Advancements in Radiology

Discussion in 'Radiology' started by dEviantrAdiologist, Aug 5, 2002.

  1. dEviantrAdiologist

    dEviantrAdiologist Evacuation proctographer

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    Radiology Folk,

    I was wondering what areas in Radiology do you think will grow the most over the next 10 years. I realize that MRI (functional MRI especially) is an exponentially growing field. This is quite the opposite of VIR, which some would say is slowly dying out. What do you ppl think?
     
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  3. xraydoc

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    It is very hard to predict the future of medicine 10 months from now let alone 10 years. IMHO I think that molecular imaging will equal or surpass MRI in the future. Tailor made molecules will seek out diseased tissues/organs in a highly specific fashion, making diagnosis of numerous diseases very sensitive and specific. This will be done on highly sophisticated PET/CT machine combos. Treatment will also be done in this fashion as well.

    We here (Michigan St.) have a molecular imaging conference each fall that you may want to check out. We are also installing a PET/16sliceCT in the spring for just this type of research and diagnosis.
     
  4. droliver

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    VIR???? (vascular interventional?)
     
  5. MacGyver

    MacGyver Banned
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    Well molecular imaging in the future can also be done with MRI using targeted contrast agents. Right now its not quite up to the resolution that PET gives, but its getting better.
     
  6. dEviantrAdiologist

    dEviantrAdiologist Evacuation proctographer

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    xraydoc,

    Can you leave a link to a website or address for more information about your school's conference?

    droliver,

    VIR=Vascular/Interventional Radiology.
     
  7. bosky

    bosky Member

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    Molecular imaging is definitely getting hot and I suspect molecular-based MRI will eventually win out because;

    1) it can give so many additional complementary forms of contrast in the same session (nosologic imaging). Think about how many different tightly-apposed soft-tissues there are in certain areas of the body - most of the enzymes/receptors being targeted are common to all tissues, so we will still need anatomical imaging.

    2) MRI lends itself to disease monitoring since you don't get hit with xrays, etc. everytime you do it.

    What about intraoperative MRI? Anyone know much about this. I know there are places in Europe, Cleveland and Boston that are pursuing this field... it also seems to have an interesting future?
     
  8. droliver

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    We have one of the intraoperative MRI's here & it is a miserable failure. There just aren't enought intracranial tumors that these make much $$$$$ sense for hospitals. Nobody likes working in them- they cramped, they have a small operative field, instruments compatible with the magnet are rare, and again there just aren't that many of the tumors out there for these things. They have been desperatley trying to get other field outside NES to come up with some indication for them & are coming up lacking
     
  9. Voxel

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    Anyone see these things live in action? I have read about them. I'd like to know how practicle they are and if these machines pay for themselves with the number of studies done per day.
     
  10. droliver

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    Yes I have, no they're not, & no they don't respectively
     
  11. MacGyver

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    What do you mean by intraoperative MRI? Is using MRI to visualize cardiac stent placement considered intraoperative? or is it only intraoperative if you are doing massive cutting of the patient?

    what about say, using MRI to monitor drug delivery?
     
  12. bosky

    bosky Member

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    Personally I meant "intraoperative MRI" mainly in the sense of tumor debulking, but I've also read some stuff about doing neurointerventional procedures with the patients head inside the magnet and their groin/leg hanging out for femoral access.

    What you are saying is kind of disappointing. Here I was ready to move to Cleveland and make a name for myself (just kidding).

    Could it just be because this is all developmental stuff? Everybody thought diffusion MRI was lame till Moseley showed that you could detect stroke in 15 minutes.
     
  13. embolicintent

    embolicintent Junior Member

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    I had the opportunity to observe an interventionalist whos primary workload was done on an interventional magnet which as I recall last year was one of about five in the country. He did numerous procedures ranging from craniotomy with cryoablation of tumors to simple drainages. It was often possible to reach areas that were not able to be accessed with CT fluoro. It was cramped and using a 0.5 tesla magnet, the images were not the best. He did a large number of cryoablations particularly renal cell carcinomas. Of course at this point it is not financially feasible and the technology has a ways to go, but I am hearing more and more about IMRI and I do think that it will have its place in the future. With a little imagination and some solid research, it could offer some interesting advancements in interventional. It certainly is not likely to be seen outside of large research institutions for quite some time. As for "intraoperative" this magnet was maintained in an OR environment.
     
  14. bosky

    bosky Member

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    Thanks for more encouraging news about iMRI. Can you recommend some institutions to consider for someone interested in this field (i.e. the 5 you allude to)?

