Dr. Chris Tucker:
Welcome to the Arthroscopy Journal podcast. I'm Dr. Chris Tucker from the Walter Reed National Military Medical Center and the podcast founding editor. Today we are discussing the use of virtual reality in orthopedic surgery training. I'm joined today by Dr. Gus Mazzocca, Medical Director of Mass General Brigham Sports Medicine. Dr. Mazzocca was an author on the article titled Head-Mounted Display Virtual Reality Is Effective in Orthopedic Training: A Systematic Review, published in the October 2023 issue of the Arthroscopy Journal. Gus, congrats on your work, and welcome to the podcast.
Dr. Gus Mazzocca:
Hey. Thank you, Chris.
Dr. Chris Tucker:
Gus, the theme for this month's AANA newsletter and our current CME podcast episode is Emerging Technology, so I'm excited to discuss with you this topic of head-mounted virtual reality and how it plays into our surgery training. But first, could you just introduce yourself a little bit, tell us about yourself and your practice and your areas of interest in orthopedic surgery?
Dr. Gus Mazzocca:
Sure. I trained Medical School at the University of Connecticut. My father was an art professor at the University of Connecticut. I did my residency at the University of Connecticut, then did a fellowship at Rush with Dr. Bach, Romeo, Cole, Bush-Joseph, Nicholson, and then came back and started working at the University of Connecticut. I worked my way up to become chairman, then had a little issue with the dean. Then I moved here to Mass General Brigham to be the Medical Director and then the Chief of Sports Medicine at Mass General Hospital.
From a research interest, we call it the three-headed monster. So interested in cell biology and how different biological substances can enact and try to help heal, the body's ability to try to heal specifically when it comes to bone tendon healing. Then moving into biomechanics, cadaver biomechanics where we look at ways to make certain processes stronger, more resilient so that we can decrease the amount of rehab time and get people back faster. Then outcomes, which looks at all of those two items, the biology and the mechanics in real life to see how people are doing and progressing. Education has always been very near and dear to my heart, the residency and fellowship at the University of Connecticut. I'm lucky enough now to be able to help a little bit with the fellows here at Mass General and then some of our residents. So, those are my-
Dr. Chris Tucker:
That was wonderful. I think your experience, especially with your research efforts and also your experience with teaching and training residents, fellows for many years lends itself to having a great perspective for this discussion. On a personal note, I remember visiting with you back during the AANA Traveling Fellowship in 2017 when we visited UConn and had the opportunity to come see you in the operating room. That was a personal highlight for that trip for me, so I appreciate you coming full circle and joining me on the podcast now to talk about education as well.
So, on to our topic at hand: Emerging Technology in Orthopedics. To better frame our discussion, let's first talk about this larger picture of orthopedic surgery training in general. I think we're all familiar with Dr. William Halsted's famous traditional method of see one, do one, teach one. However, that fairly simple summary of an approach to training has some contemporary critiques, especially in the face of patient safety concerns and the ACGME resident work hour changes that were instituted back in 2003 and again in 2011. Could you share with us your thoughts on resident training in general, your approach, and what you've seen evolve over the last few decades?
Dr. Gus Mazzocca:
Yeah. I think probably, and this almost dovetails into our next thing, but I think one thing that's really important, it happens a lot also in coaching, but you have to understand your athlete or your resident, and they're different. Some are very skilled in three-dimensional ability and some are not. It doesn't mean that one's better than the other, but you have to understand where they are lacking and where they are good so that you can concentrate and work on that. I think sometimes in training programs, we treat everybody the same. Right? We want to make sure that they have the whole same experience and everybody gets the same training, but it may not be the best way. So, I think that's probably one of the biggest things that I've learned, and it really became much more apparent to me when we started working a little bit with that VR.
I would say that the concern with the amount of reps that people get now because of the work hour decrease is an issue for a group. So, the group that needs more time or more reps doing something actually gets hurt by that. There's a certain amount of work that residents do in their training, but there's a certain amount of reps they get in the OR depending on the attending that's working with them, how patient that attending is, how much training is going on, and how much confidence the attending has in the resident to execute what they're doing. I think that's a bigger issue, and that's a huge variable that we don't really speak about that much.
