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Patient compliance and satisfaction with topical benzoyl peroxide gel prior to shoulder surgery

Open AccessPublished:March 08, 2022DOI:https://doi.org/10.1016/j.jseint.2022.02.009

      Background

      Cutibacterium acnes is a common pathogen leading to postoperative shoulder infections. Many centers are utilizing 5% topical benzoyl peroxide (BPO) gel to decrease cutibacterium acnes bioburden prior to surgery. The purpose of this study was to evaluate patient compliance, tolerance, and side effects of applying BPO to the shoulder prior to surgery. Our hypothesis was that BPO would be well tolerated with few, minor side effects, and patients would comply with a regimen of 5 treatments spanning 48 hours prior to surgery.

      Methods

      All patients undergoing operative intervention, either open or arthroscopic, about the shoulder from August 7, 2020, through July 15, 2021, by a single surgeon were instructed to apply BPO to the shoulder after showering, on dry skin, in the morning and evening, starting 48 hours before their surgical date. Patients were instructed to apply a half-dollar-sized quantity for each treatment. There were a total of 5 topical applications. On the day of surgery, patients were given a 6-question survey regarding side effects experienced, BPO treatments missed, ease of treatment, and a scenario question. Demographic information was collected, and a satisfaction survey was administered upon study completion.

      Results

      A total of 183 patients out of a possible 284 eligible patients (64.4%) completed the survey. The median (interquartile range) age at surgery was 59.9 years. Sixty-four participants (35%) in the study cohort were female. One-hundred thirteen (61.7%) had an arthroscopic surgical approach, whereas 70 (38.3%) underwent open shoulder surgery. Most patients (N = 152, 83.5%) experienced no side effects from the topical 5% BPO gel treatments. Twenty-two (12.0%) patients missed 1 treatment, 10 (5.5%) missed 2 treatments, 1 (0.5%) missed 3 treatments, 3 (1.6%) missed 4 treatments, and 4 (2.2%) missed all 5 treatments. The majority of patients, 143 (78.1%), completed all 5 treatments. When prompted to choose between serial skin preparation treatments at home leading up to surgery or a single light-based decolonization procedure in the preoperative holding area on the day of surgery, 111 (60.7%) preferred to undergo antimicrobial treatment at home and arrive for surgery as otherwise scheduled.

      Conclusion

      Serial preoperative applications of topical 5% BPO gel are well tolerated by the majority of patients. Over 20% of patients missed at least one application of BPO. Most patients prefer home-based antimicrobial treatments compared with arriving earlier on the day of surgery for a single light-based antimicrobial treatment.

