Attempted Cardiopulmonary Bypass Venous Cannula Extraction Catheter Extraction of a Rare Intracardiac Myoepithelioma.

Myoepithelioma of the soft tissue is a rare entity that can mimic myxoma when presenting within the heart. We present a case where cardiopulmonary bypass venous cannula extraction catheter removal of an intracardiac myoepithelioma was attempted with minimal debulking and subsequently required minimally invasive open-heart surgery with cardiopulmonary bypass. (Level of Difficulty: Advanced.).

Resting Physiologic Dead Space as Predictor of Postoperative Pulmonary Complications After Robotic-Assisted Lung Resection: A Pilot Study.

Lung resection surgery carries significant risks of postoperative pulmonary complications (PPC). Cardiopulmonary exercise testing (CPET) is performed to predict risk of PPC in patients with severely reduced predicted postoperative forced expiratory volume in one second (FEV1) and diffusion of carbon monoxide (DLCO). Recently, resting end-tidal partial pressure of carbon dioxide (PETCO2) has been shown as a good predictor for increased risk of PPC. However, breath-breath breathing pattern significantly affects PETCO2. Resting physiologic dead space (VD), and physiologic dead space to tidal volume ratio (VD/VT), may be a better predictor of PPC than PETCO2. The objective of this study was to prospectively determine the utility of resting measurements of VD and VD/VT in predicting PPC in patients who underwent robotic-assisted lung resection for suspected or biopsy-proven lung malignancy. Thirty-five consecutive patients were included in the study. Patients underwent preoperative pulmonary function testing, symptom-limited CPET, and a 6-min walk test. In the first 2 min prior to the exercise portion of the CPET, we obtained resting VT, minute ventilation ( V ˙ E), VD (less instrument dead space), VD/VT, PETCO2, and arterial blood gases. PPC within 90 days were recorded. Fourteen (40%) patients had one or more PPC. Patients with PPC had significantly elevated resting VD compared to those without (0.318 ± 0.028 L vs. 0.230 ± 0.017 L (± SE), p < 0.006), and a trend toward increased VD/VT (0.35 ± 0.02 vs. 0.31 ± 0.02, p = 0.051). Area under the receiver operating characteristic (ROC) for VD was 0.81 (p < 0.002), VD/VT was 0.68 (p = 0.077), and PETCO2 was 0.52 (p = 0.840). Peak V ˙ O2, V ˙ E/ V ˙ CO2 slope, pulmonary function tests, 6-min walk distance and arterial blood gases were similar between the two groups. Intensive care unit and total hospital length of stay was significantly longer in those with PPC. In conclusion, preoperative resting VD was significantly elevated in patients with PPC. The observed increase in resting VD may be a potentially useful predictor of PPC in patients undergoing robotic-assisted lung resection surgery for suspected or biopsy-proven lung malignancy. A large prospective study is needed for confirmation.

Learning Curve of Robotic Lobectomy for Early-Stage Non-Small Cell Lung Cancer by a Thoracic Surgeon Adept in Open Lobectomy.

OBJECTIVE: The aim of the study was to characterize the clinical outcomes and learning curve during the adoption of a robotic platform for lobectomy for early-stage non-small cell lung cancer by a thoracic surgeon experienced in open thoracotomy. METHODS: Retrospective review of 157 consecutive patients (57 open thoracotomies, 100 robotic lobectomies) treated with lobectomy for clinical stage I or II non-small cell lung cancer between 2007 and 2014. Clinical outcomes were compared between the open thoracotomy group and five consecutive groups of 20 robotic lobectomies. We used the following six metrics to evaluate learning curve: operative time, conversion to open, estimated blood loss, hospitalization duration, overall morbidity, and pathologic nodal upstaging. RESULTS: The robotic and open thoracotomy groups had equivalent preoperative characteristics, except for a higher proportion of clinical stage IA patients in the robotic cohort. The robotic group, as a whole, had lower intraoperative blood loss, less overall morbidity, shorter chest tube duration, and shorter length of hospital stay as compared with the open thoracotomy group. Operative time demonstrated a bimodal learning curve. Conversion rate diminished from 22.5% in the first two robotic groups to 6.7% in the latter three groups. The rate of pathologic nodal upstaging was statistically equivalent to the open thoracotomy group. CONCLUSIONS: Adoption of a robotic platform for lobectomy for early-stage non-small cell lung cancer by an experienced open thoracic surgeon is safe and feasible, with fewer complications, less blood loss, and equivalent nodal sampling rate even during the learning curve. The conversion to open rate significantly dropped after the first 40 robotic lobectomies, and operative time for robotic lobectomy approached open thoracotomy after 60 cases, after a bimodal curve.