It also becomes, it can go full circle on somebody. So, if you're not as good and you need more reps, instead of getting more reps in the OR, you actually get less reps because people are less confident in you, and they're going to give you one or two shots, and then they're going to take over. There's also a lot of pressure on faculty now to become more clinically productive, which means that the amount of time to discuss and work on small little things in the OR is cut less. That's put a bigger impact on outside of the OR surgical skills development, and how do you do that? How do you do that in a cost-effective way? How do you do that where they're actually practicing and you know what they're doing?
Those are all the issues, but I think really trying to understand and work with residents at an early time, speaking to them and trying to really let them open up on what they feel that they do well and what they feel they don't do well, letting them know that that's okay with stuff that they worry about that they don't do well, and then trying to work on that in whatever way you can. There's all different ways. Educators are terrific. People that are dedicated to education really will think up things and do different things based on their own experiences to try to help people. I think that the basis of education is everybody loves education when it's easy. It's when it's hard that the real educators start to have to rise up, and I think that's something that we need to recognize a little bit as well.
Dr. Chris Tucker:
Yeah. I love your approach to the individualization of your teaching. These ACGME workout restrictions, like you mentioned, certainly imposed an external limit on the patient contact hours that trainees are getting. It was interesting because despite the proposed risk to patient safety of overworked residents, which sparked the work hour restrictions, multiple studies have shown since then no actual effect on patient outcome improvement with the more flexible resident work hours, but what has been shown is that the resident work hour restrictions are limiting trainees' time in the operating room. So obviously that leverages the need for these outside-the-operating-room experiences like you mentioned.
I was just curious to know. Outside of virtual reality, which we're going to get to, what's been your experience with other simulation modes to supplement resident surgical training? Things like cadaver models or plastic models or knot-tying apparatuses? What's been your experience with all that stuff pre VR?
Dr. Gus Mazzocca:
I think that when you identify where you may be weak, the problem with all of those things is as a resident you're rotating through multiple services. So to have models that mimic all the different services these kids are rotating through usually doesn't happen. In the framework of say a cadaver lab, there are certain labs that are there, but it may be out of cycle. You may be on pediatrics doing spines when the multilink cadaver lab happens. So, those all sound good, but really I think trying to have individualized practice on skills that the learners may not be good at, I think is really one of the most important things.
So, models, absolutely. Working with the arthroscopic knot pusher for arthroscopic surgery, being able to tie square knots very quickly, sliding knots, knowing what knot your surgeon wants you to use, and then being able to do that, that will allow residents to be able to do a lot more. If the surgeon sees you throwing knots that are good, then they'll be happy to let you tie the knots. You know what I mean? I think that's one thing that happens.
I think also in a lot of times in complex cases as opposed to just sitting out and helping, retracting or watching, as you work with an attending, you can actually ask to do a part of the case. So say, "You know what? For this ACL or for this rotator cuff, the one thing I want to work on is passing the sutures through the tendon." "No problem," right? So now I can do whatever I have to do. Then they can work, and we can spend 10 minutes passing the sutures, talking about that and then go back. Sometimes that takes the pressure off of a faculty member that may not be as confident. The reason why I know that is that's me, right? I'm not that confident in there, so it's harder for me to let somebody go for a long time. I'm not like a great surgical educator in the OR for high-level residents or fellows. I'm much better with the more junior people only because of that, but I think that exists in a lot of realm.
So if you're a resident that may sense that, I think one thing you can do is do part of the case or talk about part of the case where, "Hey, I'm here. I'm watching. I'm happy, but how about this? How about me getting into the shoulder? Spend 10 minutes, let me get into the shoulder, do a diagnostic and then go. Then after that, then I want to do this." So, you can divide up the case into the parts, and then sometimes that allows you to work on those parts that you feel you're weak at. "So, a lot of people get in the shoulder and do a diagnostic. We don't have to spend time doing that, but I want to definitely pass the suture and tie the knots." "All right, that's what we're going to concentrate on."
So, that allows the case to go faster, but the part where the resident really needs to concentrate and learn those skills, then we can spend a little bit more time there. I think that's one thing that I've tried to develop a little bit. There's some unbelievable surgical educators that can let people go, and they can really train them while they go, and they can do the whole case. Those obviously are the best.
