SURGERY 3rd YEAR 11th Feb 2012

1. Which of the following is/are associated with metabolic acidosis? A. Uncontrolled diabetes mellitus B. Marked hyperthyroidism C. Acute renal failure D. Prolonged vomiting due to pyloric stenosis E. End-stage emphysema Answers: A. TRUE- diabetes ketoacidosis may develop. (Manipal Manual of Surgery 3 rd Edition page 160) B. TRUE type google: hyperthyroidism + metabolic acidosis (www.apsf.com.au/crisis_management/metabolic_disturbances.htm) C. TRUE/FALSE- renal failure occasionally cause ME (Wikipedia) D. TRUE- hypochloremic alkalosis will develop. (Manipal Manual of Surgery 3rd Edition page 415) E. FALSE- emphysema cause respiratory acidosis (Wikipedia.org/wiki/acidosis)

2. Which of the following statement is/are true in gallstone disease? A. 50%-70& of gallstones can be visualized on plain radiography. B. Oral cholecystography is the most sensitive and specific investigation for the presence of gallstones. C. CT scan is more reliable than ultrasound for gallstones. D. A CT can reliably diagnose gallstone pancreatitis in a patient with abdominal pain. E. MRCP will evaluate the bile duct well even if USG fails to visualize it. Answers: A. FALSE- 10% only. (Manipal Manual of Surgery 3rd Edition page 472) B. FALSE- USG is accurate. (Bailey & Loves 25th Edition page 1121) C. FALSE- USG is the choice. (Bailey & Loves 25th Edition page 1121)

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D. TRUE- gold standard investigation in acute pancreatitis (Bailey & Loves 25th Edition page 1140) E. TRUE- (Manipal Manual of Surgery 3rd Edition page 482)

3. A femoral hernia: A. Is commoner in females than males. B. Emerges below and lateral to the pubic tubercles. C. Is related on its medial side to the lacunar ligament and laterally to the femoral vein. D. Has a significantly higher rate of complications than an inguinal hernia. E. Cured by Bassinis operation. Answers: A. TRUE- most common in males AND females- inguinal but femoral is commoner in females. (S. Das 7th Edition page 445) B. TRUE- (S. Das 7th Edition page 445) C. TRUE- (S. Das 7th Edition page 445) D. TRUE- narrow opening. (S. Das 7th Edition page 445) E. FALSE- Lockwood operation. (Manipal Manual of Surgery 3rd Edition page 692)

4. Which of the following is/are known to cause small bowel obstruction? A. Crohns disease. B. Foramen of Bochdalek C. Gallstones

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D. Ladds band E. Ligament of Treitz Answers: A. TRUE- cause string of Kator& stricture obstruction. (Manipal Manual of Surgery 3rd Edition page 565/ Bailey & Loves 25th edition page 1190) B. TRUE- cause internal herniation (wikipedia) C. TRUE- (Bailey & Loves 25th edition page 1190) D. TRUE- Wikipedia E. FALSE- an anatomical landmark (surgical anatomy Lee McGregor)

5. Which of the following increases the risks of peptic ulcer and perforation?

A. Smoking. B. NSAIDs C. Steroids D. Anticoagulants E. Diuretics Answers: A. TRUE- key box 23.6 (Manipal Manual of Surgery 3rd Edition page 398) B. TRUE- key box 23.6 (Manipal Manual of Surgery 3rd Edition page 398) C. TRUE- steroid causes gastritis increase chances PU (Tara V. Shanbag Pharmacology 329)

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D. FALSE- may cause bleeding from gastrointestinal tract PU (Tara V. Shanbag Pharmacology 278) E. TRUE- spironolactone may cause PU PU (Tara V. Shanbag Pharmacology150)

6. In a patient who complains of vomiting, one can draw the following conclusions: A. Vomiting of coffee-grounds indicates bleeding. B. Faeculent vomiting occurs in long standing intestinal obstruction. C. Old food in the vomit indicates pyloric stenosis. D. Projectile vomiting is characteristic of esophageal cancer. E. Bile in the vomit indicates first part duodenal obstruction. Answers: A. TRUE- hemoglobin hematin by acids. (S. Das 7th Edition page 12) B. TRUE- (S. Das 7th Edition page 12) C. TRUE- food 2-3 days back may come out (S. Das 7th Edition page 12) D. FALSE- projectile vomits intracranial tumor/lesions (S. Das 7th Edition page 12) E. TRUE- (S. Das 7th Edition page 339)

7. A 45 years-old male present with pain in the right gluteal region. On examination you find swelling, tenderness, and crepitus. Which of the following is/are true?