Changes in tumor-antigen expression profile as human small-cell lung cancers progress.

OBJECTIVE: Our group has previously observed that in patients with small-cell lung cancers (SCLCs), the expression of a tumor antigen, glioma big potassium (gBK) ion channel, is higher at the time of death than when the cancer is first treated by surgical resection. This study aimed to determine whether this dichotomy was common in other potential lung tumor antigens by examining the same patient samples using our more extensive profile analysis of tumor-antigen precursor protein (TAPP). We then tested the hypothesis that therapeutic intervention may inadvertently cause this increased gBK production. METHODS: SCLC samples (eight surgical resections and three autopsy samples) and three control lungs were examined by quantitative real-time polymerase chain reaction for 42 potential TAPPs that represent potential T-cell-mediated immunological targets. RESULTS: Twenty-two TAPP mRNAs displayed the same profile as gBK, i.e., more mRNAs were expressed at autopsy than in their surgical counterparts. B-cyclin and mouse double minute 2, human homolog of P53-binding protein were elevated in both autopsy and surgical specimens above the normal-lung controls. When HTB119 cells were incubated with doxorubicin, gBK was strongly induced, as confirmed by intracellular flow cytometry with a gBK-specific antibody. CONCLUSION: Our findings suggested that more immunological targets became available as the tumor responded to chemotherapy and proceeded toward its terminal stages.

Small cell lung cancer cells express the late stage gBK tumor antigen: a possible immunotarget for the terminal disease.

Big Potassium (BK) ion channels have several splice variants. One splice variant initially described within human glioma cells is called the glioma BK channel (gBK). Using a gBK-specific antibody, we detected gBK within three human small cell lung cancer (SCLC) lines. Electrophysiology revealed that functional membrane channels were found on the SCLC cells. Prolonged exposure to BK channel activators caused the SCLC cells to swell within 20 minutes and resulted in their death within five hours. Transduction of BK-negative HEK cells with gBK produced functional gBK channels. Quantitative RT-PCR analysis using primers specific for gBK, but not with a lung-specific marker, Sox11, confirmed that advanced, late-stage human SCLC tissues strongly expressed gBK mRNA. Normal human lung tissue and early, lower stage SCLC resected tissues very weakly expressed this transcript. Immunofluorescence using the anti-gBK antibody confirmed that SCLC cells taken at the time of the autopsy intensely displayed this protein. gBK may represent a late-stage marker for SCLC. HLA-A*0201 restricted human CTL were generated in vitro using gBK peptide pulsed dendritic cells. The exposure of SCLC cells to interferon-γ (IFN-γ) increased the expression of HLA; these treated cells were killed by the CTL better than non-IFN-γ treated cells even though the IFN-γ treated SCLC cells displayed diminished gBK protein expression. Prolonged incubation with recombinant IFN-γ slowed the in vitro growth and prevented transmigration of the SCLC cells, suggesting IFN-γ might inhibit tumor growth in vivo. Immunotherapy targeting gBK might impede advancement to the terminal stage of SCLC via two pathways.

Adverse events after coronary revascularization procedures in California 2000 to 2010.

