CORRESPONDENCE intraclavicular Subclavian Puncture
right of the l a t e r a l pectoral nerve, a l t h o u g h less promi n e n t t h a n in real life. I do not i n t e n d to imply t h a t one should direct the needle to the m i d p o i n t of the opposite shoulder in a t h r e e - d i m e n s i o n a l v i e w a n y m o r e t h a n in o t h e r techniques one directs the needle at the center of the s u p r a s t e r n a l n o t c h , m e a n i n g s o m e w h e r e in t h e superior m e d i a s t i n u m . I hope t h a t it is clear from Figure 2 t h a t the needle should be directed to the midpoint on a two-dimensional surface projection of the shoulder. This ends up being j u s t above the suprasternal notch. Otherwise, one would be, as Dr. Lane says, "perilously close to the subclavian a r t e r y and the dome of the pleura." Dr. Lane points out a very real p r o b l e m w i t h this and other s i m i l a r in vivo studies. I could not use living p a t i e n t s in t e s t i n g t h i s new technique w i t h o u t using e x p e r i e n c e d clinicians. I found in a s k i n g c l i n i c i a n s who h a d done s u b c l a v i a n c a t h e t e r s before to use this technique, t h a t t h e y would a l m o s t i n v a r i a b l y direct the needle as t h e y were n o r m a l l y accustomed, m a k i n g the study invalid. I feel t h a t the d a t a speaks for itself when one considers the circumstances u n d e r which such a study m u s t be done. W i t h r e g a r d to complications, I can only allude to my own complication rate stated in the article and say, j u d g i n g from those clinicians c u r r e n t l y using the technique, I have received only letters affirming its low m o r b i d i t y t h u s far. I feel it is quite appropriate t h a t Dr. Lane cont i n u e to use a method to which he is accustomed.
To the Editor: The a r t i c l e , ~ N e w T e c h n i q u e for S u b c l a v i a n puncture," by Dr. Simon (7:409-411, 1978) h i g h l i g h t s some of the difficulties in describing a r e l a t i v e l y complex motor skill via the w r i t t e n word. The intraclavicular approach to s u b c l a v i a n v e n i p u n c t u r e in particular h a s defied m a n y a t t e m p t s at an a d e q u a t e description (eg, A m e r i c a n H e a r t Association Advanced Cardiac Life Support manual). Unfortunately, the new technique described does not seem to c l a r i f y m a t t e r s . The a r t i c l e does not adequately describe the ~new tubercle" and one is led to wonder at how it could have escaped the poking and prodding of physicians and a n a t o m i s t s over the centuries. A second, and critical aspect of the new technique is t h a t Dr. Simon's approach seems to direct the needle and c a t h e t e r in a considerably more posterior direction t h a n t r a d i t i o n a l approaches, ie, the site of skin puncture, and the a i m i n g of the needle t o w a r d the midpoint of the opposite shoulder t h r o u g h the subclavian muscle. F r o m the description, this would seem to put one perilously close to the subclavian a r t e r y and the dome of the pleura. Finally, testing the technique by unskilled operators on cadavers seems to be inadequate. How was it d e t e r m i n e d t h a t lung was not punctured? How was the catheter's position in the vein r a t h e r t h a n an artery insured? W h a t are the success and complication rates in skilled h a n d s in the live patient, and how do they compare with t r a d i t i o n a l techniques? Proficiency w i t h any medical or surgical skill is acquired w i t h p r a c t i c a l clinical e x p e r i e n c e t h r o u g h sound application of basic principles and j u d g e m e n t . If that sounds a bit like the advocation of motherhood, it's m e a n t to. In the m e a n t i m e , I will continue to use and teach the more t r a d i t i o n a l m e t h o d of s u b c l a v i a n venipuncture, and to e a g e r l y search for the ~Simon tubercle."
Robert R. Simon, MD Department of Emergency Medicine University of Chicago 1. Gardner, Gray, O'Rahilly: Anatomy, ed 3., p. 81. 2. Anderson JE: Grant's Atlas of Anatomy, ed 7. Baltimore, Williams and Wilkins Publishing Co, 1978, plate 17.
