Ganglion cyst

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Ganglion cyst
Other namesGanglia, synovial cyst, [1] Gideon's disease, Olamide's cyst, Bible cyst, Bible bump [2]
Ganglion-cyst.jpg
Cyst on dorsum of left hand close to the wrist
Specialty Plastic surgery, orthopedic surgery, hand surgery
Symptoms Small soft bump associated with a joint or tendon sheath [3]
Complications Only with operative treatment
Usual onsetAny age
Diagnostic method Typically based on signs [4]
Differential diagnosis Lipoma, extensor tenosynovitis [4]
Treatment Watchful waiting, splinting the affected joint, needle aspiration, surgery [3]
Prognosis Not serious [3]
Frequency~3 per 10,000 per year (wrist and hand) [5]

A ganglion cyst is a fluid-filled bump associated with a joint or tendon sheath. [3] It most often occurs at the back of the wrist, followed by the front of the wrist. [3] [4]

Contents

The cause is unknown. [3] The underlying mechanism is believed to involve an outpouching of the synovial membrane. [4] Diagnosis is typically based on examination. The ability to shine through the bump or any past decrease in size supports the diagnosis of the bump as a ganglion cyst. [4] Ganglion cysts are usually obvious upon observation. Medical imaging may be considered on infrequent occasions to rule out another diagnosis. [3] [4]

Treatment is not necessary. Options for treatment include needle aspiration or surgery. [3] About half the time, they resolve on their own. [4] About three per 10,000 people newly develop ganglion of the wrist or hand a year. [5]

Presentation

The average size of these cysts is 2 centimetres (0.79 in), but excised cysts of more than 5 centimetres (2.0 in) have been reported. [6] The size of the cyst may vary over time. Between 50 and 70% of all masses on the hand and wrist are ganglion cysts. [7] [8]

Wrist

They commonly are found near the wrist joint, especially at the scapholunate area. [9]

Common wrist ganglions include:

In a 2007 study of patients in Glasgow whose foot lumps were removed surgically, 39 of 101 cases were ganglion cysts. The study replicated earlier findings that no ganglion cysts were found on the sole or heel. The authors wrote, "Although lumps in these areas may be ganglia, the surgeon should probably consider other diagnoses in the first instance." The researchers noted a preponderance of occurrence among females (85%) and that 11 of the other cases had been misdiagnosed as ganglion cysts before surgery. [13]

Ganglion cysts are not limited to the hands and feet. They may occur near the knee, commonly near the cruciate ligaments, but they may occur at the origins of the gastrocnemius tendon, and anteriorly on Hoffa's infrapatellar fat pad. [14] At the shoulder, they typically occur at the acromioclavicular joint or along the biceps tendon. [15]

Other

From their common origin at a joint or tendon, ganglion cysts may form in a wide range of locations. Rarely, intraosseous ganglion cysts occur, sometimes in combination with a cyst in the overlying soft tissue. [6] [16] Rare cases of intramuscular ganglion cysts in the gastrocnemius muscle of the calf have been reported. [17] [18] It is possible for a cyst to be considerably displaced from the joint. In one extreme case, a ganglion cyst was observed to propagate extensively via the conduit of the common peroneal nerve sheath to a location in the thigh; in such cases surgery to the proximal joint to remove the articular connection may remove the need for a riskier, more extensive surgery in the neural tissue of the thigh. [19] The cysts may intrude into the spine, which may cause pain and dysesthesia in distant extremities. [20]

Cystic adventitial disease, in which a cyst occurs within the popliteal artery near the knee, has been proposed recently to occur by an articular mechanism, with a conduit leading from the joint, similar to the development of ganglion cysts, that spreads within the peroneal nerve. [21] One uncommon location of the cysts are in the muscle tendons of the hand, such as the extensor digitorum superficialis. [22]


Cysts that were compressing one or more nerves and causing bone erosions have been reported to occur near the shoulder joint. [23]

Causes

The most commonly accepted probable cause of ganglion cysts is the herniation hypothesis, by which they are thought to occur as an out-pouching or distention of a weakened portion of a joint capsule or tendon sheath. This description is based on the observations that the cysts occur close to tendons and joints. The microscopic anatomy of the cyst resembles that of tenosynovial tissue. The fluid is similar in composition to synovial fluid. Dye injected into the joint frequently ends up in the cyst. Dye injected into the cyst rarely enters the joint, however, which has been attributed to the apparent formation of an effective and one-way "check valve", allowing fluid out of the joint, but not back in. [6]