Public reporting of coronary artery bypass grafting (CABG) mortality in California was initiated in 2003. Drug-eluting stents were widely introduced in the same year. Adverse events after percutaneous coronary intervention (PCI) and CABG were analyzed to study the impact of these events. Annual California hospital discharge data were collected from 2000 through 2010. In-hospital mortality and hospital readmission for adverse events <1 year were determined for patients undergoing isolated CABG, PCI for acute coronary syndrome (PCI-ACS), and all other PCIs (PCI-noACS). CABG volume peaked in 2000 and subsequently decreased by 58%; PCI volume peaked in 2005 and subsequently decreased by 20%. After 2003, in-hospital mortality and 1-year mortality for CABG decreased whereas mortality after PCI remained unchanged. Event rates for acute myocardial infarction and stroke varied little over the decade; acute myocardial infarction at 1 year was 2.5% to 2.8% (CABG), 4.5% to 5.4% (PCI-ACS), and 4.6% to 5.8% (PCI-noACS); stroke rate was 1.4% to 1.7% (CABG), 1.2% to 1.6% (PCI-ACS), and 1.0% to 1.2% (PCI-noACS). Reintervention for PCI decreased markedly, from 18.8% to 12.8% (PCI-ACS) and 22.5% to 13.3% (PCI-noACS). Multiple adverse cardiovascular and cerebral events rate at 1 year decreased from 10.8% to 9.4% (CABG), 26.5% to 21.2% (PCI-ACS), and 26.8% to 18.4% (PCI-noACS). Excluding reinterventions, multiple adverse cardiovascular and cerebral events rate at 1 year was 8.3% (CABG), 14.6% (PCI-ACS), and 10.1% (PCI-noACS) in 2010. In conclusion, the volume of coronary interventions in California decreased whereas adverse event rates decreased after the introduction of public reporting and drug-eluting stents. Lower procedure volume combined with improved outcomes resulted in an annual decrease of >6,000 adverse events by the end of the decade.

The EGFR T790M mutation in acquired resistance to an irreversible second-generation EGFR inhibitor.

Molecular target therapies using first-generation, reversible epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKI), such as gefitinib or erlotinib, have been shown to be effective for patients with non-small cell lung cancer (NSCLC) who harbor activating mutations in EGFR. However, these patients eventually develop resistance to the reversible TKIs, and this has led to the development of second-generation, irreversible EGFR inhibitors. Currently, the mechanism of acquired resistance to irreversible EGFR inhibitors is not clear. Using an in vitro cell culture system, we modeled the acquired resistance to first-line treatment with second-generation EGFR-TKIs using an EGFR-mutant NSCLC cell line. Here, we report a mechanism of resistance involving T790M secondary mutation as well as a corresponding clinical case. The results of these findings suggest that inhibition of EGFR by currently available second-generation EGFR-TKIs may not be sufficient to physiologically prevent the emergence of cells that are still dependent on EGFR signaling. This finding bears important implications on the limitations of currently available second-generation EGFR-TKIs.

Intravenous leiomyomatosis presenting as acute Budd-Chiari syndrome.

Intravenous leiomyomatosis is a rare condition that has been described as being associated with venous occlusion by direct intravascular tumor extension, typically from a pelvic organ. We report an exceedingly rare case of intravenous leiomyomatosis extending into the inferior vena cava, leading to pulmonary embolism, hepatic venous outflow obstruction, and an acute Budd-Chiari syndrome. This is the second reported patient with intravenous leiomyomatosis with Budd-Chiari syndrome and, to our knowledge, the first reported patient who survived with surgery. Correlative images, illustrating computed tomography and magnetic resonance imaging findings characteristic of intravenous leiomyomatosis with secondary Budd-Chiari syndrome, are presented and discussed.

Postoperative thrombotic thrombocytopenic purpura after open heart operations.

BACKGROUND: Postoperative thrombotic thrombocytopenic purpura (pTTP) after cardiovascular operations has an alarmingly high mortality rate if untreated. Five patients after coronary artery bypass graft (CABG) procedure were diagnosed with pTTP when they were observed to have a persistent thrombocytopenia associated with symptoms of fever, renal insufficiency, thromboembolic events, or altered mental status in conjunction with a microangiopathic hemolytic anemia (MAHA). A guideline for early diagnosis, followed by timely treatment in these cases, is reviewed. METHODS: A retrospective record review of postoperative patients with thrombocytopenia identified 5 patients that met the criteria for pTTP from 2004 to 2008. We examined these 5 cardiovascular surgical patients in terms of clinical presentation, laboratory data, and outcomes. RESULTS: All patients had the combination of an unexplained thrombocytopenia (platelets < 50,000 mm(3)) in conjunction with a MAHA as determined by the presence of schistocytes. Symptoms of neurologic dysfunction and renal insufficiency developed in all patients. Thromboembolic events were noted in 1 patient. All patients underwent plasmapheresis. In 3 patients, response time to clinical recovery and normalization of hematologic laboratory values after plasmapheresis was 3, 4, and 8 days. Two patients did not recover and died. One patient had a clinical and laboratory recovery after 19 days of plasmapheresis; however, after 11 days, thrombocytopenia with MAHA developed and he died on day 53 from complications related to the operation. CONCLUSIONS: Postoperative TTP should be recognized as a possible pathophysiologic mechanism for unexplained postoperative thrombocytopenia and treatment should be initiated once the diagnosis is established.