    I've actually heard of using the magnetic fields to guide the catheter further into the brain - haven't seen in print and don't have time at the moment to search for it, but sounds COOL.

    Unlike other interventional procedures, I think it would be hard for other fields to scoop iMRI just because they'd end up bringing something metal into the theater, etc...
     
  15. embolicintent

    embolicintent Junior Member

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    The one's that I can remember are Harvard, University of Mississippi, maybe case western-not sure, and I think Univeristy of Texas Southwestern is doing work in this area as well. This was a year ago and thus probably a few more by now. It really is just an open magnet, the key is the software allowing rapid slice acquisition (less than one second). I recently spoke to a neurointerventionalist that is doing alot of work with it and he also sees a very bright yet somewhat distant future for the modality. One advantage of using magnetic resonance is that surgeons and other specialties are very unlikely to ever take the necessary time to understand the extremely complicated physics involved. Thus job security. The cardiologists on the other hand are quite aware of the potential of MR to replace many of there current studies and procedures and thus many are taking the time to learn about MR physics which is an absolute necessity to understand the images. The future of magnetic resonance imaging is tremendous and diverse. As radiologists we must do the research and maintain our hold on this modality.
     
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  17. Gradient Echo

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    I work in MR research and the only real downside I see to it is that you have an added burden when trying to bring iMRI to the clinical stage.

    I work in an interventional radiology lab on MR-guided injection therapies. Not only do I have to show that its useful and effective, but it has to be a LOT more useful and effective than other modalities because MR is so expensive relative to other therapies like CT or ultrasound.
     
  18. MustafaMond

    MustafaMond K-Diddy M.D.

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    My predictions for Radiology in the next -10 years

    1) High Speed Cardiac MR imaging will replace Nuclear Stress Tests

    2) PET/CT Dual scanning will become standard, in Oncology.

    3) ICVIR will vote to split off from Diagnostic Rads. Interventional Rads will change their name to something else (minimally invasive surgery, etc.)

    4) AI image recognition programs will become more commonly used (once PACS takes off, and most of rads is filmless), as they are already being used in mammo. Diag Rads will get paid less, because Int Med guys will stop waiting around for reports, and start treating based on the AI report.
     
  19. Voxel

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    Predictions for numbers 1-3 are interesting. With CT/PET combination already occuring as the standard in large academic centers and is the standard at Cancer specific hospitals.

    Prediction #4 sounds ungrounded in reality. Why haven't the int medicine guys just bypassed radiologists and use the AI Mammography software to read Mammograms themselves? I know several reasons why statement #4 is far off base for docs in the US. Anyway, if you read this thread try to come up with some and then get back to me. ;)
     
  20. MustafaMond

    MustafaMond K-Diddy M.D.

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    Voxel, you tryin to step to me, biyatch?;)

    Naaa..I dunno...Its not just me tha says it though....many IM guys I work with, predict the absolute downfall of diagnostic rads because of AI.

    I dont know if Id go that far, but I would think a pay cut is very likely.

    Prediction #5- I will use XRT beams on Voxels 'nads if he steps to me again.:laugh:
     
  21. droliver

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    MustafaMond,

    in re. to your predictions.

    1) the capital costs of the MR related cardiac imaging will delay wide-spread adoption of this for the near future

    2) the utility of PET scanning is not clearly established & certainly not cost effective @ this point in time for many tumors. The cost effect and the resultant impact on both cancer-related & overall mortality rates will have to be established for it to really be widely used

    3) how or rather why would interventional split from from traditional radiology? Abbreviating the traditional training (a la the integrated plastic surgery model) might be perilous for an area (at least the vascular areas) that is already heavily penetrated by one specialty (cardiology) & will soon be heavily penetrated by another (vascular surgery).


    4) what is the current state of the art on the AI for image interpretation? Voxel, I figure you might have some insight on this. However, it is very logical that several generations of processing power + software advances could make a reliable system for this a reality within our lifetime
     
  22. MustafaMond

    MustafaMond K-Diddy M.D.

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    I disagree w/ you.

    What else can I say...

    I know very well that MRI is not cost effective yet, but we are talkng 5-10 years here.

    To say that the utility of PET scan hasnt been shown is ludicrous.

    As to the when/how/why of interventional splitting from diagnostic, i would refer you to go to an ICVIR conference and chat w/ a few docs...its already being talked about.

    To who is right, I guess we'll just have to wait and see...Ill bump this thread in 2008 and we can see who is right.
     