In synovials, post-traumatic degeneration of connective tissue and inflammation have been considered as causes. Other possible mechanisms for the development of ganglion cysts include repeated mechanical stress, facet arthrosis, myxoid degeneration of periarticular fibrous tissues and liquefaction with chronic damage, increased production of hyaluronic acid by fibroblasts, and a proliferation of mesenchymal cells. [20] [24]

Diagnosis

Ganglion cyst of the hand with multiple cystic chambers containing glairy material - the walls are composed of bland fibrous tissue with no specialized lining Ganglion Cyst, Hand.jpg
Ganglion cyst of the hand with multiple cystic chambers containing glairy material - the walls are composed of bland fibrous tissue with no specialized lining

Ganglion cysts are diagnosed easily, as they are visible and pliable to touch.

Ultrasonography (US) may be used to increase diagnostic confidence in clinically suspected lesions or to view smaller "occult" cysts as a cause of dorsal wrist pain with forceful extension.

Treatment

At least 33% resolve without treatment within six years, and 50% within 10 years. [25]

Surgical excision is the primary discretionary, elective treatment option for ganglion cysts. Alternatively, a hypodermic needle may be used to drain the fluid from the cyst (via aspiration). [26] The recurrence rate is about 50% following aspiration of a ganglion cyst.

Complications

Complications of treatment may include joint stiffness and scar formation. [26] Recurrence of the lesion is more common following excision of a volar ganglion cyst in the wrist. Incomplete excision that fails to include the stalk or pedicle also may lead to recurrence, as will failing to execute a layered closure of the incision. [27]

Prognosis

Recurrence rate is higher in aspirated cysts than in excised ones. [28] Ganglion cysts have been found to recur following surgery in 12% [29] to 41% [30] of patients.

A six-year outcome study of the treatment of ganglion cysts on the dorsal wrist compared excision, aspiration, and no treatment. Neither excision nor aspiration provided long-term benefit better than no treatment. Of the untreated ganglion cysts, 58% resolved spontaneously; the postsurgery recurrence rate in this study was 39%. [31] A similar study in 2003 of ganglion cysts occurring on the palmar surface of the wrist states: "At 2- and 5-year follow-up, regardless of treatment, no difference in symptoms was found, regardless of whether the palmar wrist ganglion was excised, aspirated, or left alone." [32]

Etymology

Being a misnomer that has persisted into modern times, [33] the ganglion cyst is unrelated to the neural "ganglion" or "ganglion cell"; its etymology traces back to the ancient Greek γάγγλιον, a "knot" or "swelling beneath the skin", [34] which extends to the neural masses by analogy. Generally, Hippocrates is credited with the description of these cysts. [6] [35]

"Bible bump"

A historical method of treatment for a ganglion cyst was to strike the lump with a large, heavy book, causing the cyst to rupture and drain into the surrounding tissues. Historically, a Bible, usually the largest (or only book) in a household, was employed for this treatment. This practice led to the nickname of "Bible bumps" or "Gideon's disease" for the cysts. [2] [36] This treatment risks injuring the person and thus is not recommended. [37] [38] [39]

See also

Related Research Articles

<span class="mw-page-title-main">Carpal tunnel syndrome</span> Compression of the median nerve in the wrist

Carpal tunnel syndrome (CTS) is a nerve compression syndrome associated with the collected signs and symptoms of compression of the median nerve at the carpal tunnel in the wrist. Carpal tunnel syndrome is an idiopathic syndrome but there are environmental, and medical risk factors associated with the condition. CTS can affect both wrists.

<span class="mw-page-title-main">Cyst</span> Closed sac growth on the body

A cyst is a closed sac, having a distinct envelope and division compared with the nearby tissue. Hence, it is a cluster of cells that have grouped together to form a sac ; however, the distinguishing aspect of a cyst is that the cells forming the "shell" of such a sac are distinctly abnormal when compared with all surrounding cells for that given location. A cyst may contain air, fluids, or semi-solid material. A collection of pus is called an abscess, not a cyst. Once formed, a cyst may resolve on its own. When a cyst fails to resolve, it may need to be removed surgically, but that would depend upon its type and location.

