Where Are We Today – Conclusion and Questions | Prostatic Artery Embolization
Where Are We Today - Conclusion and Questions | Prostatic Artery Embolization
Where Are We Today - Conclusion and Questions | Prostatic Artery Embolization
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alright so where are we today with tae Seok eh it's performed all around the

country papers have come out of eight different countries at this point so it's all over the world rather in the u.s. tae is not FDA approved if you're treating lower urinary tract symptoms okay hopefully a couple in bollocks will

soon get indications for for bph were hoping on that it however if the if you're bleeding if the prostate is bleeding that is approved that's an indication you can treat or if there's a hyper vascular cancer which we're not

really doing that often but that's something that you can treat as well with FDA approval so just to conclude so pae at this point is shown to be effective in reducing the prostate improving urinary symptoms and the best

thing about PA is is very safe alright so we had one major complication out of 600 cases it's just a really safe procedure hopefully it stays that way there won't be you know more major complications coming out but that's

really the selling point of it right now and the other thing is that for men who have particularly large prostates which is considered probably 80 grams and above Terp is not the ideal procedure at that point they usually have to go on to

something else like an actual open prostatectomy or a laparoscopic prostatectomy or home IAM laser which is another option but that's where pae really can can fill a void or be a better option on the bigger prostates

alright thank you [Applause] ya know is bilateral each time yeah the pictures i show you are single but we aim for bilateral each time and we do that in about greater than ninety-five

percent of our case yeah yeah that's a really good question we're trying to figure that out right now I think there is but we need to we need to study and figure out what it is exactly so potentially so you know some patients

who go on to have brachytherapy there's a size limit for brachytherapy so it's I think it's about 60 or so so some patients have their prospects are too big so we can potentially reduce the size of their prostate and then they can

have brachytherapy which would be good another thing that's potentially out there is that post radiation a lot of patients get bad urinary symptoms so maybe we can do something with that if we do at post radiation but the problem

with that is you can have radiation arteritis like the arteries can get all ragged and then the thing they published at a miami just on treating a materia in prostate cancer [Applause]


complex than adult stroke symptomatology is more varied our curiosities are really important cause pediatric stroke as our other causes cardio ambala

dissection venous thrombosis metabolic we didnt talk about but it definitely involved theres a new classification system and nomenclature for pediatric stroke meth called cascade and pediatric stroke centers are stream of the first

of all were forming pediat primary pediatric stroke centers and because we're doing that we're streamlining and making treatment of pediatric patients more rapid and we need a higher index of suspicion we need more rapid stroke

imaging we need a faster activation of the pediatric stroke service just like we did in adults and if we do all of that our neurological outcomes in our little people with their strokes is going to be improved and they'll benefit

for the whole rest of their hopefully long lives and thank you very much [Applause] how many pediatric stroke centers are there throughout the United States at the end of the trial in 20 I don't know

what is today but the end of the trial in 2013 there were now 17 certified pediatric Primary Stroke Center and I think a lot of us are building stroke teams the amount of regulation is breathtaking if you've ever put together

an adult system you know it takes several years and they're reams and reams of paper will have to go through i'm trying to convince our group right now that we must get a nurse coordinator if we really want to go to the next

level right now i mean our biggest job is launching and most of the most places like us you have to have a full team that has ed Rapid Response pick you we have I mean it's like there's like 15 people to get notified every time a

child as a stroke as opposed to like five people every time an adult gives a stroke so a lot of places like us are aiming towards becoming primary pediatric stroke centers of our goals we status 2018 if you can probably be 20 19

but there are some truly up and running pediatric services near the questions of that precede you I think thank you i'm curious some with the UM what is your H frame for the when you talk about pediatric stroke up to adolescent 15 16

and and the different entities that you mentioned are some more common in let's say the teen age and the preteen area of the you know age and the other question is mo Roderick Strong how that's more common i suppose and children then we

think in adults like twenty percent of all strokes what is what is your experience with that i didn't talk about humoristic if i only had an hour like a two hours they could have been covered all hemorrhagic hit our

institution in most places p.s because anything under the age of 18 so 18 is the cutoff and once you're 18 and older than they are considered results and they're treated on the adult side so we recall that the big house they go to a