A. Gas in the subcutaneous tissues is also known as surgical emphysema. B. Das in the tissues usually shows up in plain X-ray.

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C. Clostridium Botulinitypically causes gas producing tissue infection. D. Anaerobic staphylococci are also common causes of gas producing necrotizing fasciitis. E. Early cases of gas gangrene also need surgery and cannot be successfully treated medically. Answers: A. TRUE- (S. Das 7th Edition page 300) B. FALSE- minimal gas wouldnt show. C. FALSE- C. botulini is BOTOX, C. Welchii is the culprit. (Manipal Manual of Surgery 3rd Edition page 27) D. FALSE- anaerobic Streptococci, NOT staphylococci. (Manipal Manual of Surgery 3rd Edition page 18) E. TRUE- (Manipal Manual of Surgery 3rd Edition page 29)

8. 55 year old woman present with a 4cm ulcer near the left medial malleolus. The ulcer has been there long but now is growing rapidly. The edges are rolled, not everted, and the base is firm. No regional nodes are palpable. Squamous cell carcinoma is the most likely diagnosis because: A. Are commoner in the leg than BCCs. B. Have rolled edges, while BCCs have everted edges. C. Are faster growing than BCCs. D. Do not spread to nodes, while BCCs do. E. More likely to develop from chronic venous ulcer than BCCs. Answers: A. TRUE- BCCs common in the face. (S. Das 7th Edition page 46) B. FALSE- BCCs have raised pearly beaded edge. (S. Das 7 th Edition page 47) C. TRUE- (S. Das 7th Edition page 47) D. FALSE- Epithelioma (S. Das 7th Edition page 53) E. TRUE- Marjolins Ulcer. (S. Das 7th Edition page 53)

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9. A physician calls to say that he is sending you a 45-year-old woman with a palpable neck mass and obvious thyrotoxicosis. His diagnosis is toxic adenoma of the thyroid. You expect to receive a patient who A. Has tachycardia. B. Complains of constipation. C. Has single thyroid nodule with diffuse enlargement of the remaining gland. D. Has elevated T3, T4, and TSH. E. The mass will be malignant on FNAC or true-cut biopsy. Answer A. True In thyrotoxicosis pulse rate is always raised and rapid indicating tachycardia (Manipal Manual of Surgery, page 290) B. False Constipation is not a feature of thyrotoxicosis C. True Adenoma presents clinically solitary nodules (Bailey & love, page 792) D. False In thyrotoxicosis, T3 and T4 will be high but the TSH will be low. (Manipal Manual of Surgery, page 292) E. False FNAC cannot differentiate follicular adenoma (benign) and follicular carcinoma (malignant). Only histological examination through true-cut biopsy can distinguish these two condition. (Manipal Manual of Surgery, page 294) 10. Which of the following cancers is/are known to be linked to a viral infection? A. Burkitts lymphoma B. Nasopharyngeal carcinoma C. Hepatoma D. Carcinoma of the cervix E. Bronchogenic carcinoma

Answer A. True It is caused by EBV which multiplies in presence of heavy malarial infestation. (Manipal Manual of Surgery, page 101)

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B. True One of the aetiology of nasopharyngeal carcinoma is early infection by the EBV. ( Bailey & Love, page 709) C. True Hepatoma is usually associate with hepatitis b virus (HBV) and hepatitis c virus (HBC). (Bailey & Love, page 1099) D. True One of the aetiology is HPV infection (Textbook of gynaecology, DC Dutta, page 311) E. False Bronchogenic carcinoma has no association with viral infection. It is associated with smoking (Davidson, page 698)

11. In which of the following causes of shock is the intravascular fluid volume likely to be normal? A. Shock following prolonged intestinal obstruction B. Shock following a large burn. C. Shock following spinal anesthesia. D. Shock following penicillin injection. E. Shock in a patient with an enteric fistula