Dr. Chris Tucker:
Gus, I think your comments are very insightful where you're recognizing your own limitations in educating. So, not only is the education individualized to the trainee, but it's also individualized to the surgeon. Like you said, these residents are rotating amongst many different surgeons on various different services, and they are getting around the world exposure to a lot of different personalities and styles, but if you as the educator can be at least introspective enough to know how you're best teaching, I think that lends itself to the best possible educator-trainee relationship.
Your experience with dividing up the case and asking the resident about what they want to work on mirrors my own. I've been faculty at Walter Reed for 15 years now. In the beginning, I think I was a little bit all over the place as a new staff letting them do as much as they could do or setting a time limit and then cutting them off, but like you said, a lot of people end up getting really good at the diagnostic scope that way, but then the latter parts of the case, they may not have that hands-on experience. So, I'm doing now what you're doing.
I talk to the residents ahead of time. I say, "Hey, let's have a focused plan. What do you want to work on today?" Just like you said, for rotator cuff, they may say, "Hey, I'm comfortable with the diagnostic. I'm comfortable with everything, but I really want to work on this technique of passing sutures or whatever." Then it helps move through the day, and they get out of it what they want to get out of it.
I applaud your introspection to recognize how to best train based on your personality as well. That being said, I wanted to move on to talking about this new technology, the head-mounted display virtual reality, which your paper was on. Could you just talk to us about just what it is, how it works, what it offers to surgeons and trainees, and just what's going on there?
Dr. Gus Mazzocca:
Yeah, so that's a great question. How it works, I don't know. It's magic, but I will say this. The head-mounted Google glasses or whatever type of glasses you have, it's very interesting to me the first time you put them on. I think the TV commercials for it don't do it justice because your brain really adapts quite quickly to the virtual area. That was really interesting to me from the very beginning. Really, your mind assimilates to the virtual world that you're in, even though you're standing in a room with a weird headset on and two joysticks in your hands. You can see your hands. You start moving your hands. They work. Really, I think from that aspect, it's definitely an emerging technology in the fact that it's just going to get better.
I joke that I went through my life when the internet, computers didn't really exist except at NASA. We started with phones and beepers, and then the beepers went to text beepers. Then there was a Blackberry and now there's a phone that you can watch live sports on. So, that technology has gone. This technology will also mimic it. They'll have a certain number of platforms. The one I do is PrecisionOS. Danny Goel who's a fellow here at MGH, a shoulder surgeon, he is really the CEO of this company, which is really a forward-thinking company. They are working on all aspects of it.
It was funny because I don't think their business model wanted to concentrate on necessarily medical student and resident education, but the minute I got my hands on it, it's the perfect thing for that. I think it's really because Chris, the biggest thing is it's practice. So like we were talking about before, going through a case, that's really a game day situation, right? You're a human being, and it's got to work, and you have to do in a certain amount of time. The longer you spend, the shoulder will blow up, things can start to go wrong.
We call it practice, but it shouldn't be. The VR allows you to practice. Even in a cadaver lab, you can't really practice. By practice I mean doing the same thing 25 times. Doing it, then back to the beginning, doing it again, back to the beginning. In cadaver lab, you can do it once, and then we can talk about the anatomy. We can do some stuff, but you really can't repeat the same thing multiple times on a cadaver. There's some things you can, but in the VR world, you can do whatever part of the case or however you want to do it multiple times.
Plus it also allows you to see in three-dimensional a lot of different aspects. I know in the specific one that we use at the University of Connecticut, they had a SCFE module, which I liked because when you pin a SCFE it's a different direction than when you're doing say an intertroch, so that's where we really started getting onto the idea of practice. When you look at the X-ray, and you put your hand with the pin, how are you adjusting your hand to make sure that your entry hole and exit are going in the same direction?
That's when this whole idea of practicing really started to come about because what the VR will allow you to do from an educational standpoint is it's called casting. They'll have a plug that goes from their goggles onto my laptop, so for the first time, you actually look through the eyes of the trainee. Most of the time you're doing an intertroch, you're doing a pinning, whatever, you're looking at the X-ray. You're looking at the resident. You're looking at whatever you need for as long as you need to look at it.