Pedicled latissimus dorsi muscle flap: routine use in high-risk thoracic surgery.

Bronchopleural fistula and empyema are serious complications after thoracic surgical procedures, and their prevention is paramount. Herein, we review our experience with routine prophylactic use of the pedicled ipsilateral latissimus dorsi muscle flap. From January 2004 through February 2006, 10 surgically high-risk patients underwent intrathoracic transposition of this muscle flap for reinforcement of bronchial-stump closure or obliteration of empyema cavities. Seven of the patients were chronically immunosuppressed, 5 were severely malnourished (median preoperative serum albumin level, 2.4 g/dL), and 5 had severe underlying obstructive pulmonary disease (median forced expiratory volume in 1 second, 44% of predicted level). Three upper lobectomies and 1 completion pneumonectomy were performed in order to treat massive hemoptysis that was secondary to complex aspergilloma. One patient underwent left pneumonectomy due to ruptured-cavitary primary lung lymphoma. One upper lobectomy was performed because of necrotizing, localized Mycobacterium avium-intracellulare infection. One patient underwent right upper lobectomy and main-stem bronchoplasty for carcinoma after chemoradiation therapy. In 3 patients, the pedicled latissimus dorsi muscle was used to obliterate chronic empyema cavities and to buttress the closure of underlying bronchopleural fistulas. No operative deaths or recurrent empyemas resulted. Two patients retained peri-flap air that required no surgical intervention. We conclude that the use of transposed pedicled latissimus dorsi muscle flap effectively and reliably prevents clinically overt bronchopleural fistula and recurrent empyema. We advocate its routine use in first-time and selected reoperative thoracotomies in patients who are undergoing high-risk lung resection or reparative procedures.

Prevalence of left atrial appendage pseudothrombus filling defects in patients with atrial fibrillation undergoing coronary computed tomography angiography.

BACKGROUND: Previous reports have shown that computed tomography (CT) is a useful, noninvasive test for detecting atrial thrombi. However, blood stasis in the left atrial appendage (LAA) of patients with atrial fibrillation (AF) may be a common cause for false-positive results. OBJECTIVES: We retrospectively evaluated the prevalence of filling defects that may simulate thrombus in the LAA of patients with AF during routine coronary CT angiography (CTA). METHODS: The LAA of 7 patients with AF was studied for the presence of filling defects and compared with 250 healthy persons. LAA volume in the patients with AF was measured at 10 different cardiac phases and compared with 30 healthy patients. RESULTS: Of the 7 patients with AF studied with CTA, 5 were positive for LAA filling defects. Follow-up imaging studies, including transesophageal echocardiogram, contrast-enhanced magnetic resonance angiography, or delayed-CT, were negative for LAA thrombus. Of 250 patients without AF, CTA showed no evidence of LAA filling defects. Patients with AF had significantly larger LAA volumes at all cardiac phases measured compared with patients without AF (15.2 +/- 6.93 mL compared with 6.85 +/- 3.01 mL at atrial contraction [P = 0.0187], 17.4 +/- 7.76 mL compared with 9.46 +/- 3.43 mL at ventricular systole [P = 0.0351], and 14.5 +/- 5.87 mL compared with 8.48 +/- 3.10 mL at mid-diastole [P = 0.0341]). Compared with the healthy persons, the patients with AF showed reduced percentages of change in LAA volume when the atrial contraction phase was compared with other phases: 44.0% +/- 25.6% compared with 16.5% +/- 12.2% compared with ventricular systole (P = 0.0004) and 29.5% +/- 23.7% compared with -1.63% +/- 8.84% at mid-diastole (P < 0.0001). CONCLUSIONS: Pseudothrombus filling defects are common in the LAA of patients with AF undergoing coronary CTA and should not be mistaken for real thrombus.

Imaging of patent foramen ovale with 64-section multidetector CT.