Answer A. False Prolonged intestinal obstruction can lead to hypovolaemic shock due to chronic vomiting. So intravascular volume is disturbed (Textbook of Surgery, S.Das, page 11) B. False Burn can cause hypovolaemia due to rapid loss of plasma from damaged tissue. (Textbook of Surgery, S.Das, page 11) C. True Spinal anesthesia cause blockade of sympathetic nervous system resulting in loss of arterial and venous tone with the pooling of blood in the dilated peripheral venous system. Intravascular fluid volume is not disturbed. (Textbook of Surgery, S.Das, page 11,12) D. True Anaphylactic shock is caused by bronchospasm, laryngeal oedema, and respiratory distress which lead to hypoxia. No fluid depletion in anaphylactic shock. (Textbook of Surgery, S.Das, page,12) E. False Common fluid and electrolyte problems seen in patients with GI fistula include hypokalemia, dehydration, hyponatremia, and metabolic acidosis. (Manipal Manual of Surgery, page 574)

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12. A 65 years old man, chronic smoker presents with painless, hard and fixed enlarged lymph glands in the neck. The most possible diagnosis is: A. Non Hodgkins lymphoma B. Infectious mononucleosis C. Sarcoidosis D. Metastatic lymph node E. Neurofibroma

Answer A. True NHL can presents with painless, hard and fixed cervical lymphadenopathy (Textbook of Surgery, S.Das, page 906) B. False The enlarged nodes in infectious mononucleosis are usually painful and tender. (Textbook of Surgery, S.Das, page 298) C. True Enlarged nodes show no tenderness or periadenitis (Textbook of Surgery, S.Das, page 299) D. True Painless swelling with hard consistency is the usual presentation of metastatic lymph node. (Textbook of Surgery, S.Das, page 308) E. False The swellings may be painful and it is mobile (Textbook of Surgery, S.Das, page 122,123)

13. Keloid scars. A. Is an excessive amount of fibrous tissue but confined to the scar B. Are common in Negroes C. Spontaneously regressed after 2 to 3 months of initial injury D. Often tender to touch E. Do not recur after they have been excised Answer A. False In keloid the normal surrounding tissue is affected by the spread of fibrosis. (Textbook of Surgery, S.Das, page 152) B. True Negroes are commonly affected (Textbook of Surgery, S.Das, page 152)

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C. False Keloid continues to get worse even after a year (Textbook of Surgery, S.Das, page 152) D. True It is often tender to touch and always itch (Textbook of Surgery, S.Das, page 152) E. False The most characteristic feature of a keloid is that it recurs even when it is excised. (Textbook of Surgery, S.Das, page 152)

14. Hypovolaemic shock is associated with: A. High cardiac output B. Low venous pressure C. High vascular resistance D. High base deficit E. High mixed venous saturation Answer A. False low cardiac output (Bailey and Loves, page 14) B. True low venous pressure (Bailey and Loves, page 14) C. True high vascular resistance (Bailey and Loves, page 14) D. True high base deficit (Bailey and Loves, page 14) E. False low mixed venous saturation (Bailey and Loves, page 14

15. Reactionary haemorrhage: A. Is a delayed haemorrhage occurring within 24 hours after operation B. Is associated with infection C. Is usually venous

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D. Can be significant, requiring re-exploration or E. Is usually caused by dislodgement of clot, normalization of blood pressure slippage of ligature

Answer A. True Reactionary haemorrhage occurs within 24 hours of injury. Majority of cases occur within 4-6 hours. (Textbook of Surgery, S.Das, page 42) B. False It is not associated with infection. Secondary haemorrhage is associated with infection. (Bailey and Loves, page 19) C. False It is usually arterial (MCQs & EMQs in Surgery, Bailey & Love Companion guide, page 9,13, question 10) D. True It may needs re-exploration depending on the situation (MCQs & EMQs in Surgery, Bailey & Love Companion guide, page 9,13, question 10) E. True It is usually caused by dislodgement of clot, normalization of blood pressure and slippage of ligature. (Bailey and Loves, page 19)

16. Complications of massive blood transfusion include: A. Hyperthermia B. Hypocalcemia C. Hypokalemia D. Coagulopathy E. Iron overload Answer A. False It should be hypothermia (Bailey and Loves, page 22) B. True hypocalcemia (Bailey and Loves, page 22) C. True patient can have both hypokalemia and hyperkalemia (Bailey and Loves, page 22) D. True coagulopathy (Bailey and Loves, page 22) E. True iron overload (Bailey and Loves, page 22)

