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[[Image:Rembrandt Harmensz. van Rijn 007.jpg|thumb|300px|An autopsy.]] | |||
'''Autopsy''' was once a mainstay of [[pathology]]. It is now in decline and uncommonly done. Fetal autopsy is dealt with in a separate article called ''[[fetal autopsy]]''. | '''Autopsy''' was once a mainstay of [[pathology]]. It is now in decline and uncommonly done. Fetal autopsy is dealt with in a separate article called ''[[fetal autopsy]]''. | ||
==Autopsy checklist | =Value of autopsy= | ||
===Minimum to proceed=== | A significant number of major findings cannot be diagnosed without histology;<ref name=pmid16324191>{{Cite journal | last1 = Roulson | first1 = J. | last2 = Benbow | first2 = EW. | last3 = Hasleton | first3 = PS. | title = Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology; a meta-analysis and review. | journal = Histopathology | volume = 47 | issue = 6 | pages = 551-9 | month = Dec | year = 2005 | doi = 10.1111/j.1365-2559.2005.02243.x | PMID = 16324191 }}</ref> thus, without a biopsy or an autopsy they cannot be diagnosed. Autopsies can be regarded as a form of [[quality control]]. | ||
One large review in ''JAMA'' suggests that approximately:<ref name=pmid12783916>{{cite journal |author=Brian Gallagher, Burton EC, McDonald KM, Goldman L |title=Changes in rates of autopsy-detected diagnostic errors over time: a systematic review |journal=JAMA |volume=289 |issue=21 |pages=2849–56 |year=2003 |pmid=12783916 |doi=10.1001/jama.289.21.2849}}</ref> | |||
* 25% of autopsies reveal a finding that would have changed clinical management. | |||
* 5% of autopsies reveal a missed [[diagnosis]] that probably affected the outcome. | |||
=Autopsy checklist= | |||
===Minimum to proceed - hospital autopsy=== | |||
*Death certificate complete. | *Death certificate complete. | ||
**Cause of death as per death certificate. | **Cause of death as per death certificate. | ||
| Line 30: | Line 38: | ||
**Expected versus unexpected. | **Expected versus unexpected. | ||
=Autopsy consent= | |||
===General=== | ===General=== | ||
*In a hospital autopsy the ''most important'' thing is: ''proper consent''. | *In a hospital autopsy the ''most important'' thing is: ''proper consent''. | ||
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===Who has authority?=== | ===Who has authority?=== | ||
*Consent should be given by the '' | *Consent should be given by the ''executor of the estate''.<ref name=olduhnconsent>URL: [http://www.docstoc.com/docs/51609856/CONSENT-FOR-AUTOPSY http://www.docstoc.com/docs/51609856/CONSENT-FOR-AUTOPSY]. Accessed on: 27 September 2010.</ref> | ||
====Hierarchy==== | ====Hierarchy==== | ||
If the '' | If the ''executor of the estate'' is not specified the hierarchy is as follows:<ref name=olduhnconsent/> | ||
#Spouse - by marriage (same sex ''or'' opposite sex) ''or'' by common-law ''or'' by together the parents of a child ''or'' by cohabitation agreement (in law). | #Spouse - by marriage (same sex ''or'' opposite sex) ''or'' by common-law ''or'' by together the parents of a child ''or'' by cohabitation agreement (in law). | ||
#If no spouse, any children 16+ years old, | #If no spouse, any children 16+ years old, | ||
| Line 55: | Line 56: | ||
Notes: | Notes: | ||
*The power a person that is designated as ''power of attorney for health care decisions'' does not have the authority to consent for an autopsy; their power ends with death (unless they are also the '' | *Exact hierarchy may vary by jurisdiction. | ||
*The power a person that is designated as ''power of attorney for health care decisions'' does not have the authority to consent for an autopsy; their power ends with death (unless they are also the ''executor of the estate''). | |||