Peter L. Lane, MD Senior Resident Queen's University Kingston, Canada
Algorithm in Cardiac Resuscitation To the Editor: "Resuscitation Algorithm for M a n a g e m e n t of Acute Emergencies" by S h o e m a k e r et al (7:361-367, 1978) h i g h l i g h t s m a n y of the a d v a n t a g e s of protocols in the emergency situation. However, a careful review of the P h a s e 1 c a r d i o p u l m o n a r y resuscitation (CPR) protocol r e v e a l s m a n y of the difficulties encountered when protocols a r e designed for the m a n a g e m e n t of complicated clinical problems, such as c a r d i o p u l m o n a r y arrest. In accordance with the A m e r i c a n H e a r t Association's (AHA) advanced cardiac life support (ACLS) reco m m e n d a t i o n s , such a protocol should carefully define r e s p i r a t o r y and cardiac arrest in t h a t order by explicit p h y s i c a l signs; differentiate b e t w e e n w i t n e s s e d and u n w i t n e s s e d arrest; provide for i m m e d i a t e defibrillation of coarse v e n t r i c u l a r fibrillation prior to establishing an i n t r a v e n o u s line, and avoid defibrillation of the a s y s t o l i c h e a r t (which is a l r e a d y c o n s i d e r a b l y depressed). The exclusion of the p n e u m a t i c t r o u s e r suit
Author's Reply A l t h o u g h Dr. L a n e s t a t e s t h e new d e s c r i p t i o n does not clarify m a t t e r s , Since the p u b l i c a t i o n of the new technique and in the previous two y e a r s of invest i g a t i o n and t e a c h i n g t h e m e t h o d , I h a v e received numerous letters t e s t i f y i n g to its s u p e r i o r i t y and low incidence of morbidity. R e g a r d i n g t h e t u b e r c l e h a v i n g a v o i d e d notice ~'over the centuries," the article does not s t a t e t h a t the tubercle is a new a n a t o m i c a l discovery, only t h a t it is a new l a n d m a r k to use. In the article, the a n a t o m y of the clavicle, i n c l u d i n g the tubercle, is pictured, b u t simply not labeled. In one reference, the tubercle is described as to the r i g h t of "groove for subclavius ''1 and in Grant's 2 it i s - p i c t u r e d j u s t above and to the
B:5 (May) 1979
JACEP
210/71
in t h e s u b s e q u e n t p h a s e 2 h y p o t e n s i o n protocol is a n o t h e r e x a m p l e of a l t e r n a t i v e s omitted. The d i f f i c u l t y o f development protocols for these clinical situations is t h a t there are m a n y v a r i a t i o n s in t h e i r presentations, and consequently a v a r i e t y of clinical options a v a i l a b l e to the p h y s i c i a n or paramedic. Each option has its own set of indications and contraindications, and each is followed by branch points in logic sequence. The r e s u l t is typically an inverted logic tree whose t e r t i a r y and q u a r t e r n a r y branches begin to run off t h e page. I a m f a m i l i a r w i t h s e v e r a l protocols w r i t t e n w i t h A H A ACLS r e c o m m e n d a t i o n s in mind. I am sure t h e r e are as m a n y holes in these as there are in t h e protocols offered by S h o e m a k e r . This, I a m afraid, is the n a t u r e of most such efforts.
ficial means, such as vasopressors, or pneumatic trouser suits. In brief, best cure of h e m o r r h a g i c shock is a p r o m p t l y placed hemostat. The exception to this m a y be the p a t i e n t w i t h a b a d l y f r a c t u r e d , "unstable pelvis where the p n e u m a t i c t r o u s e r suit m a y stabilize frac. t u r e s w i t h s h a r p b o n y edges. In p a t i e n t s w i t h in, a d e q u a t e carotid pulsations d u r i n g CPR, particularly those with b a r r e l chest or severe e m p h y s e m a , we prefer to go i m m e d i a t e l y to open chest massage as indicated by the algorithm. In essence, the protocol or a l g o r i t h m does not obviate the use of other clinical options. However, the a l g o r i t h m does help p r e v e n t g e t t i n g so lost in intermin, able, i r r e l e v a n t , nonessential options t h a t c a r r y i n g out the essential procedures of resuscitation is delayed. For this purpose, we find t h e a l g o r i t h m is useful; therefore, we use it.