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17. Factors influence wound healing include A. Smoking B. Malnutrition C. Site of wound D. Vascular insufficiency E. Steroid therapy

Answer A. True. Factors includes smoking,malnutrition, site of wound, vascular insufficiency, steroid therapy and immunity status. (Bailey and Love, 24th Edition, page 24) True. Factors includes smoking,malnutrition, site of wound, vascular insufficiency, steroid therapy and immunity status. (Bailey and Love, 24th Edition, page 24) True. Factors includes smoking,malnutrition, site of wound, vascular insufficiency, steroid therapy and immunity status. (Bailey and Love, 24th Edition, page 24) True. Factors includes smoking,malnutrition, site of wound, vascular insufficiency, steroid therapy and immunity status. (Bailey and Love, 24th Edition, page 24) True. Factors includes smoking,malnutrition, site of wound, vascular insufficiency, steroid therapy and immunity status. (Bailey and Love, 24th Edition, page 24)

B.

C.

D.

E.

18. During the process of wound healing A. The inflammatory phase begins 2-3 days after injury B. The proliferative phase last from 3 days to 3 weeks following the injury C. The remodelling phase involves fibroblast activity and production of collagen and ground substance D. Fibroblast requires vitamin C to produce collagen

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E. The white cells stick to the damaged endothelium and release adenosine diphosphate (ADP) and cytokines.

Answer

A. False (Inflammatory response begins immediately after wounding and last 2-3 days. Bailey and Love, 24th Edition, page 25) B. True. The proliferative phase starts from 3 days to 3 weeks following the injury (Bailey and Love, 24th Edition, page 25) C. False (Remodelling phase involve maturation of collagen. Bailey and Love, 24th Edition, page 25) D. True. vitamin C is required to produce collagen (Bailey and Love, 24th Edition, page 25) E. False (The platelets stick to the damaged endothelium and release adenosine diphosphate (ADP) and cytokines. (Bailey and Love, 24 th Edition, page 25)

19. With regards to intravenous fluid 0.9 per cent normal saline, the following statements explain the characters A. Has the same sodium concentration as plasma B. Has equi-molar concentration of sodium and chloride C. Is low in potassium D. Is dextrose free fluid E. Is the best fluid to be used in hypovolemia

Answer A. False (Sodium conc. in NS: 154. Normal plasma sodium level: 135-145, (Bailey and Love, 24th Edition, page 226) B. True . Both 154. (Bailey and Love, 24th Edition, page 226) C. False No potassium at all. (Bailey and Love, 24th Edition, page 226) D. True Except for: DNS. (Bailey and Love, 24th Edition, page 226) E. False Colloids are better to be used in hypovolemia. (Bailey and Love, 24th Edition, page 226)

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20. In the first post-operative day, acute shortness of breath is resulted from A. Atelectasis B. Pulmonary embolism C. Myocardial infarction D. Chest infection E. Pneumothorax

Answer
A. True Early post-op complications includes atelectasis, pulmonary

embolism, myocardial infarction and pneumothorax (http://www.patient.co.uk/doctor/common-postoperative-complications)

B. True Early post-op complications includes atelectasis, pulmonary

embolism, myocardial infarction and pneumothorax (http://www.patient.co.uk/doctor/common-postoperative-complications)

C. True Early post-op complications includes atelectasis, pulmonary

embolism, myocardial infarction and pneumothorax (http://www.patient.co.uk/doctor/common-postoperative-complications)

D. False (3-5th day. http://www.patient.co.uk/doctor/common-postoperativecomplications) E. False pneumonia. http://www.patient.co.uk/doctor/commonpostoperative-complications)

21. The following statements are true with regard to deep vein thrombosis A. Obese patient are more prone to DVT B. Clinical diagnosis is very obvious

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C. Long surgical procedure is high risk D. Conformation is by venography and for Duplex Doppler Ultrasound (US) E. Optimum hydration is essential to prevent DVT