*In clinical medicine, it is allowable to skip down the hierarchy if ''the'' "consent giver" is not reachable, e.g. if a child of the patient is present they can consent in emergency circumstances, if the spouse is ''not'' reachable. In the context of (non-corner's) autopsies, '''the hierarchy has to be followed strictly''', as there is no such thing as an "emergency autopsy"; it is ''not'' acceptable to ask the child of the decedent 'cause they aren't distraught like the spouse of the decedent. | *In clinical medicine, it is allowable to skip down the hierarchy if ''the'' "consent giver" is not reachable, e.g. if a child of the patient is present they can consent in emergency circumstances, if the spouse is ''not'' reachable. In the context of (non-corner's) autopsies, '''the hierarchy has to be followed strictly''', as there is no such thing as an "emergency autopsy"; it is ''not'' acceptable to ask the child of the decedent 'cause they aren't distraught like the spouse of the decedent. | ||
*In non-corner's cases, a physician ''cannot'' consent an autopsy. | *In non-corner's cases/non-medical examiner's cases, a physician ''cannot'' give consent for an autopsy. | ||
===Religious objections=== | ===Religious objections=== | ||
| Line 85: | Line 87: | ||
|} | |} | ||
=External exam= | |||
===General=== | ===General=== | ||
*Very important in the forensic context. | *Very important in the forensic context. | ||
| Line 94: | Line 96: | ||
Body should be examined for ''defensive-type wounds'': | Body should be examined for ''defensive-type wounds'': | ||
*Between the | *Between the fingers - especially thumb and pointing finger. | ||
*Dorsal aspect of the hand. | *Dorsal aspect of the hand. | ||
*Forearm. | *Forearm. | ||
| Line 101: | Line 103: | ||
*External exam findings are found in the ''[[forensic pathology]]'' article. | *External exam findings are found in the ''[[forensic pathology]]'' article. | ||
=Internal exam= | |||
===General=== | ===General=== | ||
*This is usually where the money is in hospital autopsies. | *This is usually where the money is in hospital autopsies. | ||
| Line 107: | Line 109: | ||
===Before the first incision=== | ===Before the first incision=== | ||
If there is suspicion of pneumothorax - one the the three following can be done:<ref name=Ref_HospAuto120-1>{{Ref HospAuto|120-1}}</ref> | If there is suspicion of [[pneumothorax]] - one the the three following can be done:<ref name=Ref_HospAuto120-1>{{Ref HospAuto|120-1}}</ref> | ||
#Create a "pleural window" (between ribs by removing soft tissue... without entering the pleural cavity). | #Create a "pleural window" (between ribs by removing soft tissue... without entering the pleural cavity). | ||
#Open chest underwater and watch for air bubbles. | #Open chest underwater and watch for air bubbles. | ||
| Line 118: | Line 120: | ||
*Y-shaped incision (standard): | *Y-shaped incision (standard): | ||
**Superior "points" of the Y ~ at the deltoid muscle. | **Superior "points" of the Y ~ at the deltoid muscle. | ||
**" | **"Confluence of lines" in the Y ~ inferior to the suprasternal notch. | ||
*Neck dissection incisions: | *Neck dissection incisions: | ||
**Deltoid to mastoid process. | **Deltoid to mastoid process. | ||
| Line 128: | Line 130: | ||
Notes: | Notes: | ||
*The | *The sternum may have cleft or foramen - as an anatomical variant.<ref name=pmid10803333>{{cite journal |author=Fokin AA |title=Cleft sternum and sternal foramen |journal=Chest Surg. Clin. N. Am. |volume=10 |issue=2 |pages=261–76 |year=2000 |month=May |pmid=10803333 |doi= |url=}}</ref> | ||
*If the decedent has a history of a [[CABG]] removal of the chest plate should be done with care to preserve the grafts. | *If the decedent has a history of a [[CABG]] removal of the chest plate should be done with care to preserve the grafts. | ||