PURPOSE: To investigate the feasibility of 64-section multidetector computed tomography (CT) by using CT angiography (a) to demonstrate anatomic detail of the interatrial septum pertinent to the patent foramen ovale (PFO), and (b) to visually detect left-to-right PFO shunts and compare these findings in patients who also underwent transesophageal echocardiography (TEE). MATERIALS AND METHODS: In this institutional review board-approved HIPAA-compliant study, electrocardiographically gated coronary CT angiograms in 264 patients (159 men, 105 women; mean age, 60 years) were reviewed for PFO morphologic features. The length and diameter of the opening of the PFO tunnel, presence of atrial septal aneurysm (ASA), and PFO shunts were evaluated. A left-to-right shunt was assigned a grade according to length of contrast agent jet (grade 1, 1 cm to 2 cm; grade 3, >2 cm). In addition, 23 patients who underwent both modalities were compared (Student t test and linear regression analysis). A difference with P < .05 was significant. RESULTS: A flap valve, seen in 101 (38.3%) patients, was patent at the entry into the right atrium (PFO) in 62 patients (61.4% of patients with flap valve, 23.5% of total patients). A left-to-right shunt was detected in 44 (16.7% of total) patients (grade 1, 61.4%; grade 2, 34.1%; grade 3, 4.5%). No shunt was seen in patients without a flap valve. Mean length of PFO tunnel was 7.1 mm in 44 patients with a shunt and 12.1 mm in 57 patients with a flap valve without a shunt (P < .0001). In patients with a tunnel length of 6 mm or shorter, 92.6% of the shunts were seen. ASA was seen in 11 (4.2%) patients; of these patients, a shunt was seen in seven (63.6%). In 23 patients who underwent CT angiography and TEE, both modalities showed a PFO shunt in seven. CONCLUSION: Multidetector CT provides detailed anatomic information about size, morphologic features, and shunt grade of the PFO. Shorter tunnel length and septal aneurysms are frequently associated with left-to-right shunts in patients with PFO.

Bachmann Bundle and its arterial supply: imaging with multidetector CT--implications for interatrial conduction abnormalities and arrhythmias.

PURPOSE: To retrospectively investigate anatomy of Bachmann Bundle (BB) and its vascular supply at 64-section multidetector computed tomography (CT) in healthy patients and patients with abnormalities. MATERIALS AND METHODS: The institutional review board approved this HIPAA-compliant study and waived informed consent. Clinical histories, electrocardiograms (ECGs), and coronary 64-section multidetector CT angiograms in 317 patients were reviewed (healthy group, 164; group with abnormalities, 153). Among patients with abnormalities, 68 had atrial fibrillation (AF) or interatrial conduction block (IAB) (P wave duration, >or=120 msec), 46 had severe coronary artery disease (CAD) (>or=70% stenosis of coronary artery giving rise to sinuatrial node [SAN] artery), and 39 had severe CAD and an abnormal ECG (AF or IAB). Length, anteroposterior and superoinferior diameters, attenuation, and vascular supply of BB were studied. Student t test for continuous variables and contingency tables for categorical variables were used. RESULTS: BB was visualized, to greater degree, in the healthy group (90.2% vs 73.9% for group with abnormalities, P < .001). Visualization of BB was similar among subgroups with abnormalities: 71.7% in patients with severe CAD, 73.5% in patients with abnormal ECG, and 76.9% in patients with severe CAD and abnormal ECG. BB measurements were similar for both groups. Patients with nonvisualized BB displayed lower overall mean attenuation in the region, with -30.6 HU +/- 33.4 (standard deviation), but mean attenuation in healthy patients was 51.3 HU +/- 59.9 (P < .001). This finding suggests fatty infiltration. BB and BB region were mainly supplied by the right SAN artery (55.5%), followed by the left SAN artery (39.6%) and both SAN arteries (4.9%). In the group with abnormalities, there was a significant difference for SAN artery nonvisualization between those with and without identifiable BB (P = .001). CONCLUSION: BB and its vascular supply can easily be demarcated on cardiac CT images. BB was visualized less in patients with severe CAD and abnormal ECG, a finding that suggests that disease of BB fibers may play a role in development of atrial arrhythmias.

MDCT of the S-shaped sinoatrial node artery.