<span class="mw-page-title-main">Wrist</span> Part of the arm between the lower arm and the hand

In human anatomy, the wrist is variously defined as (1) the carpus or carpal bones, the complex of eight bones forming the proximal skeletal segment of the hand; (2) the wrist joint or radiocarpal joint, the joint between the radius and the carpus and; (3) the anatomical region surrounding the carpus including the distal parts of the bones of the forearm and the proximal parts of the metacarpus or five metacarpal bones and the series of joints between these bones, thus referred to as wrist joints. This region also includes the carpal tunnel, the anatomical snuff box, bracelet lines, the flexor retinaculum, and the extensor retinaculum.

<span class="mw-page-title-main">De Quervain syndrome</span> Restricted movement of tendons controlling the thumb

De Quervain syndrome occurs when two tendons that control movement of the thumb become constricted by their tendon sheath in the wrist. This results in pain and tenderness on the thumb side of the wrist. Radial abduction of the thumb is painful. On some occasions, there is uneven movement or triggering of the thumb with radial abduction. Symptoms can come on gradually or be noted suddenly.

<span class="mw-page-title-main">Tenosynovitis</span> Inflammation of the fluid sheath (synovium) around a tendon

Tenosynovitis is the inflammation of the fluid-filled sheath that surrounds a tendon, typically leading to joint pain, swelling, and stiffness. Tenosynovitis can be either infectious or noninfectious. Common clinical manifestations of noninfectious tenosynovitis include de Quervain tendinopathy and stenosing tenosynovitis.

<span class="mw-page-title-main">Trigger finger</span> Locking of a finger when at full flexion

Trigger finger, also known as stenosing tenosynovitis, is a disorder characterized by catching or locking of the involved finger in full or near full flexion, typically with force. There may be tenderness in the palm of the hand near the last skin crease. The name "trigger finger" may refer to the motion of "catching" like a trigger on a gun. The ring finger and thumb are most commonly affected.

<span class="mw-page-title-main">Pisiform bone</span> Bone in the wrist

The pisiform bone, also spelled pisiforme, is a small knobbly, sesamoid bone that is found in the wrist. It forms the ulnar border of the carpal tunnel.

<span class="mw-page-title-main">Baker's cyst</span> Medical condition

A Baker's cyst, also known as a popliteal cyst, is a type of fluid collection behind the knee. Often there are no symptoms. If symptoms do occur these may include swelling and pain behind the knee, or knee stiffness. If the cyst breaks open, pain may significantly increase with swelling of the calf. Rarely complications such as deep vein thrombosis, peripheral neuropathy, ischemia, or compartment syndrome may occur.

<span class="mw-page-title-main">Thyroglossal cyst</span> Medical condition

A thyroglossal cyst or thyroglossal duct cyst is a fibrous cyst that forms from a persistent thyroglossal duct. Thyroglossal cysts can be defined as an irregular neck mass or a lump which develops from cells and tissues left over after the formation of the thyroid gland during developmental stages.

<span class="mw-page-title-main">Plantar fibromatosis</span> Thickening of the feets deep connective tissue (fascia)

Plantar fascial fibromatosis, also known as Ledderhose's disease, Morbus Ledderhose, and plantar fibromatosis, is a relatively uncommon non-malignant thickening of the feet's deep connective tissue, or fascia. In the beginning, where nodules start growing in the fascia of the foot, the disease is minor. Over time, walking becomes painful. The disease is named after Georg Ledderhose, a German surgeon who described the condition for the first time in 1894. A similar disease is Dupuytren's disease, which affects the hand and causes bent hand or fingers.

<span class="mw-page-title-main">Deep transverse metacarpal ligament</span> Ligament that connects the palmar surfaces of the heads of the second to fifth metacarpal bones

The deep transverse metacarpal ligament connects the palmar surfaces of metacarpophalangeal joints of all the fingers of the hand except the thumb.

<span class="mw-page-title-main">Extensor retinaculum of the hand</span> A thickened fascia holding the tendons of the hand extensor muscles in place

The extensor retinaculum is a thickened portion of the antebrachial fascia that holds the tendons of the extensor muscles in place. It is located on the back of the forearm, just proximal to the hand. It is continuous with the palmar carpal ligament.

