Follicular lymphoma

The diagnosis is follicular lymphoma. Such an incomprehensible and terrible at first glance disease belongs to the category of the most light and relatively safe pathologies associated with malignant neoplasms. At the same time that pleases, the considered pathology responds well to complex medical therapy, and, therefore, gives in to treatment.

[1], [2],

Causes of the follicular lymphoma

It is worth mentioning immediately that you do not have to rejoice greatly. Modern medicine still can not achieve complete remission. It can not be expected even when surgical treatment was normal and the tumor was completely removed. Even with this outcome, the disease usually returns within three years, at best - after five years.

This terminology has been treated because, in most cases, malignant neoplasm began to form and develop in the epidermal covering cells, pathologically changing the hair follicles, or as they are also called follicles.

To date, none of the doctors, the oncologist, can name all the causes of follicular lymphoma, since its nature has not been fully studied yet. One can say only one thing, that one of the sources provoking a pathological degeneration of the cell are gene mutations. But what has served as the catalyst for these metamorphoses is this question, so far, remains open.

Nevertheless, several reasons that doctors could establish, lead you can:

• Operative intervention related to organ transplantation.
• Endoprosthetics - surgery to replace the joint with implants.
• Prolonged intake of certain pharmacological agents, for example, immunosuppressants.
• A congenital definite chromosomal abnormality, but this alone is not enough for a push in the development of follicular lymphoma. For this, this pathology must be accompanied by some other factors. For example, it could be trisomy and / or monosomy, also related to genetic abnormalities.
• Various autoimmune diseases.
• Enough close contact when working with pesticides, which today is almost inevitable to avoid in the agricultural sector of human life.
• The person has bad habits. This is especially true of nicotine.
• As a consequence of obtaining a dose of ionizing radiation.
• Contact of any kind with toxic chemical compounds, carcinogens.
• The risk of developing the disease in question increases if people live in ecologically polluted areas. It can be a large metropolis with the presence of large industrial facilities. Or, for example, people living in dangerous proximity to a chemical plant.
• Acquired, or congenital defeat affecting the immune status of a person.

[3], [4]

Symptoms of the follicular lymphoma

Most often, the area of localization of the disease under consideration is: axillary cavities, inguinal zone, the head of a person and his neck. It is not strange, but this disease occurs mainly in young people who fall into the age category up to forty years.

The insidiousness of this pathology, however, like others related to oncological diseases, is that at the early stages of its progression the patient does not bother and diagnose the disease can only be by chance, undergoing another preventive examination, or in studies that have been assigned in connection with therapy of another disease.

After the tumor continues to progress, it can already be recognized by palpation. In the future, the symptoms of follicular lymphoma begin to appear:

• Malignant formation may protrude above the surface of the skin.
• "Swelling" has a clear outline.
• The hue of the lesion may be slightly pinkish or purplish-scarlet.
• Substance of increased density.
• In the place of the tumor there are painful sensations.
• Neoplasm can bleed.
• There is an expression of the epidermis.
• The patient begins to feel weakness throughout the body.
• The difference between inflammation of the lymph nodes (from infection) is that they are not only painful, but also not sensitive to antibiotics.
• Enhanced sweat production with appropriate glands.
• Physicians have a chromosomal translocation t (14:18).
• An increase in body temperature may be observed.
• A person begins to lose weight unjustifiably.
• There are problems with the digestive tract.
• Decreased efficiency.
• Nausea.
• There may be a feeling of overflow in the abdomen, a feeling of pressure in the face or on the neck, there is difficulty breathing. This may be due to increased pressure on the digestive organs from the side of the spleen, the liver or directly the lymph node (with a specific tumor location) or to other organs of the human body.
• Dizziness, down to fainting.
• Depending on the site of localization, the patient may have problems with swallowing, which is associated with an increase in the volume of the pharyngeal lymphatic ring.
• Without obvious reasons, a fever can develop.
• Hearing loss.

It should be noted that the symptomatology, depending on the localization of the affected lymph node, can combine the various manifestations of the above listed.

Sometimes this disease can be identified and diagnosed only when the malignant process begins to affect the bone marrow. It's good that asymptomatic lymphoma is rare.

