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Fedson S, Lavee J, Bryce K, Egan T, Olland A, Kanwar M, Courtwright A, Holm AM. Ethical considerations in xenotransplantation of thoracic organs - a call for a debate on value based decisions. J Heart Lung Transplant 2024; 43:1033-1038. [PMID: 38775760 DOI: 10.1016/j.healun.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 06/03/2024] Open
Abstract
Xenotransplant covers a broad ethical territory and there are several ethical questions that have arisen in parallel with the technological advances that have allowed the first porcine transplants to occur. This brief communication highlights ethical considerations regarding heart and lung xenotransplantation, with an emphasis on unresolved value-based concerns in the field. The aim of this text is therefore to encourage the readers to consider the vast potential of this emerging technique to do good, but also the risk of doing harm, and to participate in a discussion. The list of questions presented here is not exhaustive but hopefully represents some of the questions that appear to be most pressing as the field advances. The focus is on the value-based, or ethical questions, not the questions related to the practical medical procedures.
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Affiliation(s)
- Savitri Fedson
- Baylor College of Medicine; Michael E DeBakey VA Medical Center, Houston, Texas.
| | - Jacob Lavee
- Heart Transplantation Unit, Leviev Cardiothoracic Center, Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Kelly Bryce
- Behavioral Health, Henry Ford Health System; Transplant Institute, Henry Ford Health System, Detroit, Michigan
| | - Tom Egan
- Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anne Olland
- Department of Thoracic Surgery, University Hospital Strasbourg; Inserm UMR 1260 "Regenerative Nanomedicine", University of Strasbourg, Strasbourg, France
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Andrew Courtwright
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Are Martin Holm
- Department of Respiratory Medicine, Oslo University Hospital; Institute of Clinical Medicine, University of Oslo, Norway
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2
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Schmoeckel M, Längin M, Reichart B, Abicht JM, Bender M, Michel S, Kamla CE, Denner J, Tönjes RR, Schwinzer R, Marckmann G, Wolf E, Brenner P, Hagl C. Current Status of Cardiac Xenotransplantation: Report of a Workshop of the German Heart Transplant Centers, Martinsried, March 3, 2023. Thorac Cardiovasc Surg 2024; 72:273-284. [PMID: 38154473 DOI: 10.1055/a-2235-8854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
This report comprises the contents of the presentations and following discussions of a workshop of the German Heart Transplant Centers in Martinsried, Germany on cardiac xenotransplantation. The production and current availability of genetically modified donor pigs, preservation techniques during organ harvesting, and immunosuppressive regimens in the recipient are described. Selection criteria for suitable patients and possible solutions to the problem of overgrowth of the xenotransplant are discussed. Obviously microbiological safety for the recipient and close contacts is essential, and ethical considerations to gain public acceptance for clinical applications are addressed. The first clinical trial will be regulated and supervised by the Paul-Ehrlich-Institute as the National Competent Authority for Germany, and the German Heart Transplant Centers agreed to cooperatively select the first patients for cardiac xenotransplantation.
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Affiliation(s)
- Michael Schmoeckel
- Herzchirurgische Klinik und Poliklinik, LMU Klinikum, LMU München, Germany
| | - Matthias Längin
- Klinik für Anaesthesiologie, LMU Klinikum, LMU München, Germany
- DFG-Transregio-Sonderforschungsbereich TR127-Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
| | - Bruno Reichart
- DFG-Transregio-Sonderforschungsbereich TR127-Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
| | - Jan-Michael Abicht
- Klinik für Anaesthesiologie, LMU Klinikum, LMU München, Germany
- DFG-Transregio-Sonderforschungsbereich TR127-Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
| | - Martin Bender
- Klinik für Anaesthesiologie, LMU Klinikum, LMU München, Germany
- DFG-Transregio-Sonderforschungsbereich TR127-Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
| | - Sebastian Michel
- Herzchirurgische Klinik und Poliklinik, LMU Klinikum, LMU München, Germany
- DFG-Transregio-Sonderforschungsbereich TR127-Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
| | | | - Joachim Denner
- DFG-Transregio-Sonderforschungsbereich TR127-Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
- Institut für Virologie, Fachbereich für Veterinärmedizin, Freie Universität Berlin, Berlin, Germany
| | - Ralf Reinhard Tönjes
- DFG-Transregio-Sonderforschungsbereich TR127-Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
- Paul-Ehrlich-Institut, Langen, Germany
| | - Reinhard Schwinzer
- DFG-Transregio-Sonderforschungsbereich TR127-Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Georg Marckmann
- DFG-Transregio-Sonderforschungsbereich TR127-Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
