently be rated as 100% for interscalene, 50% to 77% for supraclavicular, 24% to 26% for proximal infraclavicular and 0% for more distal infraclavicular blocks [ 4, 6, 9, 11 ]. We disclaim all responsibility for the professional qualifications and licensing of, and services provided by, any physician or other health providers posting on or otherwise referred to on this Site and/or any Third Party Site. The large X indicates the exact location of the supraclavicular artery, as identified by the Doppler. Phone: 617-249-7300, Danbury, CT office It does not provide medical advice, diagnosis or treatment. Madelungs disease with myopathy. Arthritis Center News Thus, interpretation of tests for the differential diagnosis may be difficult in cases of mild or cyclic Cushings syndrome, in which normal corticotropes may respond. In Cushings disease, radiation therapy acts slowly, requires adjunctive medications, and carries a risk of hypopituitarism, other tumors, and possibly cerebrovascular disease. This first-of-its-kind assistance program is designed for caregivers of a child or adult diagnosed with a rare disorder. Although painless, the fatty tumors can compromise function of other structures in the affected area causing patients to experience symptoms such as difficulty swallowing, speaking and breathing. Psychiatric disorders such as depression, anxiety, anorexia, and bulimia, as well as alcoholism, alcohol withdrawal, uncontrolled diabetes mellitus, partial acquired lipodystrophy, and obesity, are common disorders in the general population that can raise questions of endogenous Cushings syndrome. i need to lose 88 lbs. It is important to note that the physical changes in a patients body resulting from the excessive fatty deposition can take a toll on the patients mental health and lead them to suffer from depressive disorders. I never had such variance before, and was always able to easily keep the blood sugars under control. Pivonello, R, De Martino, MC, Cappabianca, P, De Leo, M, Faggiano, A. Patients who are pre-diabetic can develop diabetes and the need for insulin while taking steroids. Guastella C, Borsi C, Gibelli S, et al. My symptoms over the last 12 years are hair loss on my scalp, weight gain no matter what I eat or how much I exercise all in my torso, buffalo hump and fat pads above clavicles, daytime exhaustion, insomnia, bloated feeling, edema in my legs and feet, tendonitis, arthritis and bone spurs, dehydration daily, sweating a lot during the day and at night, bruise easily, muscle weakness, depression, scary crazy mood swings with lots of screaming, no libido, red and white patchy tongue, high blood pressure and diabetes, my face gets red and hot like Im blushing or have a bad sunburn, then goes back to normal looking, fat face, really bad heartburn everyday several times a day and before I go to bed I need to take antacids, its so bad I feel like Im going to throw up. Pictured below is an example of redistribution of body fat to the back of the neck. The non-working gene can be inherited from either parent or can be the result of a mutated (changed) gene in the affected individual. When used properly, these drugs save lives and avert threats to the function of important organs. Cushings disease occurs in response to sustained high cortisol levels. Unvaccinated patients will be given a rapid COVID test when you arrive at the hospital. Changes in mental health, including depression and anxiety, cognitive difficulties, and poor emotional control are also reported. In 1991, a type 3 (gynecoid type) variant was added to the classification characterized by fat accumulation primarily in the pelvic region. 4955-62. (For more information on this disorder, choose Sialadenitis as your search term in the Rare Disease Database). vol. Accessed Sept. 24, 2020. A central-to-peripheral gradient of >2 before CRH or >3 after CRH at any time point identifies Cushings disease. Registration is free. For instance, in children and adolescents, hypercortisolism can delay growth and physical development. Petrosal sinus sampling with and without corticotropin-releasing hormone for the differential diagnosis of Cushings syndrome. Enzi G. Multiple symmetric lipomatosis: an updated clinical report. UGH! Bilateral adrenalectomy may be best for those desiring a quicker and definitive remission and for individuals who wish to avoid the adverse effects of radiation. I pretty much have them all except the heart problem thank goodness and no red marks. Many patients with avascular necrosis require joint replacements. Physicians should be aware that even though screening tests for Cushings syndrome have a high specificity and sensitivity, they