外傷及復(fù)雜傷口病患之處理及治療原則

外傷及複雜傷口病患之處理及治療原則臺(tái)灣衛(wèi)福部疾病管制署中區(qū)傳染病防治醫(yī)療網(wǎng)王任賢指揮官傷口癒合

(WoundHealing)傷口癒合

(WoundHealing)TissueInjuryCoagulationEarlyInflammationLateInflammationFibroblastMigration/CollagenSynthesisAngiogenesisEpithelializationRemodelingPhaseNEJM1999NEJM1999NEJM1999傷口癒合分類

(TypeofWoundHealing)一級(jí)癒合(Primaryhealing)延遲性的一級(jí)癒合(Delayedprimaryhealing)二級(jí)癒合(Secondaryhealing)表皮新生(Reepithelialization)一級(jí)癒合

(PrimaryHealing)直接縫合傷口後的癒合。延遲性的一級(jí)癒合

(DelayedPrimaryHealing)延遲縫合傷口3至7天，待傷口沒(méi)有感染現(xiàn)象再縫合後的癒合。二級(jí)癒合

(SecondaryHealing)傷口不縫合，藉肉芽組織形成及表皮新生後的癒合。表皮新生

(Reepithelialization)傷口癒合完全依靠表皮新生。Epidemiology:InUSA>10,000,000annualERvisitsAveragecostof$200perpatientHollanderetal:WoundRegistry:DevelopmentandValidation.AnnEmergMed,May1995.Causesoftraumaticwounds:

CauseofwoundNo.ofPatients%Bluntobject42Sharpobject34Glass13Wood4Bite6Human1Dog3Others5Distributionoftraumaticwounds:LocationofWound

No.ofPatients(%)

HeadandNeck

51Trunk2UpperExtremities

34LowerExtremities13Malpractice:Karcz:

MalpracticeclaimsagainstemergencyphysiciansinMassachusetts;1975-1993.AmJEmergMed1996.

woundsclaims19.85%,and3.15%totalexpenses($1,235,597)AmericanCollegeofEmergencyPhysicians.ForesightIssue49,September2000:Lacerationmismanagement&failuretodiagnosearetainedforeignbodyisthe2ndmostcommonmalpracticeclaimsagainstemergencyphysician

Condition%Claims%Totaldollarspaid1-Missedfracture14172-Woundcare1283-MissedMI10244-Abdominalpain945-Missedmeningitis3.586-Spinalcordinjury387-SAH/Stroke368-Ectopicpregnancy

28Whatpatientswant?

Adam:PatientPrioritiesWithTraumaticLacerations.

AmJEmergMed,October2000.AspectofCareAllParticipants

(n=679)FacialLacerations(n=78)OtherLacerations(n=263)Normalfunction28%27%26%Avoidinginfection20%14%23%Cosmeticoutcome17%33%14%Leastpain17%11%18%Lengthofstay10%8%10%Compassion5%4%5%Cost1%1%1%Daysmissed2%1%3%Total100%100%100%UniversalPrecautions:CDCpublishedguidelinesonuseofuniversalprecautions.Useofprotectivebarriers:eg.Gloves/gowns/masks/eyewearWilldecreaseexposuretoinfectivematerial.Gloves:UselatexfreeglovesSinceMarch1999,FDAreported:2,330latexallergicreactionsincluding21deathsSurgicalglovesduringwoundrepairBodiwala:Surgicalglovesduringwoundrepairintheaccidentandemergencydepartment.Lancet1982.Randomized337patientsto‘gloves’or‘carefulhand-washing,nogloves’:

InfectionGlovesNoglovesNone167(82.7%)170(82.5%)Mild27(13.4%)27(13.1%)Severe8(4.0%)9(4.4%)SurgicalmasksduringlacerationrepairCaliendo:Surgicalmasksduringlacerationrepair.JAmCollEmergPhys1976.Alternatedfacemask/nomaskfor99woundrepairs:Mask:1/47infectedNomask:0/42infected

LocalAnesthesia:2maingroups

1-

Esters(酯類):CocaineProcaine(Novocain)Benzocaine(Cetacaine)Tetracaine(Pontocaine)Chloroprocaine(Nesacaine)

2-

Amides(醯胺):Lidocaine(Xylocaine)Mepivacaine(Polocaine,Carbocaine)Bupivacaine(Marcaine)Etidocaine(Duranest)Prilocaine

Propertiesofcommonlyusedlocalanesthetics:AgentClassMax.savedosemg/kgOnset(min)Duration(hrs)ProcaineEster72-50.25-0.75Procaine+Epi90.5-1.5LidocaineAmide52-51-2Lidocaine+Epi72-4BupivacaineAmide22-54-8Bupivacaine+Epi38-16WhyLidocaine?