R. Myles Riner, MD G. N. Wilcox Memorial Hospital Lihue, Kauai, Hawaii
William C. Shoemaker, MD Professor of Surgery UCLA School of Medicine
Author's Reply Life Expectancy Gains with Disease Reduction
The a l g o r i t h m we proposed was not designed to r e c a p i t u l a t e t h e d e t a i l s of c a r d i a c r e s u s c i t a t i o n . Nevertheless, our references refer to the A H A recomm e n d a t i o n s as well as other a u t h o r i t a t i v e sources. For an a l g o r i t h m to r e c a p i t u l a t e all t h a t is known in resuscitation would require m a n y t h o u s a n d s of pages and that, in itself, would defeat its purpose. The p r i m a r y purpose of branch chain logic is to expedite major clinical d e c i s i o n s by o r g a n i z i n g p r i o r i t i e s and d e f i n i n g criteria. Thus, the m i n i m u m criterion for each decision is specified inside each diamond. For example, all t h a t is needed for the first decision to s t a r t CPR is a blood pressure of zero or n e a r zero. The justification for an algorithm does not depend on w h e t h e r it conforms to an investigator's bias or even the e s t a b l i s h e d n o r m a t i v e standards. The i m p o r t a n t criteria for j u d g i n g an algorithm's value is w h e t h e r it improves p a t i e n t care. A detailed description of the influence of the a l g o r i t h m during the first six months of its use is described by Hopkins et al. (Comparison of the t r e a t m e n t of surgical emergencies with and without an algorithm. A n n Surgery, submitted.) In addition, we have now h a d over two y e a r s experience with a group using the a l g o r i t h m and a concurrent control group not using the algorithm. We find that, in the e x p e r i m e n t a l group, the r e s u s c i t a t i o n time is about h a l f t h a t of the control group. P r o b a b l y because of this, the outcomes h a v e i m p r o v e d . W e conclude, t h e r e f o r e , t h a t t h e a l g o r i t h m i c approach expedites clinical decisions in emergencies. This conclusion does not preclude using the d e t a i l s t h a t a r e the fare of the s t a n d a r d textbooks. It does indicate, however, t h a t where t i m e is of the essence, the algorithm provides a useful framework upon which to h a n g m a n y of these t r a d i t i o n a l practices. W i t h respect to Dr. Riner's question on the p n e u m a tic trouser suit, we find it very useful for p a r a m e d i c s and prehospital but, w i t h rare exception, we do not find a place for its use in the hospitalized patient. We feel t h a t the proper t h e r a p y for blood volume deficit is control of h e m o r r h a g e and volume r e p l a c e m e n t r a t h e r t h a n arti-
72/211
To the Editor: Tsai, Lee, and H a r d y 1 h a v e recently reported the use of life table methodology to e s t i m a t e the potential g a i n in life expectancy t h a t significant reduction in the leading causes of death in the U n i t e d States might bring about. They conclude t h a t with a 30% reduction in major cardiovascular diseases, the n u m b e r of years gained by a newborn child would be 1.98 years, for m a l i g n a n t neoplasm 0.71 years, and motor vehicle accidents 0.21 years. Application of the s a m e reduction to the working ages, 15 to 70 years, results in a g a i n of 0.43, 0.26 and 0.14 y e a r s respectively for the t h r e e leading causes of death. E d i t o r i a l c o m m e n t s by K e y f i t z 2 s u p p o r t and amplify these observations. He points out t h a t the expectation of life at birth has risen 25 y e a r s since 1900, due mostly to the virtual e l i m i n a t i o n of m o r t a l i t y in acute infectious diseases. He points out t h a t since such diseases tended to strike y o u n g people, t h e i r control had a considerably l a r g e r impact on life expectancy t h a n can be expected by control of diseases found more in older age groups. This information will likely be used by federal authorities in p l a n n i n g r e t i r e m e n t guidelines and social security benefits. It m a y also be used in other aspects of h e a l t h care economic planning. Physicians involved in emergency care education and resource p l a n n i n g may wish to acquaint themselves w i t h these articles.
John H. Hughes, MD Director of Emergency Services The University of Arizona Tucson, Arizona 1. Tsai SP, Lee ES, Hardy RJ: The effect of a reduction in leading causes of death: potential gains in life expectancy. A m J Public Health 68:966-968, 1978. 2. Keyfitz N: Improving life expectancy: an uphill road ahead.