With the VR, you're looking through the resident's eyes, which is really unique because then all of a sudden maybe you don't see the X-ray or maybe you don't see it for as long as you think you should, and now they're looking at their hands. You can start to see things much differently, especially in your average technician. So, this is where this whole idea of three-dimensional ability comes. There are some surgeons that have great three-dimensional ability, and there's some that don't. Those of us that don't really know it, but we don't advertise it that much. But we went through a lot of things where Bob Arciero, who you know, he has unbelievable three-dimensional ability. I have average to poor three-dimensional ability.
No, no, but this is important because there's a lot of tests out there, especially for the military. You may be aware of them where they look at that, spatial awareness, three-dimensional ability. We took a lot of those tests together and anytime that we were close, I knew that that had poor content validity, which nobody knew, right? We would talk to the people, but there's a lot of this going on. The sport gaming crew is really looking at a lot of this as well.
The bottom line, it's a long answer for your question, but I think really the key part of virtual reality from an educational standpoint is this ability to cast where you look through your trainee's eyes as they execute whatever process they're doing, which is an incredibly unique perspective and gives you a lot of insight on areas that they may not know they're struggling in, where they are struggling.
Dr. Chris Tucker:
So you and your co-authors set out to determine the efficacy of this head-mounted display VR for orthopedic surgery training through your systematic review. Can you just talk me through the methodologies of what you encountered in the eight studies you ended up including? Just in terms of how training programs were implementing the use of the VR, what types or kinds of skills or cases were they teaching, and then what skills of the trainees were they evaluating? Because I'm curious to know what level of proficiency was being achieved and if there was some ceiling effect. Basically if there was a limit to the type of skill that they could train. Was it just really good at teaching novices, or was there room for improvement even in fairly experienced skilled surgeons?
Dr. Gus Mazzocca:
Yeah. Well, this was a systematic review of what other people had published, and really the bottom line behind it is yes, it much like any type of training can show improvements. So my opinion is that although for a certain type of skill and those papers, they went over different things. Some did total hips. Some did reverse shoulder arthroplasty, tibial IM nails, glenoid exposure. What or how I think it happened were people that knew about VR and are interested in VR, had seen a VR, had their kids with a VR, they were like, "Hey, that looks neat. I wonder if we could do it?" Then would relate it to whatever software they could get and then look at that in a training program.
So you could go with experts and residents. You could go with medical students to residents. You could go to medical students to experts. So it was a mixed match of all of those different types of techniques, just seeing if it would show an improvement. I think lost in all of this is one, the technology. So no question that the more you practice anything, the better you're going to get. As the technology starts to advance more, it'll definitely be able to help people do more complex cases.
I think one area that they're really working on developing is being able to download CT scans, having that three-dimensional model in the virtual world so that you can then work on reduction techniques before you go into the case. You can then look at some screw angles and positions to see how that's going to go to prepare for your case. Those are like in complex, say distal humerus fractures or something, which I think will be amazing.
From an educational standpoint, I think the idea of identifying basic skills that we want our PGY-1 and 2 residents to do, having a platform that they can then practice that on, I imagine it's in the works. The system that I used had a great module, like I said, on intertroch fracture and SCFE. I liked keeping those. They also had the reverse shoulder arthroplasty. They had a total knee, total knee revision. So, I don't want to minimize anything that they're doing, but I liked those two modules for first and second-year residents because you are taking a pin. You're looking at an X-ray. You're putting that pin on the bone, and you're trying to put it into a certain place and have it exit at a certain area. It's two different angles. It's two different ways to do it. That with the casting, you would be able to see how people would either struggle or not struggle, how many X-rays.
I had Bob Arciero who was doing hip fractures back in the 1700s, and he would be like, "In those days you'd put a pin in and you'd get a flat plate. You'd have to wait for the guy to develop it and come back and show you where you were." Now we have C-arms where we just walk the pin into where we think it would, like 10 to 15 quick shots. We've gotten a little lazy on how we can position our hands. I think that really starts to develop that three-dimensional ability, and there are some residents that have unbelievable three-dimensional ability and are very good, and then they advance.
The ones that don't have it, it doesn't mean they can't advance, but they just need more practice. I think that's where in the educational standpoint where I have the passion because I think that's a really unique opportunity from a very early time where you can identify those trainees and then really concentrate on them and then bring them up so they don't get left behind slowly. Right? There's an insidious process that can happen when you're not say the best resident and you're the bottom resident, and you don't get that many reps because everybody will take over because they know that you struggle.