Non-Hodgkin's Follicular Lymphoma

Follicular lymphoma itself belongs to the non-Hodgkin type according to the medical classification. As it does not regrettable sounds, but modern medicine only in some cases manages to recognize the disease at an early stage of its inception. In 70% of cases, the patient consults a specialist for advice, when obvious manifestations of the disease begin. For example, frequent nausea and a person begins to faint. This is due to the fact that the bone marrow has already been captured.

Often, non-Hodgkin's lymphoma at an early stage of development is diagnosed with a comprehensive medical examination using modern high-precision diagnostic equipment. It is in this regard, doctors insist that a person at least once a year should undergo a full preventive examination. This approach to their health will significantly reduce the risk of full-scale damage to the human body, obtaining irreversible pathological changes.

Lymphomas of non-Hodgkin's type are caused by cancerous growths of B- and T-cell type. The source of such a pathology can originate in any lymph node or other organ, and then "infect" lymph. In the future metastasis occurs in three ways: hematogenous, lymphogenous, hematogenous - lymphogenous.

Such lymphomas have their own qualification, which differs in morphology, clinical symptoms, as well as the parameters of the course of the disease. Depending on the area of localization, physicians share lymphomas - cancerous tumors that affect the lymphoid layers with a primary nucleus that does not affect the bone marrow, and leukemia - cancerous changes that primarily affect the bone marrow layers.

This disease affects all age groups of the population, but still a greater percentage falls on those who are already 60 years old.

To date, the etiology of lymphosarcoma is thoroughly known. Therefore, speaking about the causes that can provoke the disease, it is necessary to talk about those aspects that increase the risk of its inception and development. These include:

• Viral pathologies. For example, AIDS, Epstein-Barr virus, hepatitis, especially in hepatitis C.
• Infection of Helicobacter pylori, which is believed to be a number of scientists, is the "culprit" of ulcerative lesions of the mucosa of the digestive tract.
• Increase the likelihood of the disease can congenital or acquired immunodeficiency.
• And other reasons, already specified above.

Non-Hodgkin's type of follicular lymphoma has its own, rather extensive classification:

Lymphatic sarcomas, localized in the lymph nodes, have the term - nodal, in the case of another place of localization (salivary glands, tonsils, thyroid, epidermis, brain, lungs, etc.) - extranodal. Follicular (nodular) or diffuse them makes the structural component of the neoplasm.

There is also a division according to the rate of the course of the disease:

• Indolent - progression passes smoothly. Without medical therapy, such a patient is able to live from seven to ten years. The treatment gives a fairly favorable prognosis.
• Aggressive and highly aggressive course of the disease. Without treatment, such a patient is able to live from a few months to a year and a half or two. The treatment gives a fairly favorable prognosis.

To date, cancer medicine has more than 30 different types of non-Hodgkin's lymphomas. Most of them (about 85%) belong to B-cell lymphomas (B-lymphocytes), and the remaining 15% to T-cell lymphomas (T-lymphocytes). Each of these types is distinguished by its subtypes.

[5], [6]

In cell follicular lymphoma

This type of disease clearly dominates the diagnosis of the disease. In children, this type of disturbance of the lymphatic system practically does not occur.

To type B of cellular lymphoma by medical people is:

• Diffuse large B-cell lymphoma is the most common type of disease. 31% of diagnosed non-Hodgkin's lymphomas are of this type. The main parameters of the disease: aggressiveness, high rate of progression. But, despite such negative characteristics, with timely medical intervention, has high preconditions for complete recovery.
• In cell follicular lymphoma - the level of diagnosis of this particular type is 22 cases of one hundred recognized non-Hodgkin's lymphomas. The pathology is indolent, but there are cases when the current is transformed and acquires an aggressive diffuse form. Oncologists have such a criterion as a five-year survival rate. So this category of illness shows that 60 to 70 people out of a hundred live this five-year period. The boundary of ten years is able to overcome from 30 to 50% of patients with this diagnosis. This type carries the features of the secondary follicle. The cell consists of centrocytes and centroblasts. This kind of pathology, according to the cellular composition, is carried on three cytological species. By the cellular composition, the third cytologic type of follicular lymphoma is distinguished.
• B-cell lymphomas affecting the cells of the marginal area - the percentage of diagnosis is not high. They are not aggressive, they have a low growth rate. In the case of its detection in the early period of development are quite amenable to treatment.
• Lymphoma from mantle cells - about 6% of cases are attributed to this pathology. The disease is quite specific. Five-year boundary is overcome only by a fifth of the diseased.
• Small cell lymphocytic lymphoma and chronic lymphocytic leukemia - about 7% of patients are susceptible to this disease. This type of pathology is akin to non-Hodgkin's lymph. It is not particularly aggressive, but has a low sensitivity to antitumor treatment.
• B-cell mediastinal lymphoma - the frequency of diagnosis - 2%. Mostly it is diagnosed in women from 30 to 40 years. Only half of patients can be cured.
• Burkitt's lymphoma is about two percent. The course of the disease is aggressive, but with intensive therapy it is possible to achieve a complete cure (50% of patients).
• Waldenstrom's macroglobulinemia is only 1% of cases. It leads to an increase in the viscosity of the blood fluid, which leads to thrombosis and disruption of the integrity of blood vessels. With such a disease a person can live both 20 years and less than a year.
• Hairy cell leukemia is very rare and affects the elderly. 1
• Lymphoma of the central nervous system - the source of the lesion - the CNS, after which the metastases begin to affect the cells of the bone and brain. For five years only 30% of patients survive.