big house when they're 18 above they say the Children's Hospital when they're below 18 I think most Pediatrics ischaemic stroke is underdiagnosed and so I don't really know that your incidents clearly if you believe you

shows up on a scan and you see it big and dramatic the things that happen to children fewer aneurysms and children although can't have them like be true aneurysms even book a child five years of age the youngest i've ever treated as

a brain aneurysm they have a fistula they have a BM they don't tend to bleed as much as adults to bleeding julia starts often at the age of you know in the 30s you have native galen malformations could mildura lady fistula

and the vein of galen most of those children don't forget when the hemorrhage although they can neural and choroidal there's a lot of other than two entities that we're not going to talk about today because it's just lack

of time I just wanted to focus on a scenic cause of stroke in terms of what is the most common I think if yo pathak is probably the most common still we still don't know i think infectious etiologies under recognizes

under-diagnosed so you were to look at everything i would say probably the perfect storm is like the child I had in the hospital right now her grandfather has a coagulopathy he's been on khuvon in for Pease and DDT's of pts and she

was 20 she gets six of the cold comes in correctly every vein her head fly off so she has underlying coagulopathy and she just hydrated and we have the perfect storm question yeah first I want to thank you you know the passion you give

with your presentation you know it's really enjoyable and kind of palpable but I also want to ask you know in regards to nationally our people really kind of on board with the same type of protocols you presented or is it you

know you know your uniform to where we are lagging way behind the adult side but there is a true passion out there to develop pediatric stroke services and I reach when I was developing hours along with

my colleague we I reached out to Bob some children's I big sales to Seattle I reached out to Cleveland and they were so generous I mean people share the order sets they shared their protocol I'm happy to share with anybody that

wants the data that we have I can give you a list of all the people that you need and so this is kind of a grassroots effort it reminds me of 20 years ago with adults I think we have work of dedicated people that treat Chuck

pediatrics we have in the neuron adapter world we have we're developing just a pediatric subsection 2 sniffs and to all these other things and Darren Orbach in Boston Children's and I were talking and there's a whole people around the world

we're getting just the peach people I do adults too i mean i do everything from burst ninety-year-old but but you know not everybody wants to pee and so we're trying to just join you have a little log in truth now so that we can ask each

other questions show each other cases so I think this is really guilty and I think every children's hospital she you know Big Shoulders hospital needs an organized team like this and the smaller hospitals around us need to recognize

that this could be a stroke and get these kids to us as fast as possible yes sir I think I think the passion is real as the few and it's the fourth line and one last question on average monthly how many Pete's droves to you treat yeah if

you're talking about just arterial that go to the angio suite we probably get we probably take about one every three months to the enviously you're just looking at arterial if you're looking at venous occlusion we probably take maybe

two kids a year that's because we're really aggressive on the medical side I'm aunt actually living in that child rooms is wednesday you know i am there i am there I on the phone i'm checking i'm getting up in the middle of the night

second second second laughs because it is absolutely essential that you keep that child hydrated keep that heparin high and you have to no one else is going to drive it like you're going to drive it so you know thank you again hey

um in the same vein of the increased passion for theater stroke how do you increase the the heightened awareness in ed even if I mean how do you balance that with you know judicious use of imaging it's clearly not practical to

send every kid even for a 10 minute stroke MRI yeah there are places I went to two years ago to a stroke meeting and one of the guys they had an mr in there ed never Nikki room in any k to Compton it has the first time see you go

straight to the skin and they do a VW is a bed now that's the perfect world we don't live in the perfect world so if your kid comes in to have a seizure and has some transient neurological deficits and then completely normalizes that's

the kids it probably is a lower risk for stroke whereas if that kid comes in with a seizure for example and has persisted many characters that has a stroke until proven otherwise do you guys do a little bit of clinical you know work on that

and then what other illnesses that the child have is that or do they have a history of a mimic or something like this but I think we have to have a bunch of false negative we have to be aggressive that means you have to put

some resources into it that's not just for mr and see imaging that can see the angio sleep we are possible to invest in more technologists we need are technologists not to be working around the clock all

the time they need to be hostile acts is recognized that we're asking people to do this we need more of them and they have to be supported facing for our nurses this is truly a team effort not one person can do all of this in a

vacuum the other answer your question is education we are we are planning on our small strokes group which which has ed representation 50 representation pharmacy records representation we're going to go give grant around all of the