<span class="mw-page-title-main">Triangular fibrocartilage</span> Anatomical feature in the wrist

The triangular fibrocartilage complex (TFCC) is formed by the triangular fibrocartilage discus (TFC), the radioulnar ligaments (RULs) and the ulnocarpal ligaments (UCLs).

The posterior compartment of the forearm contains twelve muscles which primarily extend the wrist and digits. It is separated from the anterior compartment by the interosseous membrane between the radius and ulna.

Extensor digitorum brevis manus is an extra or accessory muscle on the backside (dorsum) of the hand. It was first described by Albinus in 1758. The muscles lies in the fourth extensor compartment of the wrist, and is relatively rare. It has a prevalence of 4% in the general population according to a meta-analysis. This muscle is commonly misdiagnosed as a ganglion cyst, synovial nodule or cyst.

The hand is a very complex organ with multiple joints, different types of ligament, tendons and nerves. Hand disease injuries are common in society and can result from excessive use, degenerative disorders or trauma.

Haglund's syndrome is a group of signs and symptoms consisting of Haglund's deformity in combination with retrocalcaneal bursitis. It is often accompanied by Achilles tendinitis.

<span class="mw-page-title-main">Carpal tunnel surgery</span> Surgery to relieve carpal tunnel syndrome

Carpal tunnel surgery, also called carpal tunnel release (CTR) and carpal tunnel decompression surgery, is a nerve decompression in which the transverse carpal ligament is divided. It is a surgical treatment for carpal tunnel syndrome (CTS) and recommended when there is constant (not just intermittent) numbness, muscle weakness, or atrophy, and when night-splinting no longer controls intermittent symptoms of pain in the carpal tunnel. In general, milder cases can be controlled for months to years, but severe cases are unrelenting symptomatically and are likely to result in surgical treatment. Approximately 500,000 surgical procedures are performed each year, and the economic impact of this condition is estimated to exceed $2 billion annually.

<span class="mw-page-title-main">Trapeziometacarpal osteoarthritis</span> Medical condition

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<span class="mw-page-title-main">Wrist arthroscopy</span>

Wrist arthroscopy can be used to look inside the joint of the wrist. It is a minimally invasive technique which can be utilized for diagnostic purposes as well as for therapeutic interventions. Wrist arthroscopy has been used for diagnostic purposes since it was first introduced in 1979. However, it only became accepted as diagnostic tool around the mid-1980s. At that time, arthroscopy of the wrist was an innovative technique to determine whether a problem could be found in the wrist. A few years later, wrist arthroscopy could also be used as a therapeutic tool.