LesspainfulRapidonsetLesscardiotoxicLessexpensiveMorris:Comparisonofpainassociatedwithintradermalandsubcutaneousinfiltrationwithvariouslocalanestheticsolutions.AnesthAnalg1987.24volunteerseachinjectedwith5anestheticagentsandNSvisualanalogpainscaleEtidocaine>Bupivacaine>Mepivacaine>NS>Chloroprocaine>Lidocaine(leastpainful)

MethodstoreducepainofLidocainelocalinfiltration:

1-Small-boreneedles2-Bufferedsolutions3-Warmedsolutions4-Slowratesofinjection5-Injectionthroughwoundedges6-Subcutaneousratherthanintradermalinjection7-PretreatmentwithtopicalanestheticsSkinandWoundpreparation:1-Hairremoval2-Disinfectingtheskin3-Debridement4-WoundCleansingandIrrigation5-Soaking

1-Hairremoval:

Toshaveornottoshave!Seropian,1971:

406cleansurgicalwoundsIfshavedpre-op,3.1%infectionrateIfdepilated,0.6%infectionrate

Howell,1988:

68scalplacerationsrepairedwithouthairremoval(93%within3hoursofinjury),noinfectionat5-dayfollow-up2-Disinfectingtheskin:

An‘idealagent’doesnotexist–eithertissuetoxicorpoorlybacteriostaticSimplescrubwateraroundwoundshouldbesufficientNostudieshavedemonstratedtheimpactofcleaningintactskinoninfectionrate,howeveritisimportanttodecreasebacterialloadtominimizeongoingwoundcontamination.Avoidmechanicalscrubbingunlessheavilycontaminated(increaseinflammationinanimaldata)SolutionAntimicrobialactivityMechanismofactionUsesTissuetoxicityN.Saline-WashingactionCleansesurroundingskin/irrigation-Povidine-iodine10%,1%+GermicideCleansesurroundingskin,?Irrigationcontaminatedwounds+Chlorhexidine1%,0.1%+BacteriostaticCleansesurroundingskin+HydrogenPeroxide+BactericidalCleansecontaminatedwounds+Hexachlorophene+BacteriostaticCleansesurroundingskin+Nonionicdetergents-WoundcleanserWoundcleanser-3-Debridement:DevitalizedsofttissueactsasaculturemediumpromotingbacterialgrowthInhibitsleukocytephagocytosisofbacteriaandsubsequentkillAnaerobicenvironmentwithinthedevitalizedtissuemayalsolimitleukocytefunction

DhingraV:PeriphralDisseminationofBacteriainContaminatedWounds:RoleofDevitalizedtissue:EvaluationofTherapeuticMeasures.Surgery,1976.Animalstudy,devitalizedwoundscontaminatedwith3Bacteria,treatedwithNSjetirrigationordebridementat2,4,6hrDebridementmoreeffectiveinreducingbacteriacountandinfectionrate4-WoundCleansingandIrrigation:

Decreasingwoundcontaminationandhenceinfection,"thesolutiontopollutionisdilution."IndicationsMethodsPressureSolutionVolumeSideeffects1-Indications:AnycontaminatedorbitewoundsAnimalandhumanstudiesdemonstrateirrigationlowersinfectionratesincontaminatedwounds

HollanderJEetal:Irrigationinfacialandscalplacerations:Doesitalteroutcome?AnnEmergMed1998.