Follicular lymphoma 2 of cytological type

One of the main criteria in diagnosing and proper administration of chemotherapy is the result of histological analysis. Practical doctors confirmed the necessity of dividing the examined disease into cytological types (according to the morphological principle), depending on the number of large cells defined in the patient's body.

Oncologists share:

• 1 cytological type - presence of small split cells.
• Follicular lymphoma of 2 cytological type is a set of large and small cells morphologically commensurable with each other.
• 3 cytological type - large cells of the follicle.

In the case of a repeated biopsy, a transformation of the first type in the second, but never in the third, can be observed.

When diagnosing a type, physicians rely on the results of a cytological examination. From here oncologists establish the type (depending on the number of centroblasts detected in the field of view of the microscope):

• Type 1 - from zero to 5.
• Type 2 - from 6 to 15.
• Type 3 - more than 15. This type is divided:
  • On the subtype 3 - a - in the field of view already observed and centrocytes.
  • Subtype 3-b-centroblasts constitute extensive formations without centro- cytes.

Cancerous tumors of 2 cytological type are quite aggressive in progression and require more radical measures of chemotherapy medication. But the general figures of the survival rate of patients in all cytological groups are approximately the same.

[7], [8], [9], [10]

Follicular lymphoma 3a of cytological type

If the patient is diagnosed with cytological type follicular lymphoma 3a, then the prognosis for this person is very unfavorable. In patients with this pathology, even after they underwent a complete examination and qualitative adequate treatment, more often and earlier than others (with type 1 or type 2 follicular lymphoma), there are recurrent signs of disease return.

Several improvements to this prognosis can be made when introducing into the treatment protocol such patient therapy with doxorubicin. And the presence of centrocytes in the field of vision is an occasion for oncologists to prescribe to the patient essentially aggressive therapy. Type 3 (cytological classification) - this stage is assigned when the spread of the malignant process affects one or two distant lymph nodes.

Distinguished by the most likely occurrence of early relapses, such patients show a higher percentage of five-year survival.

[11], [12], [13], [14], [15], [16]

Diagnostics of the follicular lymphoma

Even with the slightest suspicion of an oncological problem, the local doctor-therapist gives direction to his patient in a specialized oncological dispensary, where he passes the necessary examination. Diagnosis of follicular lymphoma is carried out by a more narrowly focused specialist - onco - hematologists.

Indications for the survey are a number of criteria that determine the pathological clinical picture: growth in the volume of one or more lymph nodes, the appearance of the patient obvious signs of intoxication (systemic poisoning) of the body, extranodal changes.

To establish the correct diagnosis, suggesting the presence of a patient with non-Hodgkin's lymphoma, the oncologist necessarily takes a sample of the cell substrate of the neoplasm for research. To do this, and to obtain a more complete picture of the state of human health, both instrumental techniques and laboratory tests are assigned:

• External examination of the patient.
• Palpation of the lymph nodes, which allows the specialist to assess the volume and density of the tumor. But not all education lends itself to such research. Therefore, without a comprehensive survey is indispensable.
• A biopsy of the affected lymph node is performed.
• Laparoscopy is a therapeutic or diagnostic examination of the abdominal organs.
• Thoracoscopy is an endoscopic examination of the pleural cavity.
• The bone marrow puncture is taken - this analysis allows to exclude or confirm the presence of metastases in this part of the body.