Answer A. True Obesity is one of the risk factor of DVT, apart from prolonged bed rest. (Bailey and Love 24th Edition, page 936) B. False (Many patients have no symptoms of thrombosis and may first present with signs of pulmonary embolism e.g pleuritic chest pain, hemoptysis and shortness of breath. Bailey and Love 24 th Edition, page 937) C. False (Prolong bedrest is high risk for DVT. Bailey and Love 24 th Edition, page 937) D. True Conformative investigation for DVT are Duplex Doppler and venography(Bailey and Love 24th Edition, page 937) E. False (Compression stockings, external pneumatic compression, low molecular weight heparin is essential to prevent DVT. Bailey and Love 24th Edition, page 938)

22. With regard to Glasgow Coma Scale(GSC) in head trauma A. The maximum score is 15 B. The minimum score is 0 C. A GCS of 10 means the patient is in coma D. Eye opening to command/ speech is scored 2 E. A GCS of 6 means the patient is in coma

Answer A. True (Bailey and Love 24th Edition, page 301) B. False (Minimum score is 3. Bailey and Love 24th Edition, page 301) C. False (GCS of 10 indicates patient is having moderate head injury, coma is unlikely. Bailey and Love 24th Edition, page 300) D. False (Eye opening to command is scored 3. Bailey and Love 24 th Edition, page 301)

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E. True (GCS of 6 indicates patient is having severe head injury, coma is likely. Bailey and Love 24th Edition, page 300)

23. The following statements are related to Compartment syndrome A. Loss of distal pulses and sensation are its manifestations B. Is a clinical diagnosis C. Produces pain out of proportion of injury D. Is associated with closed fracture E. Inferior vena cava is the first organ to be affected in abdominal compartment syndrome

Answer A. False (Peripheral pulse are not affected, aleration in sensation is a late sign. Bailey and Love 24th Edition, page 355) B. True Compartment syndrome can be diagnosed from the history and examination itself(Bailey and Love 24th Edition, page 355) C. True Increase in tension of the affected site exaggerate the level of pain in a patient with compartment syndrome(Bailey and Love 24 th Edition, page 355) D. False (The nature of the fracture is not a good guide to development of the syndrome. It can occur in low energy or high energy injuries, closed or open. Bailey and Love 24th Edition, page 355) E. False (Compartment syndrome only occurs wherever there is a closed compartment. Bailey and Love 24th Edition, page 355)

24. What is/are the ABSOLUTE indication for dialysis: A.volume overload B.acidosis

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C.electrolyte abnormality D.BUN >100mg/dL in patient with ARF E.need for multiple transfusion

Answer A.True, volume overload is an absolute indication B.True, acidosis is an absolute indication C.True, electrolyte abnormality is an absolute indication D.False,BUN >100mg/dL in patient with ARF is a relative indication E.False,need for multiple transfusion is a relative indication *table 2.12(Schwartz's Principles of Surgery,page 73)

25. About hyperkalemia: A.untreated hyperkalemia leads to cardiac arrest B.when ECG changes are apparent,calcium infusion with 1-2g,10% calcium gluconate given over 10-15 minutes to neutralise toxic effect C.ACEI and NSAID wont increase blood potassium level D.ketoacidosis causes potassium shift E.rhabdomyolysis causes hyperkalemia

Answer A.True,untreated hyperkalemia leads to cardiac arrest B.True,when ECG changes are apparent,calcium infusion with 1-2g,10% calcium gluconate given over 10-15 minutes to neutralise toxic effect C.False,ACEI and NSAID wont increase blood potassium level D.True,ketoacidosis causes potassium shift E.True,rhabdomyolysis causes hyperkalemia *Fluid & electrolyte management(Schwartz's Principles of Surgery,page 73)

26.Regarding anorectal abscess: A.seen in all ages

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B.less common compared to ischiorectal abscess C.particularly seen in Crohns D. The abscess typically forms in the intersphincteric space and can spread along various potential spaces. E. Common organisms implicated in abscess formation include Escherichia coli, Enterococcus species, and Bacteroides species Answer A.True,seen in all ages(http://www.webmd.com/a-to-z-guides/anal-abscess) B.False,less common compared to ischiorectal abscess (http://www.webmd.com/ato-z-guides/anal-abscess) C.True,particularly seen in Crohns (http://www.webmd.com/a-to-z-guides/analabscess) D. True,The abscess typically forms in the intersphincteric space and can spread along various potential spaces.( http://emedicine.medscape.com/article/191975overview#a0104) E. True,Common organisms implicated in abscess formation include Escherichia coli, Enterococcus species, and Bacteroides species.( http://emedicine.medscape.com/article/191975-overview#a0104)