| Line 184: | Line 186: | ||
==Neck organ pluck== | ==Neck organ pluck== | ||
===Non-suspicious cases=== | |||
#Trim tissue posterior to horns of the thyroid. | #Trim tissue posterior to horns of the thyroid. | ||
#Cut between thyroid horns & hyoid. | #Cut between thyroid horns & hyoid. | ||
#Cut off base of tongue. | #Cut off base of tongue. | ||
===Suspicious cases=== | |||
*In Canada, it is convention to do ''layered neck dissection''. | |||
**The strap muscles of the neck are lifted of in layers to look for injuries (mostly contusions). | |||
**Strap muscle hematomas may arise in a number of contexts, e.g. they are reported in drowning.<ref>{{Cite journal | last1 = Püschel | first1 = K. | last2 = Schulz | first2 = F. | last3 = Darrmann | first3 = I. | last4 = Tsokos | first4 = M. | title = Macromorphology and histology of intramuscular hemorrhages in cases of drowning. | journal = Int J Legal Med | volume = 112 | issue = 2 | pages = 101-6 | month = | year = 1999 | doi = | PMID = 10048667 }}</ref> | |||
====Hyoid bone==== | ====Hyoid bone==== | ||
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#*Check renal veins. | #*Check renal veins. | ||
#Separate IVC. | #Separate IVC. | ||
#Transect esophagus (~2 cm) distal to inferior margin of the cricoid cartilage. | #Transect [[esophagus]] (~2 cm) distal to inferior margin of the cricoid cartilage. | ||
#Take down esophagus using blunt dissection (to separate from thorax). | #Take down esophagus using blunt dissection (to separate from thorax). | ||
#Separate thorax and abdomen - by dissecting through the pericardium. | #Separate thorax and abdomen - by dissecting through the [[pericardium]]. | ||
===Common finding(s)=== | ===Common finding(s)=== | ||
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===Respiratory system=== | ===Respiratory system=== | ||
#Open trachea + bronchus (see ''Note''). | #Open [[trachea]] + bronchus (see ''Note''). | ||
#Examine proximal airway. | #Examine proximal airway. | ||
#Examine proximal pulmonary arteries. | #Examine proximal pulmonary arteries. | ||
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{{main|Adrenal gland}} | {{main|Adrenal gland}} | ||
*[[Adrenal cortical adenoma|Cortical adenoma]]s - seen in ~ 2% of autopsies.<ref name=pmid14514341>{{cite journal |author=Barzon L, Sonino N, Fallo F, Palu G, Boscaro M |title=Prevalence and natural history of adrenal incidentalomas |journal=Eur. J. Endocrinol. |volume=149 |issue=4 |pages=273–85 |year=2003 |month=October |pmid=14514341 |doi= |url=}}</ref> | *[[Adrenal cortical adenoma|Cortical adenoma]]s - seen in ~ 2% of autopsies.<ref name=pmid14514341>{{cite journal |author=Barzon L, Sonino N, Fallo F, Palu G, Boscaro M |title=Prevalence and natural history of adrenal incidentalomas |journal=Eur. J. Endocrinol. |volume=149 |issue=4 |pages=273–85 |year=2003 |month=October |pmid=14514341 |doi= |url=}}</ref> | ||
=====Others===== | =====Others===== | ||
*Atrophy - typically iatrogenic, may be [[Addison's disease]]. | *Atrophy - typically iatrogenic, may be [[Addison's disease]]. | ||
*[[Adrenal cortical hyperplasia|Hyperplasia]] (bilateral). | *[[Adrenal cortical hyperplasia|Hyperplasia]] (bilateral). | ||
*Hemorrhage ([[Waterhouse-Friderichsen syndrome]]). | *Hemorrhage ([[Waterhouse-Friderichsen syndrome]]). | ||
*[[Metastatic]] cancer, esp. in the context of lung cancer. | |||
*[[Adrenal myelolipoma]]. | |||
===Stomach=== | ===Stomach=== | ||
*Opened along greater curvature. | *Opened along greater curvature. | ||