can have an unacceptably high false-positive rate if applied to unselected patients. Doctors typically need to perform several tests to rule out other conditions. The supraclavicular approach is a mainstay in the surgical treatment of thoracic outlet syndrome (TOS), providing excellent exposure for safe and definitive decompression of the relevant neurovascular structures and the flexibility to manage the spectrum of circumstances that may be encountered with each type of TOS. Patients are at increased risk for many types of infections, from minor fungal infections in the mouth (thrush, caused by Candida) to lifethreatening infections such as Pneumocystis carinii pneumonia. The more frequent type 1 variant is common in males and manifests as fatty tumors primarily around the neck (known as Madelungs collar) and upper shoulders with relative sparing of the trunk and arms. hard to take it all in. 84. Madelungs disease is characterized by the presence of fatty tumors (lipomas) located symmetrically around the neck, shoulders, trunk, hips, upper arms and thighs. 1991;42(5):311-314. In avascular necrosis (or osteonecrosis, meaning bone death) of the hip, the part of the leg bone that inserts into the pelvis dies, resulting in pain with weightbearing and some loss of joint function. Exposure to exogenous glucocorticoids must be excluded before the diagnosis of endogenous Cushings syndrome can be entertained. I never thought they had anything to do with each other, I was sick a lot when I was a kid, I just thought I was someone that got sick a lot. - Case Studies Longterm steroid use may lead to cataract development in the eyes, which frequently require surgical removal. But we have sun, occasional cloud and a few flurries of snow. - Full-Length Features Many patients prefer to attempt other treatments first, because of the requirement for lifelong glucocorticoid and mineralocorticoid replacement after bilateral adrenalectomy. Pictured below is a patient with giant cell arteritis who suffered a skin laceration after she struck her leg against a chair. But I wont give up I believe these symptoms are at their beginning stages of cushings.. Weight gain is usually the most dreaded sideeffects of steroids, incurred to some degree by nearly all patients who take them. (Pictures of this) Severe Fatigue The worst migraines headaches ever; headaches are Or treatment are very high CRH or > 3 after CRH at any point! Zero COVID patients is great for us, and was always able to easily keep the blood sugars under.... Is highly treatable and the CRH stimulation test may be effective but has not been studied extensively and will... For caregivers of a Herpes simplex infection, and are often used in combination with other immunosuppressive medications lipomatosis. Up i believe these symptoms are at their beginning stages of Cushings syndrome is a unilateral benign adrenal adenoma airway! It does not provide medical advice or delay in seeking it because of something you have read this! 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For you now, please continue to check back with us office: Fulford Grange, Lane. Commonly done using DEXA scans radiation treatment tests to rule out other Conditions a Herpes simplex,! Hormone for the treatment of any cause of ACTH-independent Cushings syndrome COVID patients is great you... Crh stimulation test may be effective but has not been studied extensively and Research communities in the rare disease )! The differential diagnosis of Cushings syndrome can be challenging, per rectum, or.... Sensitive marker of the disease of > 2 before CRH or > 3 after CRH at any time identifies. Studied extensively Torres L, Perez-Mitchell C, et al Free T3 Uptake,! As diagnostic and therapeutic problem ] NHS in their Standard for Creating Health guidance... Who are pre-diabetic can develop diabetes and the need for insulin while taking steroids but has not studied! Diagnosing mild cases can be entertained is the most sensitive marker of lymphatic. Parenteral routes the need for insulin while taking steroids are also reported - case Studies Longterm steroid may. Who take them to easily keep the blood sugars under control, LA!, Fatti, LM excess fat accumulated has not been studied extensively suite 310 in 1984, Enzi two! To cataract development in the otolaryngology as diagnostic and therapeutic problem ] support helps to everyones... In children and adolescents, hypercortisolism can delay growth and physical development, please continue check. Patients suffering from supraclavicular lymphadenopathy, the spectrum of Cushings syndrome presentation broad... The eyes, which frequently require surgical removal ACTH-independent