      Level of evidence

      Keywords

      Cutibacterium acnes (C. acnes) is a leading cause of infection following shoulder surgery.
      • Achermann Y.
      • Sahin F.
      • Schwyzer H.K.
      • Kolling C.
      • Wust J.
      • Vogt M.
      Characteristics and outcome of 16 periprosthetic shoulder joint infections.
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      • Horneff 3rd, J.G.
      • Hsu J.E.
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      • Huffman G.R.
      Propionibacterium acnes infection in shoulder arthroscopy patients with postoperative pain.
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      • Pena-Diaz A.M.
      • Athwal G.S.
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      • Faber K.J.
      • et al.
      Cutibacterium acnes and the shoulder microbiome.
      ,
      • Sabetta J.R.
      • Rana V.P.
      • Vadasdi K.B.
      • Greene R.T.
      • Cunningham J.G.
      • Miller S.R.
      • et al.
      Efficacy of topical benzoyl peroxide on the reduction of Propionibacterium acnes during shoulder surgery.
      This is a commensal organism that resides in the sebaceous glands of the dermal layer of the skin.
      • Achermann Y.
      • Goldstein E.J.C.
      • Coenye T.
      • Shirtliff M.E.
      Propionibacterium acnes: from commensal to opportunistic biofilm-associated implant pathogen.
      ,
      • Patel A.
      • Calfee R.P.
      • Plante M.
      • Fischer S.A.
      • Green A.
      Propionibacterium acnes colonization of the human shoulder.
      In recent years, topical skin preparations including 5% topical benzoyl peroxide (BPO) gel, povidone-iodine, hydrogen peroxide, and chlorhexidine have been investigated for their ability to diminish the bioburden of C. acnes at the epidermis prior to surgical intervention.
      • Duvall G.
      • Kaveeshwar S.
      • Sood A.
      • Klein A.
      • Williams K.
      • Kolakowski L.
      • et al.
      Benzoyl peroxide use transiently decreases Cutibacterium acnes load on the shoulder.
      ,
      • Kolakowski L.
      • Lai J.K.
      • Duvall G.T.
      • Jauregui J.J.
      • Dubina A.G.
      • Jones D.L.
      • et al.
      Neer Award 2018: benzoyl peroxide effectively decreases preoperative Cutibacterium acnes shoulder burden: a prospective randomized controlled trial.
      ,
      • Sabetta J.R.
      • Rana V.P.
      • Vadasdi K.B.
      • Greene R.T.
      • Cunningham J.G.
      • Miller S.R.
      • et al.
      Efficacy of topical benzoyl peroxide on the reduction of Propionibacterium acnes during shoulder surgery.
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      • Koh J.L.
      Efficacy of surgical preparation solutions in shoulder surgery.
      • Scheer V.M.
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      • Kalen A.
      Topical benzoyl peroxide application on the shoulder reduces Propionibacterium acnes: a randomized study.
      • Scheer V.M.
      • Jungeström M.B.
      • Serrander L.
      • Kalén A.
      • Scheer J.H.
      Benzoyl peroxide treatment decreases Cutibacterium acnes in shoulder surgery, from skin incision until wound closure.
      • Singh A.M.
      • Sethi P.M.
      • Romeo A.A.
      • Anakwenze O.A.
      • Abboud J.A.
      • Namdari S.
      Strategies to decolonize the shoulder of Cutibacterium acnes: a review of the literature.
      Blue light therapy (BLT), a modality utilized in dermatology for treatment of inflammatory acne, has also been investigated for this same purpose.
      • Ammad S.
      • Gonzales M.
      • Edwards C.
      • Finlay A.Y.
      • Mills C.
      An assessment of the efficacy of blue light phototherapy in the treatment of acne vulgaris.
      ,
      • Ashkenazi H.
      • Malik Z.
      • Harth Y.
      • Nitzan Y.
      Eradication of Propionibacterium acnes by its endogenic porphyrins after illumination with high intensity blue light.
      ,
      • Bumah V.V.
      • Masson-Meyers D.S.
      • Tong W.
      • Castel C.
      • Enwemeka C.S.
      Optimizing the bactericidal effect of pulsed blue light on Propionibacterium acnes - a correlative fluorescence spectroscopy study.
      ,
      • Cotter E.J.
      • Cotter L.M.
      • Franczek E.B.
      • Godfrey J.J.
      • Hetzel S.J.
      • Safdar N.
      • et al.
      Efficacy of Combinational therapy using blue light and benzoyl peroxide in reducing Cutibacterium acnes bioburden at the Deltopectoral interval: a randomized controlled trial.
      Many shoulder centers, including the study institution, utilize a regimen of topical 5% BPO gel prior to shoulder surgery. BPO is lipophilic, and it has been reported to enter the pilosebaceous glands where it leads to the production of reactive oxygen species capable of oxidizing proteins in bacterial cell membranes.
      • Sagransky M.
      • Yentzer B.A.
      • Feldman S.R.
      Benzoyl peroxide: a review of its current use in the treatment of acne vulgaris.
      A typical preoperative regimen consists of 5 serial applications spanning 48 hours leading up to the day of surgery.
      • Sabetta J.R.
      • Rana V.P.
      • Vadasdi K.B.
      • Greene R.T.
      • Cunningham J.G.
      • Miller S.R.
      • et al.
      Efficacy of topical benzoyl peroxide on the reduction of Propionibacterium acnes during shoulder surgery.
      It is not uncommon for patients to report missing one or more doses, as well as report frustration with known side effects of BPO application, including dry skin, itching, erythema, and bleaching of clothing and towels.
      • van Diek F.M.
      • Pruijn N.
      • Spijkers K.M.
      • Mulder B.
      • Kosse N.M.
      • Dorrestijn O.
      The presence of Cutibacterium acnes on the skin of the shoulder after the use of benzoyl peroxide: a placebo-controlled, double-blinded, randomized trial.
      ,
      • Yang Z.
      • Zhang Y.
      • Lazic Mosler E.
      • Hu J.
      • Li H.
      • Zhang Y.
      • et al.
      Topical benzoyl peroxide for acne.
      To date, no investigation has evaluated patient compliance and tolerance of 5% topical BPO gel regimen prior to shoulder surgery. Preoperative skin preparations that have reliably been shown to have beneficial antimicrobial effects are only useful if patients are compliant with the treatment protocol. Differences in compliance between various preoperative skin preparation regimens may have a clinical impact on regimen efficacy.
      The purpose of this study was to (1) evaluate patient compliance with 5 preoperative applications, (2) determine the incidence of side effects from the topical BPO gel, and (3) report satisfaction with treatment. It was hypothesized that most patients would not miss a single BPO treatment, minor side effects would be common, and patients may be interested in alternative options.