1,923patients1,090patientsreceivedsalineirrigation,and833patientsdidnotNonbite,noncontaminatedfacialskinorscalplacerationswhopresentedlessthan6hoursNodifferenceinwoundinfectionrateorcosmeticappearance2-Methods:BulbsyringeIVbag+/-pressurecuffSyringeandneedleJetlavage3-Pressure:

lackofclinicalstudiesrecommendirrigationpressuresintherangeof5to8psiHigh-pressureirrigationisdefinedasmorethan8psi(useofa30-to60-mLsyringeanda18-20gaugeneedle)Animalstudies:Rodeheaver,1975&Stevenson,1976,high-pressureirrigationreducebothbacterialwoundcountsandwoundinfectionrates4-Solution:

Idealsolutionmustbe:NottoxictotissuesDoesnotincreaserateofinfectionDoesnotdelayhealingDoesnotreducetensilestrengthofwoundhealingInexpensive

DireDJ:Acomparisonofwoundirrigationsolutionsusedintheemergencydepartment.AnnEmergMed1990.531patientswererandomizedinto3groups,andirrigatedwith:NS,1%PI,orpluronicF-68Nodifferenceinwoundinfectionrate

NShasthelowestcost

Lineaweaver:Cellularandbacterialtoxicitiesoftopicalantimicrobials.PlastReconstrSurg,1985.1%povidone-iodine3%hydrogenperoxide0.25%aceticacid0.5%sodiumhypochloriteassayedinvitrousingculturesofhumanfibroblastsandStaphylococcusaureusAllagentstestedkilled100percentofexposedfibroblasts

Thenhe

lookedatdifferentdilutions……povidone-iodine0.01,0.001,0.0001%…sodiumhypochlorite0.05,0.005,0.0005%…h(huán)ydrogenperoxide3.0,0.3,0.03,0.003%…aceticacid0.25,0.025,0.0025%ONLYantisepticnotharmfultofibroblastsyetstillbacteriostaticwasPovidoneiodine0.001%

Moscati:Comparisonofnormalsalinewithtapwaterforwoundirrigation.AmJEmergMed1998.

lacerationsweremadeoneachanimalandinoculatedwithstandardizedconcentrationsofStaph.aureusirrigationwith250ccofeitherNSfromasterilesyringeorwaterfromatapnodifferenceinbacterialcountin2groups

Kaczmarek,1982:Culturedopenbottlesofsalineirrigatingsolution36/1691000ccbottleswerecontaminated16/105500ccbottleswerecontaminated

Brown,1985:

Approximatelyoneinfiveoftheopenedbottlesuseforirrigationwerecontaminated

Lammers:Bacterialcountsinexperimental,contaminatedcrushwoundsirrigatedwithvariousconcentrationsofcefazolinandpenicillin.RichardLammers,AmericanJournalofEmergencyMedicine,January2001.Ananimalbitewoundmodelwascreatedinoculatedwith0.4mLofastandardbacterialsolutioneachwoundwasscrubbedfor30secondswith20%poloxamer188andthenirrigatedwith100mLofoneof4solutions:NS(control);cefazolin+penicillinG(LD);CZ+PCN(ID);andCZ+PCN(HD)Nodifferencesinthebacterialcountsorinfectionrates4-Volume:Irrigationvolumenotstudieduse50mLto100mLofirrigantpercmoflaceration5-Sideeffects:Increasetissueinflammation(veryhighpressureirrigation),butbenefitoutweighrisk5-Soaking:

Lammers:Effectofpovidone-iodineandsalinesoakingonbacterialcountsinacute,traumaticcontaminatedwounds.AnnEmergMed,1990.Contaminatedtraumaticwoundswithin12hoursofinjury33woundsrandomizedinto:soakingineither1%PI,NS,orcoveredwithdrygauze(control)for10min.BacterialcountsnotchangedinPI+controlgroups,butincreasedinNSgroup

Infectionrate:PI=12.5%(1/8),control=12.5%(1/8),NS=71%(5/7)ForeignBodies:Glass,metal,andgravelareRadiopaqueWoodenobjectsandsomealuminumproductsareradiolucentGlassisaccuratelyvisualizedon2-viewradiographsifitis2mmorlargerandgravelifitis1mmorlarger

WoundClosure:

TimeDelayedprimaryclosureOptionsSuturingmethodTime:TheGoldenPeriod:thetimeintervalfrominjurytolacerationclosureandtheriskofsubsequentinfection,(ishighlyvariable)MorganWJ:Thedelayedtreatmentofwoundsofthehandandforearmunderantibioticcover.BrJSurg1980.