Am J Public Health 68:954-956, 1978,
JACEP
8:5 (May) 1979
right of the l a t e r a l pectoral nerve, a l t h o u g h less promi n e n t t h a n in real life. I do not i n t e n d to imply t h a t one should direct the needle to the m i d p o i n t of the opposite shoulder in a t h r e e - d i m e n s i o n a l v i e w a n y m o r e t h a n in o t h e r techniques one directs the needle at the center of the s u p r a s t e r n a l n o t c h , m e a n i n g s o m e w h e r e in t h e superior m e d i a s t i n u m . I hope t h a t it is clear from Figure 2 t h a t the needle should be directed to the midpoint on a two-dimensional surface projection of the shoulder. This ends up being j u s t above the suprasternal notch. Otherwise, one would be, as Dr. Lane says, "perilously close to the subclavian a r t e r y and the dome of the pleura." Dr. Lane points out a very real p r o b l e m w i t h this and other s i m i l a r in vivo studies. I could not use living p a t i e n t s in t e s t i n g t h i s new technique w i t h o u t using e x p e r i e n c e d clinicians. I found in a s k i n g c l i n i c i a n s who h a d done s u b c l a v i a n c a t h e t e r s before to use this technique, t h a t t h e y would a l m o s t i n v a r i a b l y direct the needle as t h e y were n o r m a l l y accustomed, m a k i n g the study invalid. I feel t h a t the d a t a speaks for itself when one considers the circumstances u n d e r which such a study m u s t be done. W i t h r e g a r d to complications, I can only allude to my own complication rate stated in the article and say, j u d g i n g from those clinicians c u r r e n t l y using the technique, I have received only letters affirming its low m o r b i d i t y t h u s far. I feel it is quite appropriate t h a t Dr. Lane cont i n u e to use a method to which he is accustomed.
To the Editor: The a r t i c l e , ~ N e w T e c h n i q u e for S u b c l a v i a n puncture," by Dr. Simon (7:409-411, 1978) h i g h l i g h t s some of the difficulties in describing a r e l a t i v e l y complex motor skill via the w r i t t e n word. The intraclavicular approach to s u b c l a v i a n v e n i p u n c t u r e in particular h a s defied m a n y a t t e m p t s at an a d e q u a t e description (eg, A m e r i c a n H e a r t Association Advanced Cardiac Life Support manual). Unfortunately, the new technique described does not seem to c l a r i f y m a t t e r s . The a r t i c l e does not adequately describe the ~new tubercle" and one is led to wonder at how it could have escaped the poking and prodding of physicians and a n a t o m i s t s over the centuries. A second, and critical aspect of the new technique is t h a t Dr. Simon's approach seems to direct the needle and c a t h e t e r in a considerably more posterior direction t h a n t r a d i t i o n a l approaches, ie, the site of skin puncture, and the a i m i n g of the needle t o w a r d the midpoint of the opposite shoulder t h r o u g h the subclavian muscle. F r o m the description, this would seem to put one perilously close to the subclavian a r t e r y and the dome of the pleura. Finally, testing the technique by unskilled operators on cadavers seems to be inadequate. How was it d e t e r m i n e d t h a t lung was not punctured? How was the catheter's position in the vein r a t h e r t h a n an artery insured? W h a t are the success and complication rates in skilled h a n d s in the live patient, and how do they compare with t r a d i t i o n a l techniques? Proficiency w i t h any medical or surgical skill is acquired w i t h p r a c t i c a l clinical e x p e r i e n c e t h r o u g h sound application of basic principles and j u d g e m e n t . If that sounds a bit like the advocation of motherhood, it's m e a n t to. In the m e a n t i m e , I will continue to use and teach the more t r a d i t i o n a l m e t h o d of s u b c l a v i a n venipuncture, and to e a g e r l y search for the ~Simon tubercle."
Robert R. Simon, MD Department of Emergency Medicine University of Chicago 1. Gardner, Gray, O'Rahilly: Anatomy, ed 3., p. 81. 2. Anderson JE: Grant's Atlas of Anatomy, ed 7. Baltimore, Williams and Wilkins Publishing Co, 1978, plate 17.