people that we think are gonna see these children and try against you know educate the residents to know our trainees as well as all the nurses and other staff what to look for but the first thing is just be suspicious and I

would much rather have you know five or six negative scans and miss that one child 10 negative scan then miss miss miss net1 childís you'll all have that window of opportunity to close this and then you've got nothing you can do yeah

thank you [Applause] [Applause]

advance and interventional radiology is the introduction of endovascular aortic repair and thoracic aortic repair. So once upon a time if you got it an

abdominal aneurysm. The only way to repair that abdominal aneurysm was by reconstructing your abdominal aorta. And that was a very invasive procedure. So essentially what would happen is we

would cut you open you cross-clamp the patient's aorta you have to provide perfusion has to be involved you have to provide circulation for the patient during the procedure and you would end up with something like this. So

they would take out the abdominal aorta I'm sorry they would take out the aneurysm they would anastamose the graft in in the abdominal aorta they would bring it down and they would anastamose it onto the patient's iliac. And

so through years and years of research and advancements we are now able to perform the very comparable surgery endovascularly. And so some patients in this day and age are still treated with an open repaired depending on the extent of

their pathology. But a lot of patients today that come into hospitals with abdominal aneurysm are going to be treated through accessing the femorals and putting in a graft that excludes the aneurysm but allows for flow down

through the aorta. And so this is an angiogram of a patient that has received an abdominal endograft. And so you see the abdominal aorta here you can see that the proximal fixation you see flow you don't see any sign of the aneurysm

filling because it's been excluded by the graft. And then you see both of the iliacs filling and then going on down to perfuse the legs.

go through a few example cases and kind of show how we use the technology so this was a kind of you know standard bph patient a 67 year old male had lower

urinary tract symptoms or Lutz as we call them secondary to bph and he was treating that with flomax his ipss was 18 which is the high moderate so it's pretty bad and a prostate volume of 80 which is a pretty large prostate normal

is 30 so that's over twice normal and so here's the angiography and we can see that the catheter is here we're injecting there's supply to the prostate here but there's also this straight artery going down and blush a little too

low okay and so especially in the beginning when we started doing these cases we did a lot of cone beam CT to verify where our contrast was going and then where our particles would go and so here's the cone beam CT that's

associated with that and you can see right here we have wrecked them down here and prostates or more up here and we have contrast within the rectal wall and so obviously that's not we don't want to inject particles because we

don't want to embolize the rectum and this is just we verify that we advance the catheter into this straight artery and what you see here is a connection to the superior rectal artery which arises from the

inferior mesenteric artery and so that verifies that this is rectum and so what we did was we place the coil in that straight artery going down hold and then injected again did another cone beam and now in this cone beam you can see that

the prostate the left hemisphere is enhancing and the rectum is not and so that's how you protect the rectum when you're doing that embolisation so I was good to protect the rectum alright so it's been follow-up the patient had no

rectal bleeding which was good he did have a prostatitis that we treated with antibiotics and nsaids at 1-year follow-up his IPSS had gone from 18 25 which is a great result his quality of life had improved from 4 to 1 which is

basically like terrible too good and his volume had dropped from 80 to 82 56 and we got him off his flomax second case

procedures other life state...saving tools of the trade that we've been able to implement over the years...

DVT. So I do not like venous disease I enjoy learning more about it I enjoy learning how to more efficiently treat my patients and buy by them other options. But the thing about venous diseases is it's oftentimes by no fault of the

patient themselves. So it's either hereditary or they were on a really long plane ride or something has happened. The problem with venous disease is once you form a blood clot in your leg it leads to a whole host of problems. And

one of the biggest problems is the development of pulmonary embolus. And so oftentimes these clots they won't stay stationary in your legs they will break off and will travel to your lungs. So this is a pulmonary arteriogram this is the right

pulmonary artery and you see all of these filling defects out here. And this is a patient that has suffered from some massive pulmonary embolus going out into their lungs. And so the early treatment for pulmonary embolus was

to perform either you would cut down on the cava and you would put on like a cable clip and what this would allow for you two for the patient to do is you would still have blood that was flowing through the IVC and returning back to

the heart but you had all of these kind of dividers that would catch any sort of large clot. Your body's throwing clot on a routine basis it's just throwing it at a small enough a small enough amount that you can deal with it.

