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Olsen RG, Svendsen MBS, Tolsgaard MG, Konge L, Røder A, Bjerrum F. Surgical gestures can be used to assess surgical competence in robot-assisted surgery : A validity investigating study of simulated RARP. J Robot Surg 2024; 18:47. [PMID: 38244130 PMCID: PMC10799775 DOI: 10.1007/s11701-023-01807-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 12/23/2023] [Indexed: 01/22/2024]
Abstract
To collect validity evidence for the assessment of surgical competence through the classification of general surgical gestures for a simulated robot-assisted radical prostatectomy (RARP). We used 165 video recordings of novice and experienced RARP surgeons performing three parts of the RARP procedure on the RobotiX Mentor. We annotated the surgical tasks with different surgical gestures: dissection, hemostatic control, application of clips, needle handling, and suturing. The gestures were analyzed using idle time (periods with minimal instrument movements) and active time (whenever a surgical gesture was annotated). The distribution of surgical gestures was described using a one-dimensional heat map, snail tracks. All surgeons had a similar percentage of idle time but novices had longer phases of idle time (mean time: 21 vs. 15 s, p < 0.001). Novices used a higher total number of surgical gestures (number of phases: 45 vs. 35, p < 0.001) and each phase was longer compared with those of the experienced surgeons (mean time: 10 vs. 8 s, p < 0.001). There was a different pattern of gestures between novices and experienced surgeons as seen by a different distribution of the phases. General surgical gestures can be used to assess surgical competence in simulated RARP and can be displayed as a visual tool to show how performance is improving. The established pass/fail level may be used to ensure the competence of the residents before proceeding with supervised real-life surgery. The next step is to investigate if the developed tool can optimize automated feedback during simulator training.
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Affiliation(s)
- Rikke Groth Olsen
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for HR & Education, The Capital Region of Denmark, Ryesgade 53B, 2100, Copenhagen, Denmark.
- Department of Urology, Copenhagen Prostate Cancer Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Morten Bo Søndergaard Svendsen
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for HR & Education, The Capital Region of Denmark, Ryesgade 53B, 2100, Copenhagen, Denmark
- Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | - Martin G Tolsgaard
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for HR & Education, The Capital Region of Denmark, Ryesgade 53B, 2100, Copenhagen, Denmark
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for HR & Education, The Capital Region of Denmark, Ryesgade 53B, 2100, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Røder
- Department of Urology, Copenhagen Prostate Cancer Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Bjerrum
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for HR & Education, The Capital Region of Denmark, Ryesgade 53B, 2100, Copenhagen, Denmark
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
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Boal MWE, Anastasiou D, Tesfai F, Ghamrawi W, Mazomenos E, Curtis N, Collins JW, Sridhar A, Kelly J, Stoyanov D, Francis NK. Evaluation of objective tools and artificial intelligence in robotic surgery technical skills assessment: a systematic review. Br J Surg 2024; 111:znad331. [PMID: 37951600 PMCID: PMC10771126 DOI: 10.1093/bjs/znad331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND There is a need to standardize training in robotic surgery, including objective assessment for accreditation. This systematic review aimed to identify objective tools for technical skills assessment, providing evaluation statuses to guide research and inform implementation into training curricula. METHODS A systematic literature search was conducted in accordance with the PRISMA guidelines. Ovid Embase/Medline, PubMed and Web of Science were searched. Inclusion criterion: robotic surgery technical skills tools. Exclusion criteria: non-technical, laparoscopy or open skills only. Manual tools and automated performance metrics (APMs) were analysed using Messick's concept of validity and the Oxford Centre of Evidence-Based Medicine (OCEBM) Levels of Evidence and Recommendation (LoR). A bespoke tool analysed artificial intelligence (AI) studies. The Modified Downs-Black checklist was used to assess risk of bias. RESULTS Two hundred and forty-seven studies were analysed, identifying: 8 global rating scales, 26 procedure-/task-specific tools, 3 main error-based methods, 10 simulators, 28 studies analysing APMs and 53 AI studies. Global Evaluative Assessment of Robotic Skills and the da Vinci Skills Simulator were the most evaluated tools at LoR 1 (OCEBM). Three procedure-specific tools, 3 error-based methods and 1 non-simulator APMs reached LoR 2. AI models estimated outcomes (skill or clinical), demonstrating superior accuracy rates in the laboratory with 60 per cent of methods reporting accuracies over 90 per cent, compared to real surgery ranging from 67 to 100 per cent. CONCLUSIONS Manual and automated assessment tools for robotic surgery are not well validated and require further evaluation before use in accreditation processes.PROSPERO: registration ID CRD42022304901.