**Large carcinomas preferentially involve the lesser curvature.<ref name=pmid2550682>{{Cite journal | last1 = Yamagawa | first1 = H. | last2 = Onishi | first2 = T. | title = [A clinicopathological study of early gastric cancers with a diameter larger than five centimeters]. | journal = Gan No Rinsho | volume = 35 | issue = 10 | pages = 1114-8 | month = Sep | year = 1989 | doi = | PMID = 2550682 }}</ref> | **Large carcinomas preferentially involve the lesser curvature.<ref name=pmid2550682>{{Cite journal | last1 = Yamagawa | first1 = H. | last2 = Onishi | first2 = T. | title = [A clinicopathological study of early gastric cancers with a diameter larger than five centimeters]. | journal = Gan No Rinsho | volume = 35 | issue = 10 | pages = 1114-8 | month = Sep | year = 1989 | doi = | PMID = 2550682 }}</ref> | ||
*GE junction should not be opened if portal hypertension is suspected (see: ''esophagus''). | *GE junction should not be opened if [[portal hypertension]] is suspected (see: ''esophagus''). | ||
====Findings==== | ====Findings==== | ||
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===Esophagus=== | ===Esophagus=== | ||
*Should be everted, if portal hypertension is suspected, as varices are thus more readily demonstrated.<ref name=Ref_HospAuto140>{{Ref HospAuto|140}}</ref> | {{Main|Esophagus}} | ||
*Should be everted, if [[portal hypertension]] is suspected, as [[esophageal varices]] are thus more readily demonstrated.<ref name=Ref_HospAuto140>{{Ref HospAuto|140}}</ref> | |||
*#Stomach opened (''without opening GE junction''). | *#Stomach opened (''without opening GE junction''). | ||
*#String tied to proximal esophagus. | *#String tied to proximal esophagus. | ||
*#Forceps inserted from stomach to grasp tied end and invert esophagus. | *#Forceps inserted from stomach to grasp tied end and invert [[esophagus]]. | ||
===Omentum=== | ===Omentum=== | ||
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**Capsule of the spleen is white - resembles sugar-coating. | **Capsule of the spleen is white - resembles sugar-coating. | ||
**Importance: ''none'' - benign. | **Importance: ''none'' - benign. | ||
*Splenomegaly secondary to portal hypertension. | *[[Splenomegaly]] secondary to [[portal hypertension]]. | ||
===Kidney=== | ===Kidney=== | ||
| Line 322: | Line 333: | ||
**''Flea-bitten appearance'' - seen in [[hypertension]].<ref name=pmid9356598>{{Cite journal | last1 = Ono | first1 = H. | last2 = Ono | first2 = Y. | title = Nephrosclerosis and hypertension. | journal = Med Clin North Am | volume = 81 | issue = 6 | pages = 1273-88 | month = Nov | year = 1997 | doi = | PMID = 9356598 }}</ref> | **''Flea-bitten appearance'' - seen in [[hypertension]].<ref name=pmid9356598>{{Cite journal | last1 = Ono | first1 = H. | last2 = Ono | first2 = Y. | title = Nephrosclerosis and hypertension. | journal = Med Clin North Am | volume = 81 | issue = 6 | pages = 1273-88 | month = Nov | year = 1997 | doi = | PMID = 9356598 }}</ref> | ||
*[[Acute tubular necrosis]] (ATN). | *[[Acute tubular necrosis]] (ATN). | ||
**ATN is difficult | **ATN is difficult to prove on autopsy material. | ||
** | **On microscopy, look for:<ref name=pmid19207286>{{Cite journal | last1 = Kocovski | first1 = L. | last2 = Duflou | first2 = J. | title = Can renal acute tubular necrosis be differentiated from autolysis at autopsy? | journal = J Forensic Sci | volume = 54 | issue = 2 | pages = 439-42 | month = Mar | year = 2009 | doi = 10.1111/j.1556-4029.2008.00956.x | PMID = 19207286 }}</ref> | ||
*** | ***Tubular epithelial whorls. | ||
*** | ***Tubulorrhexis. | ||
***Interstitial edema. | |||
===Liver=== | ===Liver=== | ||
| Line 459: | Line 471: | ||
***May be associated with blood vessel tortuosity.<ref>KC. 14 September 2010.</ref> | ***May be associated with blood vessel tortuosity.<ref>KC. 14 September 2010.</ref> | ||
=Histology= | |||