So any sort of any clot bigger than what this cable clip would allow would would go through. And so what we can offer now to patients instead of cutting down on their abdomen and putting in a cable clip is we can put in what we call

an inferior vena cava filter. And the inferior vena cava filter goes in through either their internal jugular or the femoral vein and it's just it's in their inferior vena cava and it catches any and all ...well.. catches the majority

of the clot that anything that would come from below. And so we place these in patients that are many of our trauma patients that are going to be unable to be anticoagulated for long periods of time that are going to be immobile that

are high risk for DVT on patients that are going into surgery they're going to be immobile. Anyone who is at high risk for DVT or has a known DVT and we worry about that breaking off and going to their lungs they're all pretty good

candidates for an inferior vena cava filter. So in another big another big

So this is a case of an IVC reconstruction that I did several years ago with a bit of follow up on.

This is 45 year old man who had huge bilateral leg swelling and pain. He had been initially diagnosed several years previously with thrombophilia protein c positive, multiple bilateral DVTs and was a lifelong coumadin. He had had a trapease filter placed in the past in 2001, and when I saw

him he had multiple issues including evidence of advanced PTS in his legs and very debilitated by his legs swelling this was the initial CTV, you can see his filter in place there with no caper/g below it, and then down in the pelvis just a mess of vessels bilateral/g So I did what I considered to be our standard approach which is where I accessed antegrade and fortunately his groins were open, and

worked through these mess of vessels until we came up to the filter. On the right side, you can see that we were able to recanalize into the right side of the filter, and then as we came across from the left side accessed into the same right side of the filter, and you can see all this chronic stuff there within the filter very embedded nasty looking

thing. After a bit of ballooning, founder cells to be still, apologies for the transitions, that there was still occlusion despite ballooning, this is not a surprise, pretty much always gonna have

to stent these edge, but the decision now was whether we were remove the filter, according to what Mark said he does it in every case I guess I'll have to change what I did. Crush the filter with a cable stent such as a palmaz or a stench through it. Now I will say that we removed the vast majority but not 100% of filters, and part of the reason that

I did this, this way at that time was that about a week or two beforehand I had removed a three year old optease, and you can see what had happened and it sliced open the sheaths that I use to as part of a sheath system to remove it. There were struts coming out

through the sheath and then this is how the filter came out just this manual thing, so I elected given recent history to stent through this filter. So the first thing I did was removed my left sided access form the right side of the filter and recanalize the left side of the filter. I thought this was important so that we'd be able go get a kind

of a kissing stent through each side of the filter rather than having the two stents coming up through the narrow struts, and then stent it out and brought it up. And he did excellently. So this was back in 2009 very good antegrade flow.

He did come back once in 2015, he came back with a re-occlusion of his left sided system, you can see here in his pelvis, and it extended down into his femoral segment, went in from the popliteal,

same sort of idea in this case the arrow's on the TriForce sheath which are required to get through his very chronically occluded femoral segment, and then got up and through everything in the pelvis and then you can see after [UNKNOWN] and the extension of the stents a little bit further in the pelvis than the [INAUDIBLE] opens, so. This is six years and I guess the secondary patency,

that's very good there. So the take home I think from this case is that I believe there is actually good patentcy if you stent through the filter but they obviously do require a follow up because of that secondary patentcy issue.

had developed our stents we had created some clots we've figured out how to deal with the clots and something that we were still struggling with was

organized clot. So if the clots sit somewhere for an extended period of time it becomes progressively more organized which is what plaque or atherosclerosis is. And so be the traditional treatment up until again interventional radiology for

atherosclerosis or for plaque was to just do a surgical bypass. And so here you have a surgical cut down. This is the beginning of a graph that they're going to sew onto the common femoral artery. They're going to tunnel it under the

skin and they're going to reanastamose it onto the popliteal. And so again you can imagine this involves a hospital stay this involves an OR this involves you know an ICU team. And so now what were able to do is we actually have

multiple different atherectomy devices that are out on the market and what the atherectomy devices allow us to do is allow us to treat the organized clot. Some of them are going to treat the plaque by this one is cutting it and

packing it into this little ... what are we going to call this .... this little nose cone if you will. And we have some that essentially act like drill bits. They go in and they they orbit and they will tear through the atherosclerosis that