300handandforearmlacerationsclosed<4hrhadinfectionrate7%closed>4hrhadinfectionrate21%

BerkWA:Evaluationofthe"goldenperiod"forwoundrepair:204Casesfromathirdworldemergencydepartment.AnnEmergMed1988.evaluationinathird-worldcountry-204patients<19hourstorepair:92%satisfactoryhealing>19hourstorepair:77%satisfactoryhealingException:headandfacelacerationshad95.5%satisfactoryhealing,regardlessoftime

Baker:Themanagementandoutcomeoflacerationsinurbanchildren.AnnEmergMed1990.2,834pediatricpatientsNo

differenceininfectionrateforlacerationsclosedlessthanormorethan6hrs

Delayedprimarywoundclosure:

Highriskwoundsthatarecontaminatedorcontaindevitalizedtissue

WoundisinitiallycleansedanddebridedCoveredwithgauzeandleftundisturbedfor4to5daysIfthewoundisuninfectedattheendofthewaitingperiod,itisclosedwithsuturesorskintapes

Dimick,1988:DelayedPrimaryClosure

Woundleftopenfor4or5daysuntiledemasubsides,nosignofinfection,andalldebrisandexudatesremoved>90%successrateinclosurewithoutinfectionFinalscarassameasprimaryclosureTopicalAB:

DireDJ:Prospectiveevaluationoftopicalantibioticsforpreventinginfectionsinuncomplicatedsoft-tissuewoundsrepairedintheED.AcadEmergMed,1995.

prospective,randomized,double-blinded,placebo-controlled(426Lacerations)Bacitracin-5.5%infection(6/109)Neosporin-4.5%infection(5/110)Silvadene-12.1%infection(12/99)Placebo–4.9%infection(5/101)Dressing:

Chrintz,1989:1202patientswithcleanwoundsDressingoffat24hours-4.7%infectionDressingoffatsutureremoval-4.9%

Goldberg,1981:100patientswithsuturedscalplacerationsallowedtowashhair

withnoinfectionorwounddisruption

Noe,1988:100patientswithsurgicalexcisionofskinlesionsallowedtobathenextday

withnoinfectionorwounddisruptionTetanus:Morethan250,000casesannuallyworldwidewith50%mortality100casesannuallyinUSAAbout10%inpatientswithminorwoundorchronicskinlesionIn20%ofcases,nowoundimplicated2/3ofcasesinpatientsoverage50StudySettingAge%NoProtectiveABRuben,1978NursingHomeElderly49Crossley,1979Urban>60yrsF:59,M:71Scher,1985RuralElderly29Pai,1988Urban34-60yrs,allFemales5Stair,1989ER>65yrs9.7Alagappan,1996ER>65yrs50Recommendationsfortetanusprophylaxis:

HistoryofTetanusImmunizationTdTIGUncertainor<3dosesYesYesLastdosewithin5yNoNoLastdose5-10yYesNoLastdose>10yYesNoInfectionRate:Galvin,1976 4.8%Gosnold,1977 4.9%Rutherford,1980 7.0%Buchanan,1981`10.0%Baker19901.2%ProphylacticAntibiotics:

BitewoundsContaminatedordevitalizedwoundsHighrisksiteseg.FootImmunocompromisedRiskforinfectiveendocarditisIntraoralthroughandthroughlacerationsPVDDMLymphedemaIndwellingprostheticdeviceExtensivesofttissueinjuryDeeppuncturewoundsProphylacticAntibiotics:Amoxicillin/ClavulinKeflexErythromycinrecommendedcourseis3to5daysAntibioticTherapy:

CummingsP:Antibioticstopreventinfectionofsimplewounds:Ametaanalysisofrandomizedstudies.AmJEmergMed1995.7randomizedtrials(1,734patients)AssignedpatientstoABorcontrolPatientstreatedwithABslightlyhigherinfectionrateLevelofTrainingandRateofInfection:

Adam:LevelofTraining,WoundCarePractices,andInfectionRates,AmericanJEmerg.Med,May1995.Woundswereevaluatedin1,163patientsMedicalstudents0/60(0%);Allresident17/547(3.1%)Physicianassistants11/305(3.6%)Attendingphysicians14/251(5.6%)

LevelofTrainingandCosmeticoutcome:

Adam:AssociationofTraininglevelandShort-termCosmeticApperanceofRepairedLacerations,AcademicEmerg.Med,April1996.Retrospectivestudy,552patients%achievingoptimalcosmeticscoreMedicalstudent50%R154%R266%R368%Physicianassistance70%Attendingphysician66%TreatmentofcSSTIFDAClassificationofSSTIsUncomplicatedSuperficialinfections,suchasSimpleabscessesImpetiginouslesionsFurunclesCellulitisCanbetreatedbysurgicalincisionaloneComplicatedDeepsofttissueRequiressignificantsurgicalinterventionInfectedulcersInfectedburnsMajorabscessesSignificantunderlyingdiseasestate,whichcomplicatesresponse

totreatmentFDA=USFoodandDrugAdministration;SSTI=skinandsofttissueinfection.AMajorSurgicalSiteInfection

isaCatastrophe!FromLewisKaplan,MD.Reprintedwithpermissionofauthor.FactorsLeadingtoDiabeticFootInfection1.ArmstrongDGetal.DiabetesTechnolTher.2004;6:167–177.2.LipskyBAetal.ClinInfectDis.2004;39:885–910.IschemiaImpairedhealing1Poorperfusionofoxygen,nutrients,antibiotics1Autonomic

Dry/crackedskin1Sensory

Inabilitytodetecttrauma1Motor

Abnormalbiomechanics2Polymorphonuclear

dysfunction1,2Diabetic

FootInfectionNeuropathyImmunopathyAngiopathyGramStainofPolymicrobial(AerobicandAnaerobic)DiabeticWoundInfectionMicrobesandChronicWoundsAllchronicwoundsarecontaminatedbybacteria.Woundhealingoccursinthepresenceofbacteria.Itisnotthepresenceoforganismsbuttheirinteractionwiththepatientthatdeterminestheirinfluenceonwoundhealing.Definitions

Woundcontamination:thepresenceofnon-replicatingorganismsinthewound.Woundcolonization:thepresenceofreplicatingmicroorganismsadherenttothewoundintheabsenceofinjurytothehost.WoundInfection:thepresenceofreplicatingmicroorganismswithinawoundthatcausehostinjury.MicrobiologyofWoundsThemicrobialflorainwoundsappeartochangeovertime.Earlyacutewound;Normalskinflorapredominate.S.aureus,andBeta-hemolyticStreptococcussoonfollow.(GroupBStreptococcusandS.aureusarecommonorganismsfoundindiabeticfootulcers)MicrobiologyofWoundsAfterabout4weeksFacultativeanaerobicgramnegativerodswillcolonizethewound.Mostcommonones=Proteus,E.coli,andKlebsiella.Asthewounddeteriorates

deeperstructuresareaffected.Anaerobesbecomemorecommon.Oftentimesinfectionsarepolymicrobial(4-5).MicrobiologyofWoundsInsummary:earlychronicwoundscontainmostlygram-positiveorganisms.Woundsofseveralmonthsdurationwithdeepstructureinvolvementwillhaveonaverage4-5microbialpathogens,includinganaerobes(seemoregram-negativeorganisms).Howdoyouknowwhenawoundisinfected?Thiscanbeverydifficult.Acontinuumexistsbetweenwhenpathogenscolonizethewoundandthenstarttocausedamage.Thereisnoabsolutelyfoolprooflaboratorytestthatwillaidinthisdiagnosis.Howdoyouknowwhenawoundisinfected?Onefeatureiscommontoallinfectedchronicwounds;Thefailureofthewoundtohealandprogressivedeteriorationofthewound.Unfortunately,woundinfectionsarenottheonlyreasonsforpoorwoundhealing.Howdoyouknowwhenanulcerisinfected?Thetypicalfeaturesofwoundinfections:increasedexudateincreasedswellingincreasederythemaincreasedpainincreasedlocaltemperaturePeriwoundcellulitis,ascendinginfection,changeinappearanceofgranulationtissue(discoloration,pronetobleed,highlyfriable).141microbesisolatedfrom93diabeticfootulcerStudydoneonsyrianpopulationpresentedinSDAsept2003B.hammadMDandH.JammalMDRelativeDistributionofBacteria

FromSuperficialtoDeepInfectionsStaphylococcusStreptococcusGram-negativeBacilliAnaerobesSuperficialinfectionDeepinfectionNicholsRL,etal.ClinInfectDis.2001;33(suppl2):S84-S93.Methicillin-ResistantS.aureus