After carrying out the aforementioned measures, the cellular material is submitted for further examination. A study is being conducted:

• Immunohistochemical - a technique that makes it possible to accurately determine the location of a particular cellular or tissue component (antigen) by binding it to labeled antibodies.
• Cytological - a study of the features of the structure of cells, the cellular composition of the tissues, the body fluids of the human body for the diagnosis of various diseases with the use of increasing equipment.
• Cytogenetic - microscopic study of human chromosomes, a set of techniques that establish connections between hereditary disorders and the structure of cells (especially the structures of the cell nucleus).
• Other studies.

In the process of recording the protocol of therapeutic measures in follicular lymphoma, other additional examinations are also prescribed to determine the location of the tumor and the extent of metastasis by the doctor:

• Radiography of the proposed lesion zone.
• Ultrasound examination of lymph nodes, thyroid and mammary glands, liver, spleen, scrotum and other organs.
• Computer tomography of the peritoneum and thorax, allowing to recognize even the smallest irregularities in the structure.
• Lymphoscintigraphy is a technique that allows one to obtain an image of lymphatic vessels.
• Scintigraphy of bones and internal organs - diagnosis of metastatic malignant tumor.
• Magnetic resonance imaging (MRI) is a technique for visual detection of primary and metastatic foci of cancerous tumors.
• General and biochemical analysis of blood.

If in the process of investigation small-dispersed cellular single structures are detected, the oncologist puts the first or second type of pathology. Large cell lymphoma already speaks of a higher degree of malignancy of the process: Stage 3 - one or two lymph nodes located distant from the site of the main localization are captured; 3-b stage - this is a more massive defeat of the human body, and more specifically its lymphatic system.

Quite often, in addition to non-Hodgkin's lymphomas, the oncologist also reveals numerous accompanying pathologies, which only aggravate the situation.

[17], [18], [19], [20], [21]

Treatment of the follicular lymphoma

It is in connection with the deteriorating situation with cancer diseases, the percentage of which is increasing from year to year, oncologists recommend not to ignore preventive examinations. The earlier the disease is established, the more the patient's chances are not only to continue the quality of life after receiving antitumor treatment, but in general to save his life as such. Treatment of follicular lymphoma is prescribed for each patient strictly individually, correcting it during the course of treatment. There are cases when oncologists, giving the patient certain recommendations, take a wait-and-see attitude, conducting periodic monitoring of the patient's health status and the level of growth of the tumor. Due to the relatively low rate of tumor progression, it can take up to ten years before it starts to manifest itself, so doctors are slow to take radical measures, because the appointment of surgery and chemotherapy drugs also do not pass without a trace to the human body.

That is, if the first or second stage of pathology is diagnosed with a sluggish form of development, then such a clinical picture can be observed throughout the decade, periodically alternating with periods of remission and relapse, the doctor only conducts constant monitoring of the patient's condition, ready at any time to take adequate measures.

But immediately it should be reassured, follicular lymphoma, with timely detection and adequate therapy in a few cases becomes the cause of death of the patient.

But it is possible to observe and reverse the clinical picture, when the tumor begins to rapidly progress, spreading in all directions like tentacles metastases. With such a clinical picture, physicians begin to act immediately, painting the course of laser and / or chemical therapy. If the patient has metastasis affected the bone marrow, the oncologist may decide to prescribe an operative intervention for his transplant. It is worth mentioning immediately that with such a picture of the disease, it is not worth counting on complete remission. Even if the focus of pathology has been completely removed, such a patient is able to survive for three to five years.

At later stages of pathological development, with the appearance of metastases and in the farther away from the focus organs, the attending physician-oncologist appoints such a patient with laser and / or polychemotherapy.

To date, the most popular and successful treatment regimen is the CHOP method, which is represented by a treatment protocol, which includes such drugs as vincrestine, cyclophosphamide, doxorubicin, prednisolone.

An alkaloid of vegetable origin, vincrelin, has an antitumor effect on the patient's body. The drug is administered intravenously to the patient. Schedule introduction - once a week.