- Institut für Ethik, Geschichte und Theorie der Medizin, LMU München, Germany
| | - Eckhard Wolf
- DFG-Transregio-Sonderforschungsbereich TR127-Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
- Lehrstuhl für Molekulare Tierzucht und Biotechnologie, Genzentrum der LMU München, Germany
| | - Paolo Brenner
- Herzchirurgische Klinik und Poliklinik, LMU Klinikum, LMU München, Germany
- DFG-Transregio-Sonderforschungsbereich TR127-Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
| | - Christian Hagl
- Herzchirurgische Klinik und Poliklinik, LMU Klinikum, LMU München, Germany
- DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung e.V.), Partner Site Munich, Germany
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Chen S, Sade RM, Entwistle JW. Organ Donation by the Imminently Dead: Addressing the Organ Shortage and the Dead Donor Rule. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2024:jhae028. [PMID: 38801219 DOI: 10.1093/jmp/jhae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
The dead donor rule (DDR) has facilitated the saving of hundreds of thousands of lives. Recent advances in heart donation, however, have exposed how DDR has limited donation of all organs. We propose advancing the moment in the dying process at which death can be determined to increase substantially the supply of organs for transplantation. We justify this approach by identifying certain flaws in the Uniform Determination of Death Act and proposing a modification of that law that permits earlier procurement of healthier organs in greater numbers.
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Affiliation(s)
- Sarah Chen
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Robert M Sade
- Medical University of South Carolina, Charleston, South Carolina, USA
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Iltis AS, Silverman HJ, Sade RM. Research ethics: Must subjects waive the right to withdraw from a xenotransplant clinical trial? J Thorac Cardiovasc Surg 2024; 167:1880-1884. [PMID: 37454725 DOI: 10.1016/j.jtcvs.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Ana S Iltis
- Department of Philosophy and Center for Bioethics, Health and Society, Wake Forest University, Winston-Salem, NC
| | - Henry J Silverman
- Department of Medicine, University of Maryland, School of Medicine, Baltimore, Md
| | - Robert M Sade
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC.
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George AJ. Ethics, virtues and xenotransplantation. Perfusion 2024; 39:334-343. [PMID: 36382884 PMCID: PMC10900854 DOI: 10.1177/02676591221140767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
Early in 2022 the first pig to human cardiac xenotransplant was performed. The graft initially performed well, and rejection was well controlled. However, the graft failed, and the patient died 60 days after the procedure. The ethical issues relating to xenotransplantation include the risk/benefit to the individual, the risk of porcine-derived infectious agents crossing into humans, animal welfare and rights, issues of human and animal identity and concerns relating to fair allocation of organs and appropriate use of resources.These ethical issues are often addressed using emotional arguments, or through consequentialist or deontological lens. An alternative is to use approaches based on virtue ethics to understand the moral purpose (telos) of the research and the virtues (character traits) needed to be a good research clinician. In this review we will consider the virtues of justice, courage, temperance and practical wisdom, as well as the role of clinical curiosity, and their application to xenotransplantation. This provides an alternative approach for the clinical academic and others involved in the research to reflect on their practice.
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Affiliation(s)
- Andrew Jt George
- Department of Surgery and Cancer, Imperial College London, London, UK
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Rodger D, Hurst DJ, Bobier CA, Symons X. Genetic disenhancement and xenotransplantation: diminishing pigs' capacity to experience suffering through genetic engineering. JOURNAL OF MEDICAL ETHICS 2024:jme-2023-109594. [PMID: 38395623 DOI: 10.1136/jme-2023-109594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 02/10/2024] [Indexed: 02/25/2024]
Abstract
One objection to xenotransplantation is that it will require the large-scale breeding, raising and killing of genetically modified pigs. The pigs will need to be raised in designated pathogen-free facilities and undergo a range of medical tests before having their organs removed and being euthanised. As a result, they will have significantly shortened life expectancies, will experience pain and suffering and be subject to a degree of social and environmental deprivation. To minimise the impact of these factors, we propose the following option for consideration-ethically defensible xenotransplantation should entail the use of genetic disenhancement if it becomes possible to do so and if that pain and suffering cannot be eliminated by other means. Despite not being a morally ideal 'solution', it is morally better to prevent unavoidable pain until a viable non-animal alternative becomes available.