      Methods

      This study was approved by the institutional review baord. All patients undergoing operative intervention, either open or arthroscopic, about the shoulder from August 7, 2020, through July 15, 2021, by a single surgeon were prospectively administered a short survey in the preoperative holding area on the day of surgery.

      Study participants

      Patients were included if they were scheduled to undergo open or arthroscopic surgery from the acromioclavicular joint to the proximal humerus. This included shoulder arthroplasty cases, both primary and revision, any arthroscopic shoulder procedure, any procedure on the acromioclavicular joint, and proximal humerus fracture open reduction internal fixation. Patients were excluded if they had an allergy to BPO. Prior to surgery, patients completed a short, 6-question survey regarding treatment compliance, side effects, and ease of treatment (Appendix 1). The survey was created by the investigators to be concise and objective with regard to side effects experienced, number of treatment doses missed, and whether or not patients would rather complete the 5-treatment regimen of BPO or prefer a single light-based treatment on the day of surgery in the preoperative holding area.

      Treatment description

      Patients were instructed to apply a half-dollar sized amount of 5% BPO to the front, back, and armpit of the operative shoulder after showering, on dry skin, twice daily and once on the morning of surgery, for a total of 5 applications. The treatment regimen was 3 days in duration (2 days prior to surgery, 1 day prior to surgery, and the morning of surgery). The handout with instructions given to patients can be found in Appendix 2.

      Statistical analysis

      Descriptive statistics were performed for demographic information of study volunteers and results of the satisfaction survey. Due to abnormal distribution of the data, median and interquartile ranges were reported for continuous variables. Bar graphs were created to depict the results of select survey questions. All statistical analyses were performed using RStudio software version 4.0.4 (R Foundation for Statistical Computing, Vienna, Austria).