27.Regarding post surgical infection: A.benzylpenicillin proved to be effective against most gram positive pathogens B.strep.pyogenes and strep.faecalis maybe involved after large bowel surgery C.spreading infections & signs of systemic infections justifies use of antibiotics D.infection rate in contaminated wound(open viscous with spillage) is 15-20% E.cellulitis and abscess most present within the first week. Answer A.True,benzylpenicillin proved to be effective against most gram positive pathogens B.True,strep.pyogenes and strep.faecalis maybe involved after large bowel surgery C.True,spreading infections & signs of systemic infections justifies use of antibiotics D.,True,infection rate in contaminated wound(open viscous with spillage) is 15-20% E.True,cellulitis and abscess most present within the first week but can be seen as late as the third postoperative week, even after leaving hospital *Bailey & Love E26,page 62

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(http://books.google.co.in/books? id=VpF88Tzt8_4C&printsec=frontcover#v=onepage&q&f=false)

28.Regarding blood transfusion: A.fresh frozen plasma has a shelf life of 2 years B.patients on clopidogrel and actively bleeding should not be given platelet transfusion C.packed red cell are stored in SAG-M solution D.febrile transfusion caused by graft vs. Host response from leucocytes in transfused components E.prothrombin complex concentrates contain Factor II,XI and XII Answer A.True,fresh frozen plasma has a shelf life of 2 years B.False,patients on clopidogrel and actively bleeding & undergoing major surgery should be given platelet transfusion continuously C.True,packed red cell are stored in SAG-M solution D.True,febrile transfusion caused by graft vs. host response from leucocytes in transfused components E.False,prothrombin complex concentrates contain Factor II,XI and X *Bailey & Love E26,page 21(http://books.google.co.in/books? id=VpF88Tzt8_4C&printsec=frontcover#v=onepage&q&f=false)

29.Regarding respiratory acidosis: A.there is retention of CO2 B.due to depression of respiratory center C.based on Henderson-Hesselbalch equation the denominator ratio is less than 20:1 D.compensation is by increase in rate and depth of breathing E.chloride shift into red blood cells

Answer A.True,there is retention of CO2(Schwartz Principles of Surgery page 60)

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B.True,its due to depression of respiratory center or pulmonary disease(http://www.themastersurgeon.com/tutorials/tutorials_view.aspx? TutorialNUM=3) C.True,based on Henderson-Hesselbalch equation the denominator ratio is less than 20:1 (Schwartz Principles of Surgery page 60) D.False,compensation is by retention of bicarbonate & increased ammonia formation *Schwartz Principles of Surgery page 60 E.True,chloride shift into red blood cells(http://www.themastersurgeon.com/tutorials/tutorials_view.aspx? TutorialNUM=3)

30.Regarding peritonitis: A. Digestive diseases such as Crohn's disease and diverticulitis are causes of secondary peritonitis B. Pyelonephritis,sclerosing peritonitis and splenosis are some of the differential diagnosis C. The single best predictor of spontaneous bacterial peritonitis is an ascitic fluid neutrophil count of greater than 500 cells/L D. a combination of an aminoglycoside and ampicillin are used to treat acute peritonitis E. Ultrasonography may detect increased amounts of peritoneal fluid (ascites), and it can detect quantities of less than 100 mL Answer A. True,Digestive diseases such as Crohn's disease and diverticulitis are causes of secondary peritonitis(http://www.webmd.com/digestive-disorders/peritonitissymptoms-causes-treatments) B. True,Pyelonephritis,sclerosing peritonitis and splenosis are some of the differential diagnosis(http://www.webmd.com/digestive-disorders/peritonitissymptoms-causes-treatments) C. True,The single best predictor of spontaneous bacterial peritonitis is an ascitic fluid neutrophil count of greater than 500 cells/L(http://www.webmd.com/digestivedisorders/peritonitis-symptoms-causes-treatments) D. True,a combination of an aminoglycoside and ampicillin are used to treat acute peritonitis(http://emedicine.medscape.com/article/180234-workup#aw2aab6b5b8) E. False,Ultrasonography may detect increased amounts of peritoneal fluid (ascites), but its ability to detect quantities of less than 100 mL is limited (http://emedicine.medscape.com/article/180234-workup#aw2aab6b5b8)

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