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Affiliation(s)
- Matthew W E Boal
- The Griffin Institute, Northwick Park & St Marks’ Hospital, London, UK
- Wellcome/ESPRC Centre for Interventional Surgical Sciences (WEISS), University College London (UCL), London, UK
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, UCL, London, UK
| | - Dimitrios Anastasiou
- Wellcome/ESPRC Centre for Interventional Surgical Sciences (WEISS), University College London (UCL), London, UK
- Medical Physics and Biomedical Engineering, UCL, London, UK
| | - Freweini Tesfai
- The Griffin Institute, Northwick Park & St Marks’ Hospital, London, UK
- Wellcome/ESPRC Centre for Interventional Surgical Sciences (WEISS), University College London (UCL), London, UK
| | - Walaa Ghamrawi
- The Griffin Institute, Northwick Park & St Marks’ Hospital, London, UK
| | - Evangelos Mazomenos
- Wellcome/ESPRC Centre for Interventional Surgical Sciences (WEISS), University College London (UCL), London, UK
- Medical Physics and Biomedical Engineering, UCL, London, UK
| | - Nathan Curtis
- Department of General Surgey, Dorset County Hospital NHS Foundation Trust, Dorchester, UK
| | - Justin W Collins
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, UCL, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Ashwin Sridhar
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, UCL, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - John Kelly
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, UCL, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Danail Stoyanov
- Wellcome/ESPRC Centre for Interventional Surgical Sciences (WEISS), University College London (UCL), London, UK
- Computer Science, UCL, London, UK
| | - Nader K Francis
- The Griffin Institute, Northwick Park & St Marks’ Hospital, London, UK
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, UCL, London, UK
- Yeovil District Hospital, Somerset Foundation NHS Trust, Yeovil, Somerset, UK
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Olsen RG, Konge L, Hayatzaki K, Mortensen MA, Bube SH, Røder A, Azawi N, Bjerrum F. Laypersons versus experienced surgeons in assessing simulated robot-assisted radical prostatectomy. World J Urol 2023; 41:3745-3751. [PMID: 37882808 PMCID: PMC10693505 DOI: 10.1007/s00345-023-04664-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/29/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Feedback is important for surgical trainees but it can be biased and time-consuming. We examined crowd-sourced assessment as an alternative to experienced surgeons' assessment of robot-assisted radical prostatectomy (RARP). METHODS We used video recordings (n = 45) of three RARP modules on the RobotiX, Simbionix simulator from a previous study in a blinded comparative assessment study. A group of crowd workers (CWs) and two experienced RARP surgeons (ESs) evaluated all videos with the modified Global Evaluative Assessment of Robotic Surgery (mGEARS). RESULTS One hundred forty-nine CWs performed 1490 video ratings. Internal consistency reliability was high (0.94). Inter-rater reliability and test-retest reliability were low for CWs (0.29 and 0.39) and moderate for ESs (0.61 and 0.68). In an Analysis of Variance (ANOVA) test, CWs could not discriminate between the skill level of the surgeons (p = 0.03-0.89), whereas ES could (p = 0.034). CONCLUSION We found very low agreement between the assessments of CWs and ESs when they assessed robot-assisted radical prostatectomies. As opposed to ESs, CWs could not discriminate between surgical experience using the mGEARS ratings or when asked if they wanted the surgeons to perform their robotic surgery.
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Affiliation(s)
- Rikke Groth Olsen
- Copenhagen Academy for Medical Education and Simulation (CAMES), University Hospital - Rigshospitalet, Ryesgade 53B, 2100, Copenhagen, Denmark.