      Results

      A total of 183 patients out of a possible 284 eligible patients (64.4%) completed the survey and were included in the study cohort. The median (interquartile range) age at surgery and body mass index were 59.9 years and 30.6 kg/m2, respectively. Sixty-four participants (35%) in the study cohort were female. One-hundred thirteen (61.7%) had an arthroscopic surgical approach, whereas 70 (38.3%) underwent open shoulder surgery. A complete description of subject demographics can be found in Table I.
      Table IBaseline demographics and surgical data for the study population.
      Demographics
       Number of patients183
       Age at surgery (yr)59.9 (50.7-67.8)
       Race (%)
      African American3 (1.6)
      Asian1 (0.5)
      Caucasian179 (97.8)
       Female gender (%)64 (35.0)
       Body mass index (kg/m2)30.6 (27.1-34.0)
      Surgical data
       Surgical approach (%)
      Arthroscopic113 (61.7)
      Open70 (38.3)
       Surgery performed (%)
      Percentages do not add up to 100, as patients with more than 1 surgery performed were included.
      Rotator cuff repair54 (29.5)
      Anatomic TSA13 (7.1)
      Reverse TSA51 (27.9)
      Biceps tenodesis57 (31.1)
      Clavicle ORIF1 (0.5)
      Other35 (19.1)
      TSA, total shoulder arthroplasty; ORIF, open reduction and internal fixation.
      Data presented as median (interquartile range) unless otherwise specified. One patient (0.5%) had a local skin reaction to benzoyl peroxide (BPO).
      Percentages do not add up to 100, as patients with more than 1 surgery performed were included.
      Regarding the survey questions, most patients (N = 152, 83.5%) experienced no side effects from the topical 5% BPO gel treatments (Fig. 1). Twenty-two (12.0%) patients missed 1 treatment, 10 (5.5%) missed 2 treatments, 1 (0.5%) missed 3 treatments, 3 (1.6%) missed 4 treatments, and 4 (2.2%) missed all 5 treatments. The majority, 143 (78.1%), of patients completed all 5 recommended treatments. Most patients reported that complying with the preoperative treatment regimen was either easy (N = 42, 23.0%) or very easy (N = 114, 62.3%) (Fig. 2). The median level of satisfaction with topical BPO treatment was 10 (interquartile range: 8 – 10, range: 0 – 10). When prompted to choose between serial skin preparation treatments at home leading up to surgery or a single light-based decolonization procedure in the preoperative holding area on the day of surgery, 111 (60.7%) preferred to undergo antimicrobial treatment at home rather than arrive for surgery 30 minutes earlier than scheduled to undergo one light-based antimicrobial treatment.
      Figure thumbnail gr1
      Figure 1Bar graph demonstrating responses to question 1, “Did you experience any side effects of 5% topical benzoyl peroxide (circle all that apply)?”. A = none, B = skin dryness, peeling, or flaking, C = bleaching of clothing, D = itching or burning, E = redness. One patient responded other with free text: “skin lighter on affected shoulder after doses”.
      Figure thumbnail gr2
      Figure 2Bar graph demonstrating responses to question 3, “How easy was it to comply with the treatment regimen?”.