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Affiliation(s)
- Daniel Rodger
- Institute of Health and Social Care, London South Bank University, London, UK
| | - Daniel J Hurst
- Department of Family Medicine, Rowan University School of Osteopathic Medicine, Stratford, New Jersey, USA
| | | | - Xavier Symons
- Institute for Quantitative Social Science, Harvard University, Cambridge, Massachusetts, USA
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Park S, Lee H, Park EM, Roh J, Kang PI, Shim J, Choi K, Kang HJ. Initial investigation on the feasibility of porcine red blood cells from genetically modified pigs as an alternative to human red blood cells for transfusion. Front Immunol 2023; 14:1298035. [PMID: 38035112 PMCID: PMC10682702 DOI: 10.3389/fimmu.2023.1298035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/27/2023] [Indexed: 12/02/2023] Open
Abstract
The decline in blood donation rates and the ongoing shortage of blood products pose significant challenges to medical societies. One potential solution is to use porcine red blood cells (pRBCs) from genetically modified pigs as an alternative to human red blood cells (hRBCs). However, adverse immunological reactions remain a significant obstacle to their use. This study aimed to evaluate the compatibility of diverse genetically modified pRBCs with human serum. We acquired human complement-competent serum, complement 7 (C7)-deficient serum, and hRBCs from all ABO blood types. Additionally, we used leftover clinical samples from health checkups for further evaluation. pRBCs were collected from wild-type (WT) and genetically modified pigs: triple knockout (TKO), quadruple KO (QKO), and TKO/hCD55.hCD39 knockin (hCD55.hCD39KI). The extent of C3 deposition on RBCs was measured using flow cytometry after incubation in C7-deficient serum diluted in Ca++-enriched or Ca++-depleted and Mg++-enriched buffers. The binding of immunoglobulin (Ig) M/IgG antibody to RBCs after incubation in ABO-type human serum was evaluated using flow cytometry. Naïve human serum- or sensitized monkey serum-mediated hemolysis was also evaluated. Phagocytosis was assessed by incubating labeled RBCs with the human monocytic cell line THP-1 and measurement by flow cytometry. All three genetic modifications significantly improved the compatibility of pRBCs with human serum relative to that of WT pRBCs. The extent of IgM/IgG binding to genetically modified pRBCs was lower than that of WT pRBCs and similar to that of O-type hRBCs. Total and alternative pathway complement activation in all three genetically modified pRBCs was significantly weaker than that in WT pRBCs and did not differ from that in O-type hRBCs. The extent of serum-mediated hemolysis and phagocytosis of these genetically modified pRBCs was low and similar to that of O-type hRBCs. Sensitized monkey serum-mediated hemolysis in QKO and TKO/hCD55.hCD39KI pRBCs was higher than in O-type hRBCs but lower than in TKO pRBCs. The elimination of porcine carbohydrate antigens in genetically modified pigs significantly enhanced pRBC compatibility with naïve human sera, which was comparable to that of O-type hRBCs. These findings provide valuable insights into the development of pRBCs as potential alternatives to hRBCs.