The doctor who prescribes the dosage of the medicine is appointed individually. The single starting amount of the drug administered for an adult patient is 0.4 to 1.4 mg, calculated per m2 of the patient's body surface, taken once a week. The starting dosage for small patients is 2 mg calculated on m ^{2 of} the body surface, taken once a week.

If necessary, the doctor may prescribe intrapleural administration of the drug, that is, the pharmacological fluid is supplied to the cavity between the lung membranes. With this method of feeding the patient receives 1 mg of the drug, which immediately before the procedure was diluted with 10 ml of saline.

Contraindications to the use of this medication include medical diseases of the central or peripheral nervous system, the increased sensitivity of the patient's body to one or several components of the drug. This includes the pregnancy of a woman or her feeding a newborn baby.

There are also recommendations on the very handling of drugs of this pharmacological category.

• It is necessary to introduce this medicine with special care, after making sure that the needle is in the vein. It is not necessary to admit nevenovogo receipt pharmacological fluid, in order to avoid the formation of necrosis.
• In the process of carrying out this medical procedure, the manipulative nurse must protect his eyes, and in case of getting medication in them, rinse them very quickly and thoroughly in clean running water.
• Before the introduction of chemotherapy drugs against the background of treatment, regular monitoring of the peripheral blood condition is necessary.
• A constant monitoring of the biochemical characteristics of the functioning of the liver is also necessary.
• With a decrease in the level of neutrophils, below the critical level, the chemotherapy input procedure is not assigned, postponed until the regulatory parameters are restored.
• To prevent the development of a hepatotoxic effect, a chemotherapeutic drug should not be taken in parallel with radiation therapy that affects the area of the kidneys and liver.

Medical personnel who work with these drugs used for chemotherapy are required to comply with all individual protection requirements that are imposed in close contact with toxic chemicals.

Along with CHOP, no less effective is the CVP regimen, which includes such medicines as vincrestine, cyclophosphamide, prednisolone.

The antineoplastic agent cyclophosphamide, referring to alkylating chemical compounds, which the treating doctor, on the basis of a pathological picture, can appoint as intramuscular, intravenous, intraperitoneal, and intrapleural.

Immediately on the eve of the procedure, the drug is diluted with water for injection, while the drug bottle with a dose of 0.2 g is 10 ml of diluent. In this case, the control indicator of the quality of the drug is the time for which the drug dissolves in water - it should not exceed four minutes.

The medicament is chosen by the expert independently. There are several such schemes.

• A single dose is calculated as 3 mg per kilogram of the patient's weight, about 200 mg, which are administered once a day. Method of administration of the drug: intravenously or intramuscularly.
• A single dose is calculated as 6 mg per kilogram of the patient's weight, about 400 mg, which are administered once twice twice a day. Method of administration of the drug: intravenously or intramuscularly.
• A single dose is calculated as 15 mg per kilogram of patient weight, about 1 g, which is administered intravenously once every five days.
• A single dose is calculated as 30-40 mg per kilogram of the patient's weight, about 2 to 3 g, which are administered intravenously once every two to three weeks.

The amount of medicine used for one course of therapy is from 6 to 14 g. At the end of the main course, maintenance therapy is usually practiced, which provides intravenous or intramuscular delivery of 0.1-0.2 g of the drug twice for one week.

This drug is used and as an immunosuppressant. In this case, the doctor appoints a quantitative component of the drug at a rate of 1.0 to 1.5 mg per kilogram of the patient's weight, which corresponds to a daily amount of 50 to 100 mg. If the body has an increased tolerability of the drug, the doctor can prescribe a dose and 3 to 4 mg per kilogram of the patient's weight.

With intraperitoneal or intrapleural injection, the dosage of the drug can correspond to 0.4 to 1.0 g.

Contraindication to the use of the drug in question is the increased sensitivity of the patient's body to the component composition of the drug, as well as if there is severe kidney dysfunction in the patient's history, leukopenia (with a leukocyte count in blood below 3.5.109 / L), bone marrow hypoplasia, anemia or cachexia, thrombocytopenia (with a platelet level in the blood below 120 · 109 / L). This recommendation applies to the terminal stage of the disease itself, as well as if the woman is pregnant or nursing a newborn baby.

But the oncological direction of medicine is constantly improving, scientists and pharmacologists find all new medicines, techniques and forms. To date, some cancer clinics are practicing innovative methods of treatment with the use of the patient's stem cells. Although even against the background of the current level of medicine, a disease such as follicular lymphoma has not yet been fully studied and completely incurable.