Peter L. Lane, MD Senior Resident Queen's University Kingston, Canada
Algorithm in Cardiac Resuscitation To the Editor: "Resuscitation Algorithm for M a n a g e m e n t of Acute Emergencies" by S h o e m a k e r et al (7:361-367, 1978) h i g h l i g h t s m a n y of the a d v a n t a g e s of protocols in the emergency situation. However, a careful review of the P h a s e 1 c a r d i o p u l m o n a r y resuscitation (CPR) protocol r e v e a l s m a n y of the difficulties encountered when protocols a r e designed for the m a n a g e m e n t of complicated clinical problems, such as c a r d i o p u l m o n a r y arrest. In accordance with the A m e r i c a n H e a r t Association's (AHA) advanced cardiac life support (ACLS) reco m m e n d a t i o n s , such a protocol should carefully define r e s p i r a t o r y and cardiac arrest in t h a t order by explicit p h y s i c a l signs; differentiate b e t w e e n w i t n e s s e d and u n w i t n e s s e d arrest; provide for i m m e d i a t e defibrillation of coarse v e n t r i c u l a r fibrillation prior to establishing an i n t r a v e n o u s line, and avoid defibrillation of the a s y s t o l i c h e a r t (which is a l r e a d y c o n s i d e r a b l y depressed). The exclusion of the p n e u m a t i c t r o u s e r suit
Author's Reply A l t h o u g h Dr. L a n e s t a t e s t h e new d e s c r i p t i o n does not clarify m a t t e r s , Since the p u b l i c a t i o n of the new technique and in the previous two y e a r s of invest i g a t i o n and t e a c h i n g t h e m e t h o d , I h a v e received numerous letters t e s t i f y i n g to its s u p e r i o r i t y and low incidence of morbidity. R e g a r d i n g t h e t u b e r c l e h a v i n g a v o i d e d notice ~'over the centuries," the article does not s t a t e t h a t the tubercle is a new a n a t o m i c a l discovery, only t h a t it is a new l a n d m a r k to use. In the article, the a n a t o m y of the clavicle, i n c l u d i n g the tubercle, is pictured, b u t simply not labeled. In one reference, the tubercle is described as to the r i g h t of "groove for subclavius ''1 and in Grant's 2 it i s - p i c t u r e d j u s t above and to the
B:5 (May) 1979
JACEP
210/71
in t h e s u b s e q u e n t p h a s e 2 h y p o t e n s i o n protocol is a n o t h e r e x a m p l e of a l t e r n a t i v e s omitted. The d i f f i c u l t y o f development protocols for these clinical situations is t h a t there are m a n y v a r i a t i o n s in t h e i r presentations, and consequently a v a r i e t y of clinical options a v a i l a b l e to the p h y s i c i a n or paramedic. Each option has its own set of indications and contraindications, and each is followed by branch points in logic sequence. The r e s u l t is typically an inverted logic tree whose t e r t i a r y and q u a r t e r n a r y branches begin to run off t h e page. I a m f a m i l i a r w i t h s e v e r a l protocols w r i t t e n w i t h A H A ACLS r e c o m m e n d a t i o n s in mind. I am sure t h e r e are as m a n y holes in these as there are in t h e protocols offered by S h o e m a k e r . This, I a m afraid, is the n a t u r e of most such efforts.
ficial means, such as vasopressors, or pneumatic trouser suits. In brief, best cure of h e m o r r h a g i c shock is a p r o m p t l y placed hemostat. The exception to this m a y be the p a t i e n t w i t h a b a d l y f r a c t u r e d , "unstable pelvis where the p n e u m a t i c t r o u s e r suit m a y stabilize frac. t u r e s w i t h s h a r p b o n y edges. In p a t i e n t s w i t h in, a d e q u a t e carotid pulsations d u r i n g CPR, particularly those with b a r r e l chest or severe e m p h y s e m a , we prefer to go i m m e d i a t e l y to open chest massage as indicated by the algorithm. In essence, the protocol or a l g o r i t h m does not obviate the use of other clinical options. However, the a l g o r i t h m does help p r e v e n t g e t t i n g so lost in intermin, able, i r r e l e v a n t , nonessential options t h a t c a r r y i n g out the essential procedures of resuscitation is delayed. For this purpose, we find t h e a l g o r i t h m is useful; therefore, we use it.