References

  1. ↑ "National Library of Medicine - Medical Subject Headings (MeSH) - Ganglion Cyst". Archived from the original on March 10, 2016. Retrieved August 27, 2013.
  2. 1 2 "E-hand.com The Electronic Textbook of Hand Surgery". The American Society for Surgery of the Hand assh.com. Archived from the original on March 9, 2014. Retrieved April 12, 2014.
  3. 1 2 3 4 5 6 7 8 "Ganglion Cyst of the Wrist and Hand-OrthoInfo". orthoinfo.aaos.org. March 2013. Archived from the original on 6 July 2017. Retrieved 10 June 2017.
  4. 1 2 3 4 5 6 7 Ferri FF (2014). Ferri's Clinical Advisor 2015 E-Book: 5 Books in 1. Elsevier Health Sciences. p. 472. ISBN   9780323084307. Archived from the original on 2017-09-10.
  5. 1 2 Cooney WP (2011). The Wrist: Diagnosis and Operative Treatment. Lippincott Williams & Wilkins. p. 1089. ISBN   9781451148268. Archived from the original on 2017-09-10.
  6. 1 2 3 4 Craig A. Camasta, DPM (1993). "excision of the ganglion cyst" (PDF). Podiatry Institute. Archived (PDF) from the original on 2013-11-01.
  7. ↑ Stretanski MF (2020-01-01), Frontera WR, Silver JK, Rizzo TD (eds.), "Chapter 32 - Hand and Wrist Ganglia", Essentials of Physical Medicine and Rehabilitation (Fourth Edition), Philadelphia: Content Repository Only!, pp. 169–173, ISBN   978-0-323-54947-9 , retrieved 2020-10-24
  8. ↑ Fess EE, Gettle KS, Philips CA, Janson JR, eds. (2005-01-01), "CHAPTER 17 - Splinting for Work, Sports, and the Performing Arts", Hand and Upper Extremity Splinting (Third Edition), Saint Louis: Mosby, pp. 456–479, doi:10.1016/b978-080167522-5.50022-8, ISBN   978-0-8016-7522-5 , retrieved 2020-10-24
  9. ↑ "Ganglion cysts". The British Society for Surgery of the hand. BSSH. Archived from the original on April 7, 2017. Retrieved April 6, 2017.
  10. 1 2 3 4 5 6 Pal J, Wallman J (2014-01-01), Cooper C (ed.), "36 - Ganglions and Tumors of the Hand and Wrist", Fundamentals of Hand Therapy (Second Edition), St. Louis: Mosby, pp. 500–507, doi:10.1016/b978-0-323-09104-6.00036-5, ISBN   978-0-323-09104-6 , retrieved 2020-10-24
  11. ↑ Kirk Watson H, Sorelle J (2010-01-01), Slutsky DJ (ed.), "CHAPTER 45 - Dorsal Wrist Syndrome and Rotatory Subluxation of the Scaphoid", Principles and Practice of Wrist Surgery, Philadelphia: W.B. Saunders, pp. 487–491, ISBN   978-1-4160-5646-1 , retrieved 2020-10-24
  12. 1 2 3 Cooper C (2007-01-01), Cooper C (ed.), "Chapter 21 - Ganglion Cysts and Other Common Tumors of the Hand and Wrist", Fundamentals of Hand Therapy, Saint Louis: Mosby, pp. 412–420, doi:10.1016/b0-32-303386-5/50024-2, ISBN   978-0-323-03386-2 , retrieved 2020-10-24
  13. ↑ Duncan JM Macdonald, et al. (August 2007). "The Differential Diagnosis of Foot Lumps: 101 Cases Treated Surgically in North Glasgow Over 4 Years". Annals of the Royal College of Surgeons of England. 89 (3): 272–275. doi:10.1308/003588407x168235. PMC   1964714 . PMID   17394713.
  14. ↑ Jon Arthur Jacobson (2007). Fundamentals of Musculoskeletal Ultrasound. Elsevier Health Sciences. ISBN   978-1416035930. Archived from the original on 2014-07-04.
  15. ↑ Arend CF. Ultrasound of the Shoulder. Master Medical Books, 2013. Sample chapter available on acromioclavicular joint ganglion Archived 2014-05-18 at the Wayback Machine .
  16. ↑ Muir B, Kissel JA, Yedon DF (December 2011). "Intraosseous ganglion cyst of the humeral head in a competitive flat water paddler: case report". J Can Chiropr Assoc. 55 (4): 294–301. PMC   3222705 . PMID   22131566. (includes MRI images)
  17. ↑ Jae Jeong Park, et al. (2010). "Case Report : Intramuscular Ganglion Cyst of the Gastrocnemius Muscle". Korean Journal of Dermatology. Archived from the original on 2013-06-17.
  18. ↑ Park S, Jin W, Chun YS, Park SY, Kim HC, Kim GY, Park JS, Ryu KN (October 2009). "Ruptured intramuscular ganglion cyst in the gastrocnemius medialis muscle: sonographic appearance". Journal of Clinical Ultrasound. 37 (8): 478–81. doi:10.1002/jcu.20609. PMID   19618443. S2CID   20586520.