OBJECTIVE: The purpose of this study was to use 64-MDCT to investigate the anatomic characteristics of the S-shaped variant of the sinoatrial node (SAN) artery and to describe the clinical implications of the findings in ablative procedures involving the left atrium. MATERIALS AND METHODS: Coronary CT angiograms of 250 patients (152 men, 98 women; mean age, 60 +/- 12 [SD] years) were retrospectively analyzed for identification of the origin, number, anatomic course, mode of termination, and S-shaped variant of the SAN artery. RESULTS: At least one SAN artery was detected in 244 patients. The S-shaped variant was seen in 35 (14.3%) of these patients. Thirty-four of the variants (30.6% of all left SAN arteries) arose from the proximal to middle portion of the left circumflex artery (mean distance between the ostium of the left circumflex artery and the origin of S-shaped variant, 28.7 +/- 13.1 mm). The other variant (0.7% of all right SAN arteries) originated from the distal right coronary artery. The S-shaped variant was the only artery supplying the SAN in 28 (11.4%) of the patients. In patients with two arteries supplying the SAN, the right SAN artery and the S-shaped variant of the left SAN artery were seen together in seven patients. The S-shaped SAN artery (mean distance from atrial wall, 2.43 +/- 0.992 mm) had a predictable proximal course, lying in the posterior aspect in a groove between the orifices of the left superior pulmonary vein and the left atrial appendage close to the left atrial wall. The terminal segment of the artery approached the nodal tissue posterior to the superior vena cava in 22 patients, anterior to the vena cava in 10 patients, and through branches surrounding the vena cava in two patients. CONCLUSION: The S-shaped variation of the SAN artery is common and has a characteristic anatomic course. MDCT can be used to plan surgical and catheter-based left atrial interventions in which this artery is at risk of injury.

Harvest technique for pedicled transposition of latissimus dorsi muscle: an old trade revisited.

Transposition of extrathoracic muscle flaps has been the cornerstone of treatment of a number of complex intrathoracic pathologies such as bronchopleural fistulas and residual infected pleural spaces. We present a simple step-wise technique for preservation and harvesting of the most common muscle flap employed by thoracic surgeons, namely latissimus dorsi, just prior to performing a standard posterolateral thoracotomy. Since 2004, we have successfully utilized pedicled latissimus muscle as our preferred prophylactic flap against development of postoperative bronchopleural fistulas or recurrent empyemas. This technique should be part of every thoracic surgeon's surgical armamentarium.

Arterial supply to sinuatrial and atrioventricular nodes: imaging with multidetector CT.

PURPOSE: To retrospectively evaluate the depiction of anatomic characteristics of the arterial supply to the sinuatrial node (SAN) and the atrioventricular node (AVN) with 64-section computed tomography (CT). MATERIALS AND METHODS: The institutional review board approved this HIPAA-compliant study; informed consent was not required. Anatomic origin, number, course, and variants of the arteries to the SAN and AVN were examined with coronary multidetector CT in 102 patients (55 men, 47 women; mean age, 57 years +/- 13 [standard deviation]). Known accessory blood supplies to the AVN, including left and right Kugel anastomotic arteries, were investigated. Possible extension of the first septal perforating artery to the AVN was evaluated. Univariate and bivariate statistical data were reported. Means +/- standard deviations, 95% confidence intervals, and percentages were calculated. RESULTS: A single sinuatrial nodal artery originated from the proximal 40 mm of the right coronary artery (RCA) in 67 and from the proximal 35 mm of the left circumflex (LCX) artery in 28 patients. A dual blood supply to the SAN was seen in six patients. The sinuatrial nodal artery was not visualized in one patient. An S-shaped variant was seen in 18% of left sinuatrial nodal arteries and invariably traveled posteriorly in the sulcus between the left superior pulmonary vein and left atrial appendage. The sinuatrial nodal artery approached the nodal tissue by one of three routes-retrocaval (47.5%), precaval (42.6%), or pericaval (9.9%). The AVN was supplied by the RCA in 89 patients, the LCX artery in 11 patients, and by both arteries in two patients. Two left and six right Kugel anastomotic arteries were detected as supplying the AVN area. The first septal perforating artery had no detectable connection to the AVN. CONCLUSION: The arterial blood supply to the SAN and the AVN is variable and can be imaged with multidectector CT. SUPPLEMENTAL MATERIAL: http://radiology.rsnajnls.org/cgi/content/full/2461070030/DC1.