  23. embolicintent

    embolicintent Junior Member

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    I too would have to disagree with you somewhat Dr. Oliver.

    My $0.02

    1. The cost of cardiac MR will not be a major factor as most medical centers and imaging centers already have capable magnets. The cost comes to a great extent from software. The tremendous amount of money that is currently spent on cardiac imaging (Echo, Nuclear, Caths) would largely be redirected rather than additional. It is certainly unlikely that MR can replace all of these modalities, but it can replace a lot. It can certainly reduce radiation exposure which is a big deal. We have had two cases in the last year of cardiologists causing radiation burns on patients. I do agree that is a ways off, but to deny its potential would be foolish and in the long run quite costly.

    2. I attend thoracic malignancy conference with the oncologists and CT surgeons weekly and greater than 50% of or cases have and rely heavily on PET findings. Cost is an issue because of cyclotron availability, but in major medical centers PET is a crucial part of staging and follow up for certain malignancies (Breast, Lung...). Thus many centers cough up the money for a cyclotron and then cost is not a real issue once the machines are paid for. I agree that is is not very good for certain malignancies and a great deal more research must be done. However, it is rapidly becoming an important part of oncology and like so many things in medicine that effect mortality, we cannot wait for the results of such research; most of it will be retrospective.

    3. As for vascular/interventional becoming a separate specialty, I agree with you 100%. It is not likely and I sincerely hope it does not occur. As for cardiology, most interventionalists are not concerned with them intruding. The simple fact is that interventional procedures are dangerous and bad results happen sometimes. A cardiolgist in a court of law will have no more justification for doing procedures outside of the heart than a dentist doing plastics. An expert witness radiologist would eviscerate them. Besides only the really greedy cardiolgists even try to do procedures outside of the heart such as renal artery angioplasty. As far as vascular surgery, while we do butt heads frequently, we are on the same team and in private practice it is seldom ever a problem. As for things like AAA stent grafts, vascular surgery will likely win that battle because they see the patients in clinic. But, if the vascular surgeons want to do the thousands of mind numbing dialysis declots and innumerable PICC, TEMP, and PERM cath placements, then I doubt many interventionalists would mind. I don't think that is why they went into surgery. Most Interventionalists are not driven by case load and monetary benefit, but rather by challenge and interest. Developing new procedures and finding better ways to accomplish goals without major risk and morbidity is what drives most. We can generally make just as much money reading films, but frankly interventional is a blast. There will always be turf battles, but interventional is not going anywhere. Interventionalists do not want to be surgeons and I doubt that surgeons want to be interventionalists. [quietly stepping off of soap box]

    4. As for computer interpretaion of imaging it is akin to DaVinci replacing heart surgeons. It is a machine and does not think. If it could, its first thought would be "I wanna get paid". The development of AI in radiologyhas mostly been in Mammo where busy centers use it to screen films after the radiologist and point out areas that might need further scrutiny. It is very useful because we are often busy and rushed and are afterall human. We miss things. Most often the computer points out normal findings, but since every breast doesn't look like the one Frank Netter drew, the machine can't tell the difference. Ever seen two people with identical chest x-rays? How about the same person on the same day with identical chest films? It will get better. However, for a clinician to rely soley on a computer screen would be lunacy. It cannot think nor more importantly judge. What it can do is help a radiologist be more productive and effective.
     
  24. Voxel

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    #1. If Cardiac MR and conventional tests have similiar receiver operating characteristitcs (sensitivity and specificity) AND the cost is similiar then it will/can replace diagnostic angiograms and cardiac stress tests for perfusion or wall motion abnormalities at without the effects of radiation.

    #2 CT/PET is being routinely used and has been proven effective (additive information usually sensitivity) for certain types of lung cancer, lymphoma, and a variety of other cancers. It is just a matter of time before more hospitals aquire the equipment not only to aquire images but to produce the radiolnucleotides used in PET. Many solid tumors are *routinely* imaged with PET/CT even without definitive studies at Cancer specific hospitals.

    #3. I have heard of the buzz about this, but politically it would be a tough thing to do. However I'm not sure what the future of IR is anyway.

    #4. Technologically the mammo AI is very weak, it mostly points out normal findings, but on occasion does help the busy radiologist examine some area of interest. So unless there is some drastic increase in the "robustness" of AI, technically speaking we are a long way off. Politically speaking, it would be very tough sell as radiologist would fight it. Liability: Also, you would have to get hospitals and current referring physicians to take on legal liability of missing a finding or misinterpreting a finding. You would have to get patients to be comfortable with a computer reading and giving you (or missing a diagnosis). The software manufacture may have to be willing to take on the legal liability of claiming to be able to see the abnormality (or no abnormality) and providing a reasonable differential dx and the consequences such as sending someone to biopsy unnecessarily, or missing a diagnosis.
     