- Department of Urology, Copenhagen Prostate Cancer Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation (CAMES), University Hospital - Rigshospitalet, Ryesgade 53B, 2100, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Mike Allan Mortensen
- Department of Urology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sarah Hjartbro Bube
- Copenhagen Academy for Medical Education and Simulation (CAMES), University Hospital - Rigshospitalet, Ryesgade 53B, 2100, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Urology, Zealand University Hospital, Roskilde, Denmark
| | - Andreas Røder
- Department of Urology, Copenhagen Prostate Cancer Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nessn Azawi
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Urology, Zealand University Hospital, Roskilde, Denmark
| | - Flemming Bjerrum
- Copenhagen Academy for Medical Education and Simulation (CAMES), University Hospital - Rigshospitalet, Ryesgade 53B, 2100, Copenhagen, Denmark
- Department of Surgery, Herlev-Gentofte Hospital, Herlev, Denmark
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Xie S, Grimstrup S, Nayahangan LJ, Wang Z, Wan X, Konge L. Using a novel virtual-reality simulator to assess performance in lumbar puncture: a validation study. BMC MEDICAL EDUCATION 2023; 23:814. [PMID: 37904177 PMCID: PMC10614418 DOI: 10.1186/s12909-023-04806-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 10/25/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND A lumbar puncture procedure's success depends on a competent physician minimizing the risk of failing to get a sample and avoiding complications such as post-dural headache. A new virtual-reality simulator might be helpful in deciding when a physician is competent to perform lumbar puncture. We aimed to investigate validity evidence for a simulator-based test in lumbar puncture and establish a pass/fail standard to allow a mastery learning training program. METHODS Validity evidence was investigated using Messick's framework by including participants who were novices, intermediates, or experienced in lumbar puncture. Each participant performed two lumbar puncture procedures on the simulator, and fifty-nine predefined simulator metrics were automatically recorded. Cronbach's alpha was used to explore internal consistency reliability. Intergroup comparisons were made using independent sample t-tests with Tukey's correction for multiple comparisons. The learning effect was explored using paired sample t-test analysis, and a pass/fail standard was established using the contrasting groups' method. RESULTS 73 novices, 18 intermediates, and 19 physicians performed the test resulting in a total of 220 procedures. 25 metrics (42.4%) had good discriminatory ability, and the reliability of these metrics was good, Cronbach's α = 0.81. The experienced physicians were significantly better than the novices (18.3 vs. 13.3, p < 0.001), and the pass/fail standard was established at 16 points. This standard resulted in 22 (30.1%) novices passing (i.e., false positives) and 5 (26.3%) physicians failing (i.e., false negatives). CONCLUSION This study provides validity evidence for a simulator-based test of lumbar puncture competence. The test can help ensure basic competence at the end of a simulation-based training program for trainees, i.e., a mastery learning training program.
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Affiliation(s)
- Sujun Xie
- Guangzhou University of Chinese Medicine, Jichang Road 12, Guangzhou, 510405, China.
- Guangdong Academy for Medical Simulation (GAMS), No.10 Hongming Road, East District, Huangpu District, Guangzhou, 510530, China.
| | - Søren Grimstrup
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for Human Resources and Education, Ryesgade 53B, opg. 98A, Copenhagen, 2100, Denmark
| | - Leizl Joy Nayahangan
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for Human Resources and Education, Ryesgade 53B, opg. 98A, Copenhagen, 2100, Denmark
| | - Zheng Wang
- Guangdong Academy for Medical Simulation (GAMS), No.10 Hongming Road, East District, Huangpu District, Guangzhou, 510530, China
| | - Xing Wan
- Guangzhou University of Chinese Medicine, Jichang Road 12, Guangzhou, 510405, China.
| | - Lars Konge
- Guangdong Academy for Medical Simulation (GAMS), No.10 Hongming Road, East District, Huangpu District, Guangzhou, 510530, China
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for Human Resources and Education, Ryesgade 53B, opg. 98A, Copenhagen, 2100, Denmark
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Rodler S, Kidess MA, Westhofen T, Kowalewski KF, Belenchon IR, Taratkin M, Puliatti S, Gómez Rivas J, Veccia A, Piazza P, Checcucci E, Stief CG, Cacciamani GE. A Systematic Review of New Imaging Technologies for Robotic Prostatectomy: From Molecular Imaging to Augmented Reality. J Clin Med 2023; 12:5425. [PMID: 37629467 PMCID: PMC10455161 DOI: 10.3390/jcm12165425] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 08/01/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
New imaging technologies play a pivotal role in the current management of patients with prostate cancer. Robotic assisted radical prostatectomy (RARP) is a standard of care for localized disease and through the already imaging-based console subject of research towards combinations of imaging technologies and RARP as well as their impact on surgical outcomes. Therefore, we aimed to provide a comprehensive analysis of the currently available literature for new imaging technologies for RARP. On 24 January 2023, we performed a systematic review of the current literature on Pubmed, Scopus and Web of Science according to the PRISMA guidelines and Oxford levels of evidence. A total of 46 studies were identified of which 19 studies focus on imaging of the primary tumor, 12 studies on the intraoperative tumor detection of lymph nodes and 15 studies on the training of surgeons. While the feasibility of combined approaches using new imaging technologies including MRI, PSMA-PET CT or intraoperatively applied radioactive and fluorescent dyes has been demonstrated, the prospective confirmation of improvements in surgical outcomes is currently ongoing.
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Affiliation(s)
- Severin Rodler
- Department of Urology, University Hospital of Munich, 81377 Munich, Germany (T.W.); (C.G.S.)
| | - Marc Anwar Kidess
- Department of Urology, University Hospital of Munich, 81377 Munich, Germany (T.W.); (C.G.S.)
| | - Thilo Westhofen
- Department of Urology, University Hospital of Munich, 81377 Munich, Germany (T.W.); (C.G.S.)
| | | | - Ines Rivero Belenchon
- Urology and Nephrology Department, Virgen del Rocío University Hospital, Manuel Siurot s/n, 41013 Seville, Spain;
| | - Mark Taratkin
- Institute for Urology and Reproductive Health, Sechenov University, 117418 Moscow, Russia;
| | - Stefano Puliatti
- Department of Urology, University of Modena and Reggio Emilia, 42122 Modena, Italy;
| | - Juan Gómez Rivas
- Department of Urology, Hospital Clinico San Carlos, 28040 Madrid, Spain;
| | - Alessandro Veccia
- Urology Unit, Azienda Ospedaliera Universitaria Integrata Verona, 37126 Verona, Italy;
| | - Pietro Piazza
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Enrico Checcucci
- Department of Surgery, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, 10060 Turin, Italy;
| | - Christian Georg Stief
- Department of Urology, University Hospital of Munich, 81377 Munich, Germany (T.W.); (C.G.S.)