To the factors that increase the risk of an unfavorable outcome, oncologists include:

• The age group of patients older than 60 years.
• The patient's hemoglobin level is determined by figures below 120 g / l.
• If the patient is diagnosed with a third or fourth stage of development.
• Growth of lactate dehydrogenase.
• If the doctor observes the patient has an oncology affecting more than four groups of lymph nodes.

After the course of chemotherapy or laser therapy, the patient is obligatorily prescribed maintenance therapy, designed to increase his immune status, significantly reduced by treatment.

After receiving chemotherapy drugs, the immunity of the patient is greatly reduced and in order not to get a secondary infection, which in many cases is the cause of death, this patient should stay in a sterile environment for a certain period of time.

If a secondary leukemia that develops in the background of follicular lymphoma, affecting the areas of the bone marrow, is detected, the oncologist is forced to prescribe a transplantation of this substance to the patient from one of his immediate relatives. Otherwise, it will be difficult to find a full-fledged donor. But if the operation was normal, then this technique shows high therapeutic results.

The most important thing is not to miss the moment and turn to a specialist as soon as possible! Sometimes it depends on time not only the further quality of a person's life, but also his life!

Prevention

It is difficult enough to give advice on preventing the pathology considered in this article, but it is worthwhile to stipulate some vital moments that will help reduce the risk of any cancerous growths.

Therefore, prevention of follicular lymphoma is indicated by several recommendations:

• Maintaining a healthy lifestyle.
• Rejection of bad habits.
• Balanced, rational nutrition, rich in trace elements and vitamins.
• Maintaining the proper immune system.
• When the disease (of any nature), treatment should be treated in a timely manner and until complete recovery.
• Ensure that the body does not respond to prolonged hypothermia or overheating.
• Do not abuse sunbathing, baths, saunas and solariums.
• When choosing the location of your home, it is desirable to give preference to areas with a clean ecosystem, away from large industrial zones.
• Exception of hypodynamia. Movement is life.
• Many experts believe that the idea is material, so as not to check the negative aspect of this expression - think only positively, relax and pleasant music is welcomed.
• The mode of the person's day should harmoniously combine the time of workloads and rest periods.
• Regularly, at least once a year undergo a comprehensive preventive examination in a specialized medical institution.

[22], [23], [24], [25]

Forecast

It is problematic to evaluate the consequences of pathology for a patient with a diagnosis of neo-Hodgkin's lymphoma, since the result of antitumor therapy largely depends on the degree of the disease.

If physicians diagnose pathology of the first or second degree, showing nodular rate of progression, then in nine patients out of ten the prognosis of follicular lymphoma is quite favorable, which is based on a correctly diagnosed and adequate chemotherapy regimen.

In the case of establishing non-Hodgkin's lymphoma, which has one of the varieties of the third stage of development, the prognosis of the nodular course of the disease is less favorable. The survival rate for this clinical picture is only five out of ten diagnosed cases.

I am glad that the pathological development of the disease of the fourth stage, when metastases are already affecting and sufficiently remote organs, is very rarely established. The prognosis for this course of the disease is unfavorable, even when necessary therapeutic measures are taken. Therapeutic therapy makes it possible only to prolong the life of the patient a little (at best for several years), but the lethal outcome is almost inevitable.

Quite often, the death of such a patient does not come directly from a cancerous growth, but the cause of death is a secondary infection that easily falls into a weakened organism.

Monitoring the survival rate of such patients is quite regrettable, out of twenty patients who were diagnosed with follicular lymphoma of the fourth stage, two to three survive.

The contaminated environment, food and the rapid rhythm of life do not give the modern person health. A monoclonal tumor consisting of mature B lymphocytes is a follicular lymphoma. The diagnosis of cancer kills a person, and his close relatives, from the rut, becoming confronted with a dilemma - what to do? The answer is only one - not hesitating for a minute to seek advice from a specialized oncological center, undergo a full examination and a possible, oncologist-appointed treatment. Only a timely and rapid response to the problem and adequate therapy can increase the patient's chances of the quality of his later life, or even just life itself. Do not ignore preventive examinations. "Take care of your health in youth" - this alternative wisdom comes to the topic of today's article! Take care of yourself and be well!

[26],