  25. MustafaMond

    MustafaMond K-Diddy M.D.

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    Voxel, I totally agree, that there is a big liabilty issue, and maybe in the future, it will be circumvented...i mean...internists can do echos now, and Im sure that when they started that, the cardiologists raised hellfire, just like rads guys are going to, if AI becomes reality for Chest films/CTs , etc.

    I disagree w/ your assumption that the AI is not yet good enough. AI mammo, is pretty "robust" right now. Check out this new article in Radiology. Lots of guys in the community are using "R2", and AI image reader for mammo.
    Some images:

    [​IMG]

    Article on AI Mammo

    [​IMG]
     
  26. droliver

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    I think I was misunderstood a little with my point about MR & the cardiac imaging. Each MR unit is a huge capital investment that requires a large amount of space as well as additional fixed cost for maintainance & staffing of the machines. As it stands @ all the facilities I work at (5-6) you can't just "send them to the MRI" for non-emergent scans. There are often long waiting periods for what is precious magnet time. This should improve somewhat as more scanners are bought, but this is going to take a long time in many hospitals for it to trickle in for cost issues. Also consider the smaller hospitals that are regional med. centers with cardiac programs. Keeping a CT scanner @ places like that stress their budget, and now you expect them to invest more money to add another scanner to replace a satisfactory technology for cardiac imaging. My point was, not that MR won't replace current practice, just that it is alot farther off from WIDESPREAD adoption than the 5-10 year estimates that were predicted due to the economics of it.


    Also, I don't argue that PET imaging is not an advance, but PET scanning still has a long way to go before it's proclaimed as standard of care for follow-up of many tumors. For widespread adoption of it with its costs, you're going to have to show some survival benefit from some of the information you get with the various tumors. Right now for many tumors it gives information that may ultimately not mean much in the way of improved outcomes. With scarce health care dollars, the people who pay the bills will demand outcome-driven based practice.

    Emobolicintent- the battle for advanced endovascular tx. and even arteriography is absolutely a financial issue b/w the 3 fields involved in it. In point of fact, cardiology has prob. been the MOST aggressive about many of the peripheral vascular & carotid stenting procedures being done as they look for new sources of revenue (with the new generation of cardiac stents that appear will be much longer lasting & decrease the number of repeat procedures done per patient). Talk to the cardiology fellows where you are & ask them about the hottest topics @ the meetings - they will tell you it's non-cardiac endovascular. These are high-paying procedures & as such become very attractive to all involved. As far as liability, I don't know why it would be higher for cardiology over IR, they certainly do more endovascular work than almost any IR & can point to their #'s to document expertise (it's not really a large technical stretch to go from cardiac to peripheral angioplasty & stenting). I think a source where your liability arises is if you aren't able to have surgical backup for it- a very real strong-arm tactic that I bet you see in the future from the vascular surgeons in some hospitals (It will prob. divy up piecemeal in most places & its not clear to me who will be the major player)

    The AI prospect is interesting. It just seems logical @ some point that you can get the software to perhaps outperform humans (after all it could have a database with billions of images to compare to)

    Great thread guys!:clap:
     
  27. embolicintent

    embolicintent Junior Member

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    Radiology is a field that is constantly having our nuts cracked by blind squirrels. ER is trying to make off with our ultrasound (Visions of a circus monkey with a football come to mind). Cards and vascular are circling lower and lower on interventional. Ortho wants to read their own films (Just waiting on that Black and Decker MRI for dummies book). Why the hell doesn't anybody want nuclear medicine and defecatography? How about Mammo; any takers?

    I think you are right about vascular and cards because vascular has taken such a hit from endovascular that they have to adapt in order to survive. Cards on the other hand are like fleas. There gets to be so many on one poor anemic mutt that they have to start jumping on other dog's a$$es just to survive.

    As far as liability goes, you are probably right there too. I wouldn't let most cardiologists snake my toilet mush less put a wire in my artery. I have heard them stand around and talk about patients dying on the cath table like it was a bad round of golf. If the government hasn't restricted them yet, they aren't likely to start now. Heck let's let them embolize cerebral aneurysms too; after all they are fed by the heart.

