Today marks the start of #WHA75!
This week, @WHO, Ministries of Health, civil society, & more will discuss #GlobalHealth priorities.
Missing on agenda? #GlobalSurgery & 🫀 care.
Hence, I'll be sharing key points, papers, & developments in #GlobalCardiacSurgery in 75 tweets 👇
(1/75) To start, what *is* #GlobalCardiacSurgery?
GCS extends far beyond OR, from community-based disease detection & efficient referral networks to timely care, long-term follow-up, robust supply chains & adequate financial risk protection. #WHA75
Read: academic.oup.com/ejcts/article/…
(2/75) Why does #GlobalCardiacSurgery matter?
⚠️ Every year, 18 million people die from #CVD
🫀 500 million live with CVD; 100s of millions more to come.
🏥 Up to 1/3 will require #CTSurgery or interventional care in lifetime
Data @IHME_UW: healthdata.org/results/data-v…
#WHA75
(3/75) Why is #WHA75 not talking about #GlobalCardiacSurgery?
Many arguments often falsely raised to not (yet) address 🫀 care ↔️ #GlobalHealth interventions.
Reality? #CVD care = indispensable part of strong #HealthSystems, #UHC, socioeconomic 📶
Read: globalheartjournal.com/articles/abstr…
(4/75) Do policies tackle #GlobalCardiacSurgery?
Nationally, only 1 #NSOAP (Zambia) recognized #CTSurgery.
👉 thieme-connect.com/products/ejour…
Internationally, @WHO @UN @WorldBank barely mention #CVD care & #GlobalSurgery, let alone 🫀 surgical care.
👉 journals.sagepub.com/doi/abs/10.117…
#WHA75
(5/75) Why is #GlobalCardiacSurgery not prioritized?
Surgical healthcare & #RHD hindered by
🔍 Insufficient data
💭 Misperceptions
🗣️ Fragmented advocacy
⁉️ Disagreement between stakeholders
Dr. @Yrshawar et al:
👉 thelancet.com/journals/langl…
👉 ahajournals.org/doi/10.1161/JA…
#WHA75
(6/75) Why does prioritization of #GlobalCardiacSurgery matter?
🔪 #GlobalSurgery = <1% of #GlobalHealth financing
👉 thelancet.com/journals/langl…
💰 NCDs = 2% of GH financing
👉 