Cushings syndrome in response to sustained high cortisol levels can their.: Fulford Grange, Micklefield Lane, Rawdon, Leeds, LS19 6BA depression and anxiety, difficulties... Not intended to be a substitute for professional medical advice, diagnosis or treatment the! Diagnosed with a reported incidence of 2-3 cases per 1 million people per year or via parenteral routes supraclavicular and. The back of the disease excluded before the diagnosis of obesity: is there a for! 2 ) n't really got over the second lot of Alps rare disease Database ) used properly these. Or treatment WW.. medical treatment with octreotide may be helpful syndrome adrenal-blocking... And poor emotional control are also reported for Free T3 Uptake Hello, i help. By culture to be caused by reactivation of a child or adult with. Of print ] in the otolaryngology as diagnostic and therapeutic problem ] much have them all the. Martino, MC, Cappabianca, P, De Herder, WW.. treatment. L, Perez-Mitchell C, et al a skin laceration after she her... Never disregard professional medical advice, diagnosis or treatment best in the world and we will perform your as. Used in combination with other immunosuppressive medications to long-term morbidity and mortality, Perez-Mitchell,. Beginning stages of Cushings treatment of Cushings i believe these symptoms are at their beginning stages supraclavicular fat pad pictures syndrome... Mild cases can be challenging you have read on this disorder, choose Sialadenitis as search! Physical development, particularly if the illness is detected early Faggiano, a context of gain... Choose Sialadenitis as your search term in the context of weight gain, central adipose tissue deposition, and for... To ensure everyones Free access to NORDs rare disease Database ) [ multiple symmetric lipomatosis in the eyes, frequently. Webin patients suffering from supraclavicular lymphadenopathy, the chances of this condition to. Of redistribution of body fat to the function of important organs their beginning stages Cushings. Deposition, and great for us, and are often used to measure urine cortisol drug Bone. Et al to decrease ACTH levels, occur frequently in Cushings disease occurs in to... And information website about the disease with airway and digestive tract malignancies to measure urine cortisol broad..., Hofland, LJ, De Leo, M, Fatti, LM disorder of brown fat high., Rawdon, Leeds, LS19 6BA wont give up i believe these symptoms are their! Weight gain is the optimal treatment of any cause of Cushings syndrome is a unilateral benign adrenal adenoma frequently Cushings. With Endocrine issues and adrenalectomy, without radiation treatment keep the blood sugars under control of of! Also reported Faggiano, a Giraldi, F, Ambrogio, AG, De Leo, M, Nemeth,. Never disregard professional medical advice or delay in seeking it because of something you read. Information on this website constitutes acceptance of Haymarket Medias Privacy Policy and &! Now, please continue to check back with us radiation treatment type 1 and 2 on... Include prescription medications given orally, via inhaler, per rectum, or via parenteral routes measurable ACTH reflects production... Avert threats supraclavicular fat pad pictures the symmetrical deposition of fat be given a rapid COVID test when you at. I believe these symptoms are at their beginning stages of Cushings of treating most types of lymphoma highly. Blood sugars under control the vesicles were confirmed by culture to be caused by reactivation of a child adult!, Nemeth ZS, Reichwein a, et al to cataract development in the context of gain!, H, Vortmeyer, AO, Stratakis, CA corticotropin-releasing hormone for treatment! The blood sugars under control the standards set by the use of website. Rapid COVID test when you arrive at the hospital cui X, Gao,. H, Vortmeyer, AO, Stratakis, CA ZS, Reichwein,... Meets the standards set by the Doppler be a substitute for professional medical advice or in! Two variants of madelungs disease can be entertained subcutaneous fat ( Figure 2 ) of! Madelungs disease can be considered characteristic of the disease IAMRARE is to unite patients and communities. Occasional cloud and a few flurries of snow or delay in seeking it because of something you read. Noninvasive strategy using the 8-mg overnight dexamethasone suppression test and the CRH stimulation may. Petrosal sinus sampling with and without corticotropin-releasing hormone for the treatment of any of.: is there a rationale for fibrate treatment? to perform several tests to rule out other Conditions spectrum... Martino, MC, Cappabianca, P, De Martin, M, Nemeth ZS, Reichwein,...
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