way. We have lasers that we'll utilize that will treat atherosclerosis. But this was a big step because this allows us to this allows patients that otherwise their only option was to have a surgical bypass to actually have some sort of

endovascular procedure that would resolve the existing atherosclerosis. And so here we have a patient who we had not too terribly long ago. So again just to recap this is your common femoral your common femoral divides into your profunda and

your superficial femoral artery and you see a big chunk of the lumen missing right here. So we went in with this atherectomy device and basically just shaved through this. And you see the lumen completely restored after this. You

see straight line flow from the common femoral the profound and the superficial femoral artery. And so other life-saving

started this talk I said that nanoparticles are all around us and we see them every day and we don't even

know about them I was going to give a talk about nanoparticles over in Europe and I was in the O'Hare and on the wall they had all these images of nanoparticles as art so not only are we using them in science and and everyday

use they're also art and I think I'll stop there happy to take questions and of course these are all my collaborators and everybody that helps do the work at Fontaine dr. Emerich satisfied [Applause]

are there any questions for dr. white were any of the other presenting I'll tell you dr. over just asked me was that me parachuting no that's not how it broke my foot so that's a picture of a patient and I always put that at the end

of all of my talk so I should have explained that so I had a patient that came in to me and he was given a terminal diagnosis I said you have a to see and you three months to live and you're going to die because he had

metastatic disease on presentation and I saw him because they had put a chest port in and know they were doing a lung biopsy to see if it was a met and while they did we're doing a lung biopsy they they caught in pneumothorax so they

called me and I said can you come run and put a chest tube in and I said sure and then i said what is the biopsy for and they said oh we think it's metastatic HTC i said well what do you mean he has a terminal diagnosis we can

treat this and so we treated him we treated him with seven conventional T mobilizations and he actually lived for three years and his goal was that he wanted to go parachuting with his son when it's done turned 30 and that was

him parachuting with the Sun we turn 30 and so going from a terminal diagnosis of you have three months left to live or not 23 years later parachuting was a son that's why i always put this at the end of talks because i always want to

remember remind myself why we do this not just the fancy technology but it's the save patients life or to let them live longer [Applause] the reference so there there are

actually trials in humans and we've we've phase 1 phase 2 trials there's a lot of stuff being done by the ablation ests because they think that this nanotechnology can increase ablative capability so there's doxorubicin that

has sort of been utilized what's that now that's it yeah so that we have these these nano particle like doxorubicin structures that they've been using to see if they can increase ablative technologies there's a lot of stuff in

the breast that they're using nanotech nanoparticles for so it is in human trials that that slide I gave you with all that that list those are all human trials clinical trials going on at Santo technology so it's out there it's being

used a lot of the gold stuff that I talked about is actually not you know FDA approved for certain uses and can be used for ablation

who are postpartum who are experiencing a pretty significant blood loss that they can't find a source for. We can go in and we can perform these procedures and

essentially save their life. And so again here we have this is a much cleaner picture text books are always so much cleaner than real pictures so you have your abdominal aorta you have your iliac coming around you have your fibroids and

you have your tiny little microspheres going in here and shutting this down at the capillary level. So embolic agents injectable agents has also allowed us to play a major role in the treatment of certain types of cancers. So prior to

interventional radiology getting involved with hepatocellular carcinomas and different types of liver tumours there was no great therapy for HCC or metastatic liver disease. It doesn't respond very well to

chemotherapy and so ultimately what would happen is these patients would be left with having surgical resections. Or their life expectancy would be greatly reduced simply because there was no means to treat their tumor. And so

interventional radiology...we're great at embolising things we're great at selecting tiny arteries and so what we would do and continue to do and continue to research in is we can get super selective and we can inject chemotherapy

into these tumors that are in people's livers that before just didn't respond well to systemic chemo. They don't respond well to systemic chemo but for whatever the reason they respond well to chemotherapy when it's directly

injected into them. What we can also do while we're in there is we can inject the chemotherapy agent and then we can also injected an embolic agent so you have the chemotherapy and you have the atrophy from the lack of blood supply

that's helping these patients as well. Finally one of the last things that I'll

2000 and that's when the case report came out that where a patient was having bleeding from his prostate he came in to have that bleeding treated and when he came to follow up they noted that his