    As for AI, go watch the movie it is much more plausible.

    Anyhow, I am rambling and getting off the subject and I only do that at work.
     
  28. Voxel

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    Dr. Oliver, in fact while CT/PET may not alter mortality (kaplin meyer curves, etc), it may upstage (or downstage) disease making it better for patients to get the appropriate treatment based upon better staging. This is a non-financial but very persuasive arguement especially since we are talking about cancer.

    Also, CT/PET may also save money to find disseminated disease where an operation would be not be appropriate anymorer thus saving healthcare dollars that would have been spent on the operation and pre and post op-care. Whether this financial benefit outweighs instances where PET imaging downstages the number of CT findings, which may justify additional treatment, is a matter of debate.
     
  29. Voxel

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    Just because a general internist can perform echos does not mean that they are not open to the same legal liability issues. This is what keeps different fields especially primary care from performing special procedures. They are afraid and given the current state of malpractice in this country, I don't blame them. If that general internists misses a finding he'll get fried on the witness stand by his friendly neighborhood cardiologist. Also, if you think the cardiology group in a hospital are going to let the hospital credentialling committee ok that general internist to do *inpatient* echocardiograms then I have a bridge for sale in brooklyn with your name on it. ;)
     
  30. Voxel

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    I have seen the R2 in action and it isn't as great as the hype it's made out to be. But it does work well enough that radiologists (not breast surgeons, or internists for many different reasons) are willing to buy the machines themselves because it does occasionally point out areas of interest. It continues to point out areas that are normal.

    In fact mammography is a very specific application. The question for the software application really is, "Is there any abnormality that has the characteristics of breast cancer taken on mammography?" The AI is far off for being able to answer the myrid of clinical problems that can and do arise among diagnostic imaging tools such as CT,MRI, U/S, plain films.
     
  31. MustafaMond

    MustafaMond K-Diddy M.D.

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    :laugh: The thing about cardiologists is hilarious!

    I actually did watch AI, and I loved it. Again, we are talking 5-10 years down the road...the way things are going, with everything getting filmless, I bet a Plug-In image processor, that would identify possible lesions, is not far away. As far as this software being sweet enough to read better than a radiologist...thats more of a stretch, I guess.
     
  32. dEviantrAdiologist

    dEviantrAdiologist Evacuation proctographer

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    This is very true. One of the major hurdles to other specialties encroaching on Radiology is the liability involved. If an ER doc does a "Fast Scan" (ultrasound) they are held to the same standard as a board certified radiologist, fellowed in U/S. In these cases, it is very hard for the ER doc, if he reads the scan incorrectly, to protect himself from expert witness testimony. In theory, a Psychiatrist can perform open heart surgery because they have an MD after their name, but if any complications ensued they would be held accountable as if they were a CT surgeon (no hospital I know of would give priviledges like this, nor would any patient in their right mind allow them to be operated on in this way).

    What I think is interesting is cardiac nuclear imaging/MR cardiac imaging. Some of the advances in this field are coming from cardiologists, and if they get ahold of some magnets, we might see a board certified cardiologist fellowed in MR Cardiac imaging and Intervention.

    My questions is, how do we protect this turf? Does the RSNA or some other organization need to make a formal stance on this issue in order for other specialties to keep their hands off? Will it have to happen on a local level, with radiologist's striking in order to get professional attention? Thoughts?
     
  33. droliver

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    Voxel- nice points about the PET


    dEviantrAdiologist - I think the spectre of liability for interpreting FAST scans (trauma ultrasounds) is not real. It's more of blunt screening tool (yes/no for fluid) rather than a formal imaging study requiring much interpretation. There are now multiple studies documenting very high sensitivity for intraperitoneal & pericardial fluid of the test in the hands of surgeons (it was 100% here for several years worth of published data in appropriate patients) & I'm sure similar data exists for ER physicians. What's more is that there is usually no photodocumentation kept that could be pointed to to show that you "misinterpreted" the study. As long as you're familiar with contrainidcations of the technique and indications for further imaging (pelvic fx., lower rib fx., obesity, persistant abdominal c/o, lap-belt bruises ) you're on pretty solid grounds. We frequently use it to identify patients we feel do not need routine further CT imaging of their abdomen. I think most ER physicians today would still prob. proceed with CT scans in all but the most minor blunt trauma patients or have surgical consultation to clear the abdomen for liability shifting reasons. This may change as more EM residency programs put more of their graduates out there post 1999 (about when FAST really caught on) who feel comfortable with the technology
     

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