===General=== | ===General=== | ||
It's the at the pathologists discretion. In ''decomp'' cases it is reasonable to submit nothing. | It's the at the pathologists discretion. In ''[[decomp]]'' cases it is reasonable to submit nothing. | ||
===Forensic context=== | ===Forensic context=== | ||
| Line 582: | Line 554: | ||
*Muscle. | *Muscle. | ||
*[[Lymph nodes]]. | *[[Lymph nodes]]. | ||
=Autopsy report= | |||
==Normal size parameters== | |||
===Normal organ masses (adult)=== | |||
Caucasoid population of 684 adults:<ref name=pmid11376980>{{cite journal |author=de la Grandmaison GL, Clairand I, Durigon M |title=Organ weight in 684 adult autopsies: new tables for a Caucasoid population |journal=Forensic Sci. Int. |volume=119 |issue=2 |pages=149–54 |year=2001 |month=June |pmid=11376980 |doi= |url=}}</ref> | |||
{| class="wikitable" | |||
| | |||
|'''Men''' | |||
|'''Women''' | |||
|- | |||
|'''Heart''' | |||
|365 +/- 71 g | |||
|312 +/- 78 g | |||
|- | |||
|'''Right lung''' | |||
|663 +/- 239 g | |||
|546 +/- 207 g | |||
|- | |||
|'''Left lung''' | |||
|583 +/- 216 g | |||
|467 +/- 174 g | |||
|- | |||
|'''Liver''' | |||
|1677 +/- 396 g | |||
|1475 +/- 362 g | |||
|- | |||
|'''Spleen''' | |||
|156 +/- 87 g | |||
|140 +/- 78 g | |||
|- | |||
|'''Right kidney''' | |||
|162 +/- 39 g | |||
|135 +/- 39 g | |||
|- | |||
|'''Left kidney''' | |||
|160 +/- 41 g | |||
|136 +/- 37 g | |||
|} | |||
===Pediatrics=== | |||
{{Main|Growth charts}} | |||
==Negative autopsy== | ==Negative autopsy== | ||
| Line 598: | Line 611: | ||
*[[Sudden infant death syndrome]]. | *[[Sudden infant death syndrome]]. | ||
==See also | ==Histology checklist== | ||
{| class="wikitable sortable" | |||
! Section/organ | |||
! Expected finding(s)/common finding(s) | |||
! Findings to consider | |||
|- | |||
| [[Bone marrow]] | |||
| | |||
*trilineage hematopoiesis | |||
| | |||
*infection | |||
*tumour | |||
|- | |||
| [[Coronary arteries]] | |||
| | |||
*[[atherosclerosis]] - should give percent stenosis for major arteries (LMCA, LAD, LCx, RCA) | |||
| | |||
*atherosclerotic plaque rupture | |||
*thrombi | |||
*inflammation | |||
|- | |||
| [[Heart]] muscle | |||
| | |||
*fibrosis - esp. post. LV (old [[myocardial infarction|MI]]) | |||
*nuclear enlargement, arteriolosclerosis, periarteriolar fibrosis ([[hypertensive heart disease]]) | |||
| | |||
*hemorrhage | |||
*wavy fibres (early ischemic change) | |||
*[[necrosis]] - coagulative/contraction band (recent MI) | |||
*inflammatory infiltrate - not associated with necrosis | |||
*hyaline material ([[cardiac amyloidosis]]) | |||
*fibre disarray ([[hypertrophic cardiomyopathy]]) | |||
*fatty replacement ([[ARVC]]) | |||
|- | |||
| [[Adrenal gland]] | |||
| | |||
*no pathology | |||
| | |||
*tumour | |||
**primary (cortex, medulla) | |||
**metastatic | |||
*hemorrhage | |||
*fat | |||
|- | |||
| [[Kidney]] | |||
| | |||
*vessels (atherosclerosis, [[arterial hyaline|arteriolar hyalinization]]) | |||
| | |||
*tumour | |||
*glomeruli (enlargement, crescents, [[mesangial expansion]], inflammation - esp. [[PMN]]s) | |||
*vessels - thrombi ([[thrombotic microangiopathy]]) | |||
*interstitial (fibrosis, inflammation, edema) | |||
*tubules (inflammation, tubular epithelial whorls, tubulorrhexis) | |||
|- | |||
| [[Liver]] | |||
| | |||
*steatosis - should give severity (mild, mederate, severe), location & type (macrovesicular vs. microvesicular) | |||
| | |||
*fibrosis (septa, rounded contours, [[cirrhosis]]), inflammation (cell type, location (portal, interface, lobular)) | |||
*tumour - esp. metastatic | |||
*bile ducts | |||
*[[ballooning degeneration]] ([[steatohepatitis]])/feathery degeneration ([[cholestasis]]) | |||
*necrosis (location important) | |||
|- | |||
| [[Spleen]] | |||
| | |||