R. Myles Riner, MD G. N. Wilcox Memorial Hospital Lihue, Kauai, Hawaii
William C. Shoemaker, MD Professor of Surgery UCLA School of Medicine
Author's Reply Life Expectancy Gains with Disease Reduction
The a l g o r i t h m we proposed was not designed to r e c a p i t u l a t e t h e d e t a i l s of c a r d i a c r e s u s c i t a t i o n . Nevertheless, our references refer to the A H A recomm e n d a t i o n s as well as other a u t h o r i t a t i v e sources. For an a l g o r i t h m to r e c a p i t u l a t e all t h a t is known in resuscitation would require m a n y t h o u s a n d s of pages and that, in itself, would defeat its purpose. The p r i m a r y purpose of branch chain logic is to expedite major clinical d e c i s i o n s by o r g a n i z i n g p r i o r i t i e s and d e f i n i n g criteria. Thus, the m i n i m u m criterion for each decision is specified inside each diamond. For example, all t h a t is needed for the first decision to s t a r t CPR is a blood pressure of zero or n e a r zero. The justification for an algorithm does not depend on w h e t h e r it conforms to an investigator's bias or even the e s t a b l i s h e d n o r m a t i v e standards. The i m p o r t a n t criteria for j u d g i n g an algorithm's value is w h e t h e r it improves p a t i e n t care. A detailed description of the influence of the a l g o r i t h m during the first six months of its use is described by Hopkins et al. (Comparison of the t r e a t m e n t of surgical emergencies with and without an algorithm. A n n Surgery, submitted.) In addition, we have now h a d over two y e a r s experience with a group using the a l g o r i t h m and a concurrent control group not using the algorithm. We find that, in the e x p e r i m e n t a l group, the r e s u s c i t a t i o n time is about h a l f t h a t of the control group. P r o b a b l y because of this, the outcomes h a v e i m p r o v e d . W e conclude, t h e r e f o r e , t h a t t h e a l g o r i t h m i c approach expedites clinical decisions in emergencies. This conclusion does not preclude using the d e t a i l s t h a t a r e the fare of the s t a n d a r d textbooks. It does indicate, however, t h a t where t i m e is of the essence, the algorithm provides a useful framework upon which to h a n g m a n y of these t r a d i t i o n a l practices. W i t h respect to Dr. Riner's question on the p n e u m a tic trouser suit, we find it very useful for p a r a m e d i c s and prehospital but, w i t h rare exception, we do not find a place for its use in the hospitalized patient. We feel t h a t the proper t h e r a p y for blood volume deficit is control of h e m o r r h a g e and volume r e p l a c e m e n t r a t h e r t h a n arti-
72/211
To the Editor: Tsai, Lee, and H a r d y 1 h a v e recently reported the use of life table methodology to e s t i m a t e the potential g a i n in life expectancy t h a t significant reduction in the leading causes of death in the U n i t e d States might bring about. They conclude t h a t with a 30% reduction in major cardiovascular diseases, the n u m b e r of years gained by a newborn child would be 1.98 years, for m a l i g n a n t neoplasm 0.71 years, and motor vehicle accidents 0.21 years. Application of the s a m e reduction to the working ages, 15 to 70 years, results in a g a i n of 0.43, 0.26 and 0.14 y e a r s respectively for the t h r e e leading causes of death. E d i t o r i a l c o m m e n t s by K e y f i t z 2 s u p p o r t and amplify these observations. He points out t h a t the expectation of life at birth has risen 25 y e a r s since 1900, due mostly to the virtual e l i m i n a t i o n of m o r t a l i t y in acute infectious diseases. He points out t h a t since such diseases tended to strike y o u n g people, t h e i r control had a considerably l a r g e r impact on life expectancy t h a n can be expected by control of diseases found more in older age groups. This information will likely be used by federal authorities in p l a n n i n g r e t i r e m e n t guidelines and social security benefits. It m a y also be used in other aspects of h e a l t h care economic planning. Physicians involved in emergency care education and resource p l a n n i n g may wish to acquaint themselves w i t h these articles.
John H. Hughes, MD Director of Emergency Services The University of Arizona Tucson, Arizona 1. Tsai SP, Lee ES, Hardy RJ: The effect of a reduction in leading causes of death: potential gains in life expectancy. A m J Public Health 68:966-968, 1978. 2. Keyfitz N: Improving life expectancy: an uphill road ahead.
Am J Public Health 68:954-956, 1978,
JACEP
8:5 (May) 1979