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Jørgensen RJ, Olsen RG, Svendsen MBS, Stadeager M, Konge L, Bjerrum F. Comparing Simulator Metrics and Rater Assessment of Laparoscopic Suturing Skills. JOURNAL OF SURGICAL EDUCATION 2023; 80:302-310. [PMID: 37683093 DOI: 10.1016/j.jsurg.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/17/2022] [Accepted: 09/25/2022] [Indexed: 09/10/2023]
Abstract
BACKGROUND Laparoscopic intracorporeal suturing is important to master and competence should be ensured using an optimal method in a simulated environment before proceeding to real operations. The objectives of this study were to gather validity evidence for two tools for assessing laparoscopic intracorporeal knot tying and compare the rater-based assessment of laparoscopic intracorporeal suturing with the assessment based on simulator metrics. METHODS Twenty-eight novices and 19 experienced surgeons performed four laparoscopic sutures on a Simball Box simulator twice. Two surgeons used the Intracorporeal Suturing Assessment Tool (ISAT) for blinded video rating. RESULTS Composite Simulator Score (CSS) had higher test-retest reliability than the ISAT. The correlation between the number performed procedures including suturing and ISAT score was 0.51, p<0.001, and 0.59 p<0.001 for CSS. We found an inter-rater reliability (0.72, p<0.001 for test 1 and 0.53 p<0.001 for test 2). The pass/fail rates for ISAT and CSS were similar. CONCLUSION CSS and ISAT provide similar results for assessing laparoscopic suturing but assess different aspects of performance. Using simulator metrics and raters' assessments in combination should be considered for a more comprehensive evaluation of laparoscopic knot-tying competency.
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Affiliation(s)
- Rikke Jeong Jørgensen
- Copenhagen Academy for Medical Education and Simulation, Centre for HR and Education, Capital Region, Copenhagen, Denmark.
| | - Rikke Groth Olsen
- Copenhagen Academy for Medical Education and Simulation, Centre for HR and Education, Capital Region, Copenhagen, Denmark
| | - Morten Bo Søndergaard Svendsen
- Copenhagen Academy for Medical Education and Simulation, Centre for HR and Education, Capital Region, Copenhagen, Denmark
| | - Morten Stadeager
- Copenhagen Academy for Medical Education and Simulation, Centre for HR and Education, Capital Region, Copenhagen, Denmark; Department of Surgery, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation, Centre for HR and Education, Capital Region, Copenhagen, Denmark; University of Copenhagen, Copenhagen, Denmark
| | - Flemming Bjerrum
- Copenhagen Academy for Medical Education and Simulation, Centre for HR and Education, Capital Region, Copenhagen, Denmark; Department of Surgery, Herlev-Gentofte Hospital, Herlev, Denmark
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Abstract
OBJECTIVE This systematic review aims to examine the use of standard-setting methods in the context of simulation-based training of surgical procedures. SUMMARY OF BACKGROUND Simulation-based training is increasingly used in surgical education. However, it is important to determine which level of competency trainees must reach during simulation-based training before operating on patients. Therefore, pass/fail standards must be established using systematic, transparent, and valid methods. METHODS Systematic literature search was done in four databases (Ovid MEDLINE, Embase, Web of Science, and Cochrane Library). Original studies investigating simulation-based assessment of surgical procedures with application of a standard setting were included. Quality of evidence was appraised using GRADE. RESULTS Of 24,299 studies identified by searches, 232 studies met the inclusion criteria. Publications using already established standard settings were excluded (N = 70), resulting in 162 original studies included in the final analyses. Most studies described how the standard setting was determined (N = 147, 91%) and most used the mean or median performance score of experienced surgeons (n = 65, 40%) for standard setting. We found considerable differences across most of the studies regarding study design, set-up, and expert level classification. The studies were appraised as having low and moderate evidence. CONCLUSION Surgical education is shifting towards competency-based education, and simulation-based training is increasingly used for acquiring skills and assessment. Most studies consider and describe how standard settings are established using more or less structured methods but for current and future educational programs, a critical approach is needed so that the learners receive a fair, valid and reliable assessment.
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