  19. ↑ Robert J. Spinner, et al. (2012). "Re: Pure Peroneal Intraneural Ganglion Cyst: Hindsight is 20/20" (PDF). Turkish Neurosurgery. pp. 527–528. Archived (PDF) from the original on 2013-10-14.
  20. 1 2 Sang Woo Kim, et al. (April 2011). "A Ganglion Cyst in the Second Lumbar Intervertebral Foramen". J Korean Neurosurg Soc. 49 (4): 237–240. doi:10.3340/jkns.2011.49.4.237. PMC   3098430 . PMID   21607185. (original source cites eight additional references for the quoted paragraph)
  21. ↑ R. J. Spinner, et al. (2012-08-29). "Evidence to support that adventitial cysts, analogous to intraneural ganglion cysts, are also joint-connected". Clin. Anat. 26 (2): 267–81. doi:10.1002/ca.22152. PMID   22933403. S2CID   37986961.
  22. ↑ Meza-Hernandez J, González-Cantú I, Jimenez-Jimenez J, Ramirez-Sosa L, Martínez-Wagner R. Synovial Cyst of the extensor digitorum superficialis: A case report. JPRAS Open. 2024 Feb 28;40:145-149. doi:10.1016/j.jpra.2024.02.014. PMID: 38854624; PMCID: PMC11156691.
  23. ↑ Field LD (2003). MasterCases: Shoulder and Elbow Surgery. Thieme. p. 241. ISBN   9780865778733.
  24. ↑ Ribes R (2010). Learning Musculoskeletal Imaging. Springer. p. 197. ISBN   9783540880004.
  25. ↑ "Clinical treatments for wrist ganglia" (PDF). ROYAL AUSTRALASIAN COLLEGE OF SURGEONS. Archived from the original (PDF) on 27 March 2018.
  26. 1 2 The Gale encyclopedia of surgery: a guide for patients and caregivers, Volume 1. Gale. 2003. pp.  560. ISBN   9780787677213.
  27. ↑ Camasta, Craig A., DPM, Excision of the Ganglion Cyst Archived 2013-11-01 at the Wayback Machine , podiatryinstitute.com, update 1993, 1993 33 pdf, pages 181–5
  28. ↑ Pocket Guide to Musculoskeletal Diagnosis. Springer. 2005. p. 63. ISBN   9781597450096.
  29. ↑ Gallego S, Mathoulin C (2010). "Arthroscopic resection of dorsal wrist ganglia: 114 cases with minimum follow-up of 2 years". Arthroscopy. 26 (12): 1675–1682. doi:10.1016/j.arthro.2010.05.008. PMID   20952152.
  30. ↑ Lidder S, Ranawat V, Ahrens P (2009). "Surgical excision of wrist ganglia; literature review and nine-year retrospective study of recurrence and patient satisfaction". Orthop Rev. 1 (1): e5. doi:10.4081/or.2009.e5. PMC   3143961 . PMID   21808669.
  31. ↑ Dias JJ, Dhukaram V, Kumar P (October 2007). "The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention". The Journal of Hand Surgery, European Volume. 32 (5): 502–8. doi:10.1016/J.JHSE.2007.05.007. PMID   17950209. S2CID   21853864.
  32. ↑ Dias J, Buch K (Apr 2003). "Palmar wrist ganglion: does intervention improve outcome? A prospective study of the natural history and patient-reported treatment outcomes". J Hand Surg Br Vol. 28 (2): 172–6. doi:10.1016/s0266-7681(02)00365-0. PMID   12631492. S2CID   44865301.
  33. ↑ J.C. Segen (1992). The Dictionary of Modern Medicine. CRC Press. ISBN   9781850703211. Archived from the original on 2017-09-10. (see the entry for aneurysmal bone cyst, which "like pyogenic granuloma and ganglion cyst, a misnomer that has withstood the sands of time and the dint of logic")
  34. ↑ "Etymology of the Greek word ganglion (γάγγλιον)". Archived from the original on 2013-10-06.{{cite web}}: CS1 maint: unfit URL (link)
  35. ↑ See Hippocrates' "On the Articulations" (part 40) at Wikisource
  36. ↑ Dacombe PJ, Robinson, J (Mar 27, 2012). "Falling Up the Stairs: the Equivalent of 'Bashing it with a Bible' for an ACL Ganglion Cyst of the Knee". BMJ Case Reports. 2012: bcr0120125591. doi:10.1136/bcr.01.2012.5591. PMC   3316796 . PMID   22605799.
  37. ↑ Hammond C. "Should you bash a 'bible bump'?" . Retrieved 2018-08-09.
  38. ↑ "Ganglions". Archived from the original on 2009-04-15. Retrieved 2009-05-27.
  39. ↑ Hammond C. "Should you bash a 'bible bump'?" . Retrieved 24 November 2018.
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