      Discussion

      The main findings of this study demonstrate that the preoperative treatment regimen of 5% topical BPO gel was well tolerated with adequate overall compliance and few side effects. Most patients (N = 152, 83.5%) experienced no side effects to the treatment. Of those patients who did report side effects, bleaching of clothes (3.8%), itching or burning (3.3%), and multiple side effects (4.9%) were most commonly reported. Forty (N = 21.9%) patients failed to complete at least one of the required 5 doses of BPO prior to surgery. The majority of patients (N = 111, 60.7%) responded that they would prefer to undergo microbial treatment at home rather than undergo a one-time antimicrobial treatment consisting of light-based treatment in the preoperative area.
      In this study, the application of BPO was well tolerated and had a high rate of satisfaction; however, greater than 20% of patients reported missing at least 1 of the 5 required doses prior to surgery. Various studies have demonstrated the efficacy of BPO treatment prior to shoulder surgery.
      • van Diek F.M.
      • Pruijn N.
      • Spijkers K.M.
      • Mulder B.
      • Kosse N.M.
      • Dorrestijn O.
      The presence of Cutibacterium acnes on the skin of the shoulder after the use of benzoyl peroxide: a placebo-controlled, double-blinded, randomized trial.
      ,
      • Kolakowski L.
      • Lai J.K.
      • Duvall G.T.
      • Jauregui J.J.
      • Dubina A.G.
      • Jones D.L.
      • et al.
      Neer Award 2018: benzoyl peroxide effectively decreases preoperative Cutibacterium acnes shoulder burden: a prospective randomized controlled trial.
      ,
      • Scheer V.M.
      • Bergman Jungestrom M.
      • Lerm M.
      • Serrander L.
      • Kalen A.
      Topical benzoyl peroxide application on the shoulder reduces Propionibacterium acnes: a randomized study.
      Scheer et al randomized 40 patients to topical at home treatment with either 5% BPO or chlorhexidine soap on the operative shoulder.
      • Scheer V.M.
      • Bergman Jungestrom M.
      • Lerm M.
      • Serrander L.
      • Kalen A.
      Topical benzoyl peroxide application on the shoulder reduces Propionibacterium acnes: a randomized study.
      The authors found that the application of topical BPO significantly reduced the presence of C. acnes on the skin at the time of surgery and at 2 hours after surgical preparation compared with chlorhexidine soap. Kolakowski et al similarly demonstrated that treating with 5% BPO for 3 days prior to surgery led to fewer positive cultures relative to chlorhexidine and contralateral shoulder negative control.
      • Kolakowski L.
      • Lai J.K.
      • Duvall G.T.
      • Jauregui J.J.
      • Dubina A.G.
      • Jones D.L.
      • et al.
      Neer Award 2018: benzoyl peroxide effectively decreases preoperative Cutibacterium acnes shoulder burden: a prospective randomized controlled trial.
      In contrast, Hsu et al found that neither a 10% BPO soap nor a 4% chlorhexidine solution was effective at decreasing C. acnes burden from the skin surface or dermal edge of the incision.
      • Hsu J.E.
      • Whitson A.J.
      • Woodhead B.M.
      • Napierala M.A.
      • Gong D.
      • Matsen F.A.
      Randomized controlled trial of chlorhexidine wash versus benzoyl peroxide soap for home surgical preparation: neither is effective in removing Cutibacterium from the skin of shoulder arthroplasty patients.
      Notably, patients in the study by Hsu et al were instructed to only apply treatment to the surgical shoulder twice (once the night prior and once the morning of surgery) rather than 5 applications.
      • Hsu J.E.
      • Whitson A.J.
      • Woodhead B.M.
      • Napierala M.A.
      • Gong D.
      • Matsen F.A.
      Randomized controlled trial of chlorhexidine wash versus benzoyl peroxide soap for home surgical preparation: neither is effective in removing Cutibacterium from the skin of shoulder arthroplasty patients.
      Due to variability in current BPO treatment protocols in the literature, it is unclear whether treatment compliance may have an impact on the bioburden of C. acnes and the subsequent risk of periprosthetic joint infection. The protocol of 5 serial treatments described by Sabetta et al was used in the current study.
      • Sabetta J.R.
      • Rana V.P.
      • Vadasdi K.B.
      • Greene R.T.
      • Cunningham J.G.
      • Miller S.R.
      • et al.
      Efficacy of topical benzoyl peroxide on the reduction of Propionibacterium acnes during shoulder surgery.
      However, asking patients to complete more treatments may lead to a subset of patients missing one or more treatment, which was corroborated by the findings of the present study. The clinical implication of missing at least one treatment remains unknown, but the data put forth by Hsu et al do raise concern that fewer applications may lead to inferior antimicrobial effect.
      • Hsu J.E.
      • Whitson A.J.
      • Woodhead B.M.
      • Napierala M.A.
      • Gong D.
      • Matsen F.A.
      Randomized controlled trial of chlorhexidine wash versus benzoyl peroxide soap for home surgical preparation: neither is effective in removing Cutibacterium from the skin of shoulder arthroplasty patients.
      Further work is needed to elucidate the optimal preoperative regimen of BPO application to maximize antimicrobial effects and compliance.
      Drawbacks to topical BPO treatment prior to shoulder surgery have previously been described. These include side effects (bleaching of clothes, contact dermatitis), serial treatment applications leading to poor compliance, and failure of BPO to penetrate deep enough into the superficial dermis where sebaceous glands are located.