(MRSA)andDiabeticFootInfectionsInalargemulticentertrialinpatientswithdiabeticfootinfection1:11%of473specimenswereMRSAOftheMRSAspecimens,only13%werepureMRSAcultures15%ofpatientsgrew>1StaphylococcusspeciesInanothermulticentertrialinpatientswithdiabeticfootinfection,MRSAwasisolatedfrom25/361patients(7%)2MRSAisisolatedinbothinpatientandcommunitysettings3

MRSAisolationisassociatedwith2:PreviousantibiotictherapyWorseclinicaloutcomes1.CitronDMetal.Bacteriologyofdiabeticfootinfections(DFI):1640isolatesfrom473specimens[abstract].IDSA;2005.2.LipskyBAetal.ClinInfectDis.2004;38:17–24.3.LipskyBAetal.ClinInfectDis.2004;39:885–904.MRSA-AnincreasingproblemRetrospectiveanalysisof63swabsfrominfectedfootulcerGram+aerobic84.2%staph.Au.79%30.2%MRSANotrelatedtopriorantibioticusage

(dangandal.diab.med.20;2:159feb2003)InapriorstudyMRSAisassociatedwithpreviousantibiotictreatment

(tentolourisandal.diab.med.16;9:767sep1999)

MSSA(n=18)*

MRSA(n=12)*

Characteristics

Age 57.4(41–72)years 56.8(40–75)yearsDurationofDM 10.4(6.4–17.1)years 11.2(7.1–18)yearsNeuropathiculcers 50.0% 58.3% Ulcerarea 2.74(0.25–7.2)cm2 2.64(0.16–10.5)cm2Numberoforganisms 0.8(0–2) 1.1(0–3) HbA1c 9.0%

0.5% 8.9%

0.7%Creatinine 165.4

42.1mmol/L 148.8

13.8mmol/LCourse

Timetohealing 17.8(8–24)weeks 35.4(19–64)weeks?Amputations 2 2 *Resultsareshownasmean(range)ormean

SEM.?Statisticallysignificant(P=.03).ImpactofMRSAandMSSAinaDiabeticFootClinicTentolourisNetal.DiabetMed.1999;16:767-771.MRSASurgicalSiteInfectionConsequencesInmultivariableanalysis,MRSASSIwasassociatedwithSignificantlyhighermortalityrate(P=0.003)Significantlyincreasedhospitalcharges(P=0.03)Increasedlengthofstay(P=0.11)PatientsDyingMeanChargesPerCaseHospitalStayPostInfectionMRSAN=12120.7%$118,41422daysMSSAN=1656.7%$73,16513.2daysS.aureusBacteremiainSurgicalPatientsGottliebGS,etal.JAmCollSurg.2000;190:50-57.23.6%ofpatientsdevelopedSABpostoperatively33%developedasecondarycomplication

(endocarditisormetastaticfoci)Attributablemortalitywas11%PatientswithpostoperativeSABhadundergone27cardiothoracicprocedures15abdominalprocedures9neurosurgicalprocedures9orthopedicproceduresoramputations13miscellaneousproceduresSourceofS.aureusBacteremiainSurgicalPatientsPresumedSourceofBacteremian(%)Primarysurgicalwoundinfection49(67)Intravascularcatheter12(16)Post-operativepneumonia4(5.5)Other(biliarydrains,etc)6(8.2)Unknown2(2.7)AdaptedfromGottliebGS,etal.JAmCollSurg.2000;190:50-57.CommonCSSSIswithpolymicrobialcharacterDiabeticfootSurgicalwoundinfectionRadiationdermatitisMajortraumaDeepneckinfectionNecrotizingfasciitisAntimicrobialsCurrentlyAvailableforMRSAInfections—2008VancomycinLinezolidDaptomycinTigecyclineMinocyclineClindamycinSulfamethoxazole/TrimethoprimFluoroquinolonesRifampinAminoglycosidesGapsInEmpiricAgentsSpectrumsClassMRSAGram-FermentersESBLsP.aeruginosaAnaerobesPip/Tazo-++-++++++-++++++Imipenem/Meropenem-++-+++++++-+++++Ertapanem-++-++++++-+++FQs-+-+++++-++++-++ESC(Extended-spectrumceph)-++-+++-+-+++Tygacil+++++-++++++-+++1.GrazianiALeta