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Affiliation(s)
- Sangkeun Park
- Department of Laboratory Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Haneulnari Lee
- Department of Laboratory Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Eun Mi Park
- Department of Laboratory Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Juhye Roh
- Department of Laboratory Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Pul Ip Kang
- Department of Transgenic Animal Research, Optipharm Inc., Cheongju, Republic of Korea
| | - Joohyun Shim
- Department of Transgenic Animal Research, Optipharm Inc., Cheongju, Republic of Korea
| | - Kimyung Choi
- Department of Transgenic Animal Research, Optipharm Inc., Cheongju, Republic of Korea
| | - Hee Jung Kang
- Department of Laboratory Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
- Department of Laboratory Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
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Kropf M. Ethical Aspects of Human Induced Pluripotent Stem Cells and Alzheimer's Disease: Potentials and Challenges of a Seemingly Harmless Method. J Alzheimers Dis Rep 2023; 7:993-1006. [PMID: 37849627 PMCID: PMC10578332 DOI: 10.3233/adr-230018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 08/14/2023] [Indexed: 10/19/2023] Open
Abstract
Dementia currently affects more than 55 million people worldwide, and scientists predict that this number will continue to rise. The most common form is Alzheimer's disease (AD), which is triggered, among other things, by dysfunctional cells in the human brain. Stem cell research attempts to counteract neurodegenerative processes, for example by replacing or treating diseased cells. In addition to human embryonic stem cells, since the successes of Takahashi and Yamanaka in 2006, there has been an increased focus on human induced pluripotent stem cells (hiPS cells). These cells avoid ethically challenging questions about the moral status of human embryos, but there are numerous problems, such as high production costs, side effects from the reprogramming process, or a potentially new moral status. These ethical issues will be examined primarily in relation to AD. The first part will be a discussion of hiPS cells and their importance for stem cell research, after which the focus turns to AD. Based on scientific studies, the relationship between hiPS cells and AD will be outlined as well as ethical implications presented. While potential limitations of hiPS cells have been discussed by numerous authors, an ethical perspective on the link between hiPS cells and AD seems to be neglected in the scientific community. The following risk analysis aims to identify a possible research agenda. In conclusion, the focus on individuals with AD may help to adopt an ethical stance that recognizes existing limitations and constructively engages with the possibilities of research.
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Affiliation(s)
- Mario Kropf
- Faculty of Catholic Theology, Institute of Moral Theology, University of Graz, Graz, Austria
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9
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First-of-its-kind Xenotransplantation: Bedarf an ethischer Reflexion in Wissenschaft und Gesellschaft. Ethik Med 2023. [DOI: 10.1007/s00481-023-00750-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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10
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Galvao FHF, Grinberg M. Bioethics and xenotransplantation from pig to human. Clinics (Sao Paulo) 2023; 78:100170. [PMID: 36738646 PMCID: PMC9932344 DOI: 10.1016/j.clinsp.2023.100170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/05/2023] [Indexed: 02/05/2023] Open
Affiliation(s)
- Flavio Henrique Ferreira Galvao
- Departamento de Gastroenterologia, Disciplina de Transplanre de Órgãos do Aparelho Digestivo, Laboratório de Investigação Medical (LIM) 37, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil; Bioethical Committee from Hospital das Clínicas, Faculdade de Medicina, Universidade de Sao Paulo (USP), São Paulo, SP, Brazil.
| | - Max Grinberg
- Departamento de Gastroenterologia, Disciplina de Transplanre de Órgãos do Aparelho Digestivo, Laboratório de Investigação Medical (LIM) 37, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil; Departamento de Cardiologia, Instituto do Coração Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil; Bioethical Committee from Hospital das Clínicas, Faculdade de Medicina, Universidade de Sao Paulo (USP), São Paulo, SP, Brazil
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Bobier C, Rodger D, Hurst DJ, Omelianchuk A. In defense of xenotransplantation research: Because of, not in spite of, animal welfare concerns. Xenotransplantation 2023; 30:e12791. [PMID: 36573621 DOI: 10.1111/xen.12791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/11/2022] [Accepted: 12/12/2022] [Indexed: 12/28/2022]
Abstract
It is envisioned that one day xenotransplantation will bring about a future where transplantable organs can be safely and efficiently grown in transgenic pigs to help meet the global organ shortage. While recent advances have brought this future closer, worries remain about whether it will be beneficial overall. The unique challenges and risks posed to humans that arise from transplanting across the species barrier, in addition to the costs borne by non-human animals, has led some to question the value of xenotransplantation altogether. In response, we defend the value of xenotransplantation research, because it can satisfy stringent welfare conditions on the permissibility of animal research and use. Along the way, we respond to the alleged concerns, and conclude that they do not currently warrant a cessation or a curtailing of xenotransplantation research.
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Affiliation(s)
- Christopher Bobier
- Department of Theology and Philosophy, Hendrickson Institute for Ethical Leadership, St. Mary's University of Minnesota, Winona, Minnesota, USA
| | - Daniel Rodger
- Operating Department Practice, Institute of Health and Social Care, School of Allied and Community Health, London South Bank University, London, UK.,Department of Psychological Sciences, Birkbeck, University of London, London, UK
| | - Daniel J Hurst
- Department of Family Medicine Rowan University School of Osteopathic Medicine Stratford, New Jersey, USA
| | - Adam Omelianchuk
- The Center for Medical Ethics and Health Policy at Baylor College of Medicine, Houston, Texas, USA
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