      • van Diek F.M.
      • Pruijn N.
      • Spijkers K.M.
      • Mulder B.
      • Kosse N.M.
      • Dorrestijn O.
      The presence of Cutibacterium acnes on the skin of the shoulder after the use of benzoyl peroxide: a placebo-controlled, double-blinded, randomized trial.
      ,
      • Heckmann N.
      • Sivasundaram L.
      • Heidari K.S.
      • Weber A.E.
      • Mayer E.N.
      • Omid R.
      • et al.
      Propionibacterium acnes persists despite various skin preparation techniques.
      ,
      • Paithankar D.Y.
      • Sakamoto F.H.
      • Farinelli W.A.
      • Kositratna G.
      • Blomgren R.D.
      • Meyer T.J.
      • et al.
      Acne treatment based on selective photothermolysis of sebaceous follicles with topically delivered light-absorbing gold microparticles.
      ,
      • Yang Z.
      • Zhang Y.
      • Lazic Mosler E.
      • Hu J.
      • Li H.
      • Zhang Y.
      • et al.
      Topical benzoyl peroxide for acne.
      The concerns regarding the depth of penetration of topical preparations such as BPO are important, as C. acnes resides predominantly in the pilosebaceous gland in the dermis of the skin. Accordingly, recent efforts have focused on identifying viable alternative treatments that offer similar efficacy and potentially deeper penetration into the dermal layer of skin to BPO with fewer drawbacks. One such alternative that has been extensively investigated in the dermatology literature for the treatment of mild-to-moderate acne caused by high C. acnes burden is photodynamic therapy or BLT.
      • Ammad S.
      • Gonzales M.
      • Edwards C.
      • Finlay A.Y.
      • Mills C.
      An assessment of the efficacy of blue light phototherapy in the treatment of acne vulgaris.
      ,
      • Ashkenazi H.
      • Malik Z.
      • Harth Y.
      • Nitzan Y.
      Eradication of Propionibacterium acnes by its endogenic porphyrins after illumination with high intensity blue light.
      ,
      • Bumah V.V.
      • Masson-Meyers D.S.
      • Tong W.
      • Castel C.
      • Enwemeka C.S.
      Optimizing the bactericidal effect of pulsed blue light on Propionibacterium acnes - a correlative fluorescence spectroscopy study.
      ,
      • Cotter E.J.
      • Cotter L.M.
      • Franczek E.B.
      • Godfrey J.J.
      • Hetzel S.J.
      • Safdar N.
      • et al.
      Efficacy of Combinational therapy using blue light and benzoyl peroxide in reducing Cutibacterium acnes bioburden at the Deltopectoral interval: a randomized controlled trial.
      BLT has demonstrated effective antimicrobial action against C. acnes as well as other common bacteria,
      • Ashkenazi H.
      • Malik Z.
      • Harth Y.
      • Nitzan Y.
      Eradication of Propionibacterium acnes by its endogenic porphyrins after illumination with high intensity blue light.
      ,
      • Dai T.
      • Gupta A.
      • Murray C.K.
      • Vrahas M.S.
      • Tegos G.P.
      • Hamblin M.R.
      Blue light for infectious diseases: Propionibacterium acnes, Helicobacter pylori, and beyond?.
      penetrates into the dermal and subdermal layers where the sebaceous glands reside,
      • Ash C.
      • Dubec M.
      • Donne K.
      • Bashford T.
      Effect of wavelength and beam width on penetration in light-tissue interaction using computational methods.
      ,
      • Barolet D.
      Light-emitting diodes (LEDs) in dermatology.
      and may reduce susceptibility to bacterial resistance relative to antibiotic topicals and oral agents.
      • Bumah V.V.
      • Masson-Meyers D.S.
      • Tong W.
      • Castel C.
      • Enwemeka C.S.
      Optimizing the bactericidal effect of pulsed blue light on Propionibacterium acnes - a correlative fluorescence spectroscopy study.
      In the present study, approximately 40% of patients responded that they would prefer to undergo one-time BLT on the day of surgery rather than serial treatments with BPO prior to surgery. However, light-based treatments are in the early experimental stages within orthopedics, and it remains to be seen if these treatments will be useful as part of skin preparation prior to shoulder surgery.

      Limitations

      This study is not without limitations. Consecutive patients managed by a single surgeon at our institution were approached in the preoperative holding area for completion of the survey, and approximately 35% of patients failed to complete the survey. These results are from a single center in a single region of the country. It is unknown if other centers in other locations would have similar compliance from their patient population in completing BPO treatments. Finally, compliance with BPO treatment was determined based on patient self-reported surveys, which may have resulted in underestimation or overestimation of the true compliance rate.

      Conclusion

      Serial preoperative applications of topical 5% BPO gel are well tolerated by the majority of patients. Over 20% of patients missed at least one application of BPO. Most patients prefer home-based antimicrobial treatments over arriving earlier on the day of surgery for a single light-based antimicrobial treatment.

      Disclaimers

      Funding: No funding was disclosed by the authors.
      Conflicts of interest: Dr. Grogan reports board or committee membership for the American Shoulder and Elbows Surgeons. The other authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

      Supplementary Data

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