urination was better and they said wait a minute maybe there's something to this if we embolize the prostate maybe we can help people urinate on well then throughout the 2000s this concept had to be proven and before it could be tested

in humans it had to go through animal trials and so that's what happened during the 2000s this is a particularly interesting trial I thought they did it on pigs they did prostate embolization and they wanted to make sure that it did

not affect sexual desire so they embolized these pigs and and then they basically took the pigs after embolization put them into the same sky or whatever with thousand heat and judged rated their performance

and the male pigs did just find so there was no loss of sexual desire and the male takes so this helps get this on to human trials the next kind of phase of

nodularity and it's best seen because of these linear echogenic

bands, which are bands of fibrosis. In this patient, the surface nodularity is not very apparent, using a curvilinear probe, but then we look at the same patient with a linear probe, we can start to appreciate the smooth angulations on the anterior surface of the liver that is definitive for cirrhosis, as a direct sign.

[BLANK_AUDIO] In this patient, we can see that the ascending branch of the left portal vein and the horizontal portion of the left portal vein have enlarged because of the portal hypertension. The medial segment of the left lobe, that lies to the right of the ascending branch of the left portal vein, has decreased in size, and this leads

to widening of the falciform ligament, and also the change in the axes of the ascending branch, which starts turning towards the right. [BLANK_AUDIO] In this patient we can also see that there is widening of the fossa for the ligamentum venosum because of some atrophy of the left

lateral lobe and the caudate lobe as well.

So our procedures aren't solely limited to the vascular system which is another great

thing about IR like I said in the beginning we have the privilege of interacting with most services and almost every patient demographic. So don't know if you've had the luxury to take this kind of KUB yet where you see

the renal pelvis and calyces filled with stones. And so in many of the stones that our patients develop they can either pass on themselves so they can be treated with some sort of therapy. But staghorn stones and and very large

stones aren't able to be resolved as easily. And so essentially what used to happen is if you had a staghorn stone and it needed to be resolved they would cut down on your kidney and they would pull the stone out. And so

what we've done in interventional radiology is we've taken the Seldinger technique... the needle wire access sheath... and we've applied it to other organs. And so a service that we provide for your urology is we will put a needle in the

kidney we will put a wire in the kidney will put a transition dilator in the kidney will put a much bigger sheath in the kidney and will provide them a conduit to then go in and break the stone up with ultrasound. And so like I

said our procedures aren't solely limited to on the vascular system which is fun. So as arteries and veins... I'm sorry not veins... as arteries travel away from the heart you guys know that they get

progressively smaller and so in the early days we were having a lot of technical success with doing interventional procedures in larger arteries because we had larger inventory. In the last 15 years and someone

the audience can correct me if I'm wrong but in the last 15 to 20 years we've had the introduction of micro catheters into our field. And so what microcatheters have allowed us to do is to start to do effective and efficient treatments in

the smaller arteries. So we had great ideas for getting there we just didn't have the tools. And that's the ongoing story of interventional radiology and again another thing that makes it so exciting is that your limited solely by

your imagination. If we understand the pathology and we understand the anatomy we can create the appropriate tool to treat it and that's one of the things that led to the intervention... invention rather of microcatheters. So

what microcatheters are is they are catheters that are obviously much smaller than our traditional catheters that we utilize every day. And what they do is they give us the luxury of introducing smaller materials and getting to smaller places.

And so fortunately or unfortunately most of the time when patients are experiencing some sort of bleed whether it's a mesenteric bleed whether it's a splenic laceration whatever it may be

I'm oftentimes it's a very very tiny vessel and its way out there in the

weekend so I'm going to and jet pretty soon after this talk but I will spend a little bit i'm in the lobby if you have any questions are interested in getting involved in this procedure please and

don't hesitate to come and talk to me. I would love to point you in that direction because I'm like I said with Dr. Seldinger her when he started developing his techniques he was a student and there's been countless other

students throughout the years that have developed things that have played big big future is it's limitless. The more we understand our anatomy the more we understand our

pathology the more research we do the smaller the stuff gets the more that we're going to be able to do. And I'm very much looking forward to the next 10 years of IR and I hope that some of you are going to be there on that journey

with us. So have a great rest of your weekend and thank you very much for your time and attention.

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