*normal white pulp/red pulp | |||
| | |||
*tumour | |||
*surface abnormalities | |||
|- | |||
| Gastrointestinal tract | |||
| | |||
*autolytic changes | |||
| | |||
*tumour | |||
*vessels | |||
*inflammation - esp. [[PMN]]s | |||
*fibrosis | |||
|- | |||
| [[Thyroid gland]] | |||
| | |||
*no pathology | |||
| | |||
*tumour - papillary thyroid carcinoma, goitre | |||
*inflammation | |||
|- | |||
| [[Lung pathology|Lung]] | |||
| | |||
*pulmonary edema | |||
*[[emphysema]] | |||
| | |||
*infectious pneumonia | |||
*[[pulmonary hypertension]] (may be focal) | |||
*interstitial fibrosis | |||
*tumour | |||
*[[granuloma]]s | |||
*hemorrhage | |||
*hyaline membranes ([[diffuse alveolar damage]]) | |||
|} | |||
===List form=== | |||
====Bone marrow==== | |||
*Trilineage hematopoiesis present. | |||
*Negative for infection and negative for tumour. | |||
====Cardiovascular system==== | |||
[[Coronary arteries]]: | |||
*[[Atherosclerosis]] - | |||
**Left main coronary artery 30%. | |||
**Left anterior descending coronary artery 75%. | |||
**Left circumflex coronary artery 30%. | |||
**Right coronary artery 85%. | |||
*No identified atherosclerotic plaque rupture. | |||
*No thrombosis. | |||
*No vasculitis. | |||
[[Heart]] muscle: | |||
*Fibrosis - posterior left ventricle. | |||
*Nuclear enlargement, arteriolosclerosis and periarteriolar fibrosis. | |||
*No hemorrhage. | |||
*No wavy fibres. | |||
*No [[necrosis]]. | |||
*No inflammatory infiltrate. | |||
*No hyaline material. | |||
====Endocrine organs==== | |||
[[Adrenal gland]]: | |||
*No pathology apparent. | |||
*No tumour. | |||
*No hemorrhage. | |||
*No fatty replacement. | |||
Thyroid gland: | |||
*Normal thyroid gland. | |||
*No tumour. | |||
*No inflammation. | |||
====Genitourinary system==== | |||
[[Kidney]]: | |||
*Atherosclerosis, mild. | |||
*Arteriolar hyalinization. | |||
*No tumour. | |||
*Normal glomeruli (no enlargement, no crescents, no [[mesangial expansion]], no inflammation). | |||
*No thrombi. | |||
*No interstitial fibrosis, no inflammation, and no edema. | |||
*No tubular inflammation, no whorls, and no fragmentation. | |||
*No apparently pathologic renal casts. | |||
====Gastrointestinal system==== | |||
[[Liver]] | |||
*Steatosis - mild, centrilobular, macrovesicular. | |||
*No fibrosis. | |||
*No inflammation. | |||
*No tumour. | |||
*Normal bile ducts. | |||
*No [[ballooning degeneration]] and no feathery degeneration. | |||
*No necrosis. | |||
Luminal GI tract: | |||
*Autolytic changes. | |||
*No tumour | |||
*No vasculitis. | |||
*No siginificant atherosclerosis. | |||
*No inflammation. | |||
*No fibrosis. | |||
====Spleen==== | |||
*Normal white pulp/red pulp. | |||
*No tumour. | |||
*No surface abnormalities. | |||
====Lung==== | |||
*Pulmonary edema. | |||
*Infectious pneumonia, mild. | |||
*Emphysema, mild. | |||
*No pulmonary hypertension. | |||
*No interstitial fibrosis. | |||
*No tumour, | |||
*No granulomas, | |||
*No significant hemorrhage. | |||
*No hyaline membranes. | |||
==Sign out== | |||
===Sample clinical history=== | |||
<pre> | |||
A 63 year old male with a history of alcohol abuse was admitted on December 13, 2018 for | |||
recurrent alcohol related pancreatitis. On December 21, he was found unresponsive at 0:15. | |||
Approximately fifteen minutes earlier, he was on oxygen and in no apparent distress. A code | |||
blue was called; however, the attempted resuscitation was unsuccessful. Death was declared | |||
at 1:00 on December 21, 2018. | |||
</pre> | |||
=See also= | |||
*[[Fetal autopsy]]. | *[[Fetal autopsy]]. | ||
*[[Forensic pathology]]. | *[[Forensic pathology]]. | ||
=References= | |||
{{reflist|2}} | {{reflist|2}} | ||
=External links= | |||
[[Category:Autopsy]] | [[Category:Autopsy]] | ||