Now you do less and less, so instead of having more practice, you actually have less practice, but you're not harmful. You're not terrible, and that becomes an issue as well, so now you have to go out. Now you go to your fellowship, and then that's where they discover that there's these deficiencies or worse, now you're going to practice where those deficiencies are discovered. So, I think that would be a really important area for us to concentrate on where we can really help these kids practice areas that they may be weak on. It's not everybody, but there's a significant amount of people out there that can use practice for those things.
The last part is as that technology gets better, you'll see whenever you do a skill, especially when somebody's watching you and you don't do it well, there's a lot of excuses you can give, right? So there's this concept of haptics, which is the feel, so VR, I don't know if they're struggling, but they work on it, right? No one likes the feel of VR. You can't feel it so well, the vibration, whatever. The haptics are not. No one's wowing about the haptics on VR, but I also think sometimes that's an excuse for us when we're not executing well, and I can see that. There's some people that can handle not doing something well and understand that they need to practice it more, and there's some people that can't handle that.
I think that's a really important area to have. It's also a really unique time where you and a resident are connected. I'm watching the monitor on the laptop, and they're next to it doing it. I enjoyed it. It takes a lot of time, so probably it's not something that everybody can do all the time. The idea would be the resident would be able to practice it on their own, but I think the residents in my experience like accomplishing the whole case, and they want to do the whole case. They don't want to practice the areas that they're bad at. Who the heck wants to do that? So, they'll go through the case, and then they'll check it off, and then they're good. Now they practiced, but when you're casting with it, you can just make them repeat it. "Do it again, do it again," which of course is not great for them. They're not so enthralled by it, but I think it makes them better.
Dr. Chris Tucker:
Absolutely. I think you highlighted a number of the advantages of the VR. When I looked at your review in detail, as you mentioned, the studies that have been done on using VR for education really do span a fairly broad spectrum of procedures. Like you said, you enjoy using it for training, things like hip pinning and SCFE because it's that tactile three-dimensional space skill, but I also saw studies that you reviewed of general techniques like IM nails, glenoid exposure, which is really more about soft tissue management and exposure more than a drill or a pin position, and then start to finish cases like total hips and reverse total shoulders.
One of the things I observed, which was almost uniform across eight studies, I think one or two of them did not show, was that not only were people's skills getting better, but it was really the time to completion that improved as well. There was a Uni-total knee study of residents and med students on Sawbones. They actually showed no difference in the performance of the tasks, but their time to completion was significantly improved with the VR training versus traditional methods.
I think that was a theme throughout. The time to completion was better in tibial nails. Time to completion was faster with glenoid exposure. So not only were the trainees getting the skills correct, but they were doing it faster as well. Maybe that has to do with that lifelike third-person visualization and the repetition, but I think that's interesting to note that that was one of the takeaways from your review. I don't know if you noticed that as well. When you see your trainees in the OR after using this technology, do they seem more confident? Do they seem faster at the procedures they practiced?
Dr. Gus Mazzocca:
Yeah, I imagine they did. At UConn, we were on call much less so you would be working with them, and then they'd be on call with other people, so we would ask around in that. We never had that direct, but no question that could be it. The other thing that hasn't been developed to my knowledge yet, which I think will be fabulous, is being able to throw in complications. Now we can train complications, which is an extremely important part of surgical education and is absolutely random. Thank God, but just like the pilots train, we'll be able to train. Then theoretically I could be taking you through a reverse shoulder, and then we get into significant bleeding. Now what do we do? How do we find it? You know what I mean?
Now we can train those residents to be able to handle that situation, know they've been there before, have great confidence. I think that will really be a big improvement in surgical training, is the simulation of different types of complications, complications that we worry about. As a group of educators, we can all bring them together. "Here, I had this complication. You'd never believe this happened to me. This is what I did." So all those solutions can also be put in there so that the educators can be. I may not know all the possible issues, but we would have that for us so that we could throw those in and then see those scenarios and then work them out. I think that'll be really a big thing that's absolutely coming.
Dr. Chris Tucker:
Absolutely. That's wonderful insight. I mean, that's like having a virtual M&M, which we try and utilize as a training tool for our program. But like you said, if a resident doesn't happen to be in the room for the M&M for the complication that happens once every three years, they're not going to glean the knowledge from that, but now, boom. Plug it in and make them go through it. What a wonderful potential advantage.
So, we have talked a lot about the benefits and the advantages of VR. I was just wondering if we could at least speak briefly about some of the potential drawbacks that you've seen. I know you already mentioned the haptics lagging behind in their development, which obviously can be improved. Are there any other drawbacks you see to VR? Things like cost or availability or how to use it? Anything else that's potentially not ideal about it right now?
Dr. Gus Mazzocca:
I'll liken it to the evolution from the beeper to the smartphone. It's going to get better. Yeah, when they were looking at that soft tissue exposure, that's not as lifelike as you want, and that's probably why I gloss over it. No question that you can go through those, but really when it's talking about doing an open shoulder, it's when you don't have the visualization that you want. What are the tricks you do to get that visualization? That's not been really recreated in the VR world yet. It's standard. You go down, the soft tissues move. You have to identify them and stuff, but you go fairly quickly and easily. You're not running into a stiff shoulder that you can't dislocate. You know what I mean? You're not running into where you can't see the back half of the glenoid and what are you going to do and why that is or what you're worried about. So I think as that technology develops, it'll get better.
The issue I think, from the business side of it is they need more money in investment because the computer programs and the programs that are doing this cost a lot, and it's a tremendous amount of time. Like I said, I don't think any of these VR platforms thought that resident education or surgical training would be the way to go. I do think that it's going to be a great advantage for the third-world surgeons that don't have the ability to fly to watch somebody or to go to a conference or to see all the videos, but where they would be able to get that.
Then I know Dr. Warner has done a lot of this where you'll be able be in the virtual OR together, so the surgeon and the expert can be there together talking, communicating in that virtual environment, going through a case. That's another huge advantage, which I think not only will help medical students, residents and fellows but also all of us. As we start doing different cases or are worried about something, that ability to communicate in the virtual world and actually see things and do things together just to see where you put your hands, or this is how I would do this, this is how I expose it, will be a huge advantage.
Dr. Chris Tucker:
Absolutely. That's very exciting. Gus, you've provided us a really nice summary of the use of VR in the realm of orthopedic surgery residency training. Although your sample size was small, these early studies that you reviewed are really showing that there's equivalent efficacy in this technology as compared to traditional modes of education and actually a majority of your studies pointing to superior efficacy for VR. As you stated in your paper, further study is certainly needed, but this is really an emerging technology that can allow for smaller training institutions that may not have a bio skills lab or like you said, international surgeons who may not have the ability to travel, to have access to a fairly highly effective training simulation. Did you have any other closing remarks before we wrap up?
Dr. Gus Mazzocca:
I think the VR, as far as a practice tool, very rarely in orthopedic training do we practice. I think that's one huge advantage of it. I think two, with the ability to put in the simulated complications will be a huge advantage for education. I think three, have an invited professor come into the virtual world with you while you're doing a case. As that expands, they don't have to spend all the time. They can be in their kitchen, and you can be in your kitchen, and the residents can be in their kitchen, and everybody can be working and learning without having to travel and do a lot of stuff. That'll really make things more efficient as far as that.
I do think as this develops, this will be a fabulous thing going forward. So in the world of emerging technology, this we should follow. I think that even from a small scale, depending on what company or what you use, I think making sure it has that ability to cast, in other words, connect the goggles to the laptop. That's a huge advantage because when you don't, they're all doing their own thing and you have no idea what's going on because they're on their own virtual world, so you have no idea, but when you can see it, then it's amazing. I think that's really a big advantage.
Dr. Chris Tucker:
Gus, I think you did a wonderful job of highlighting the advantages of VR and also injecting your own personal experience with it into your remarks today. So, I want to congratulate you on your work, and thank you for sharing your time and your thoughts with us today.
Dr. Gus Mazzocca:
Thank you, Chris. Great work by you.
Dr. Chris Tucker:
Dr. Mazzocca's article titled “Head-Mounted Display Virtual Reality Is Effective in Orthopedic Training: A Systematic Review” is published in the October 2023 issue of the Arthroscopy Journal, which is available online at www.arthroscopyjournal.org.
This concludes this edition of the Arthroscopy Journal podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal. Thank you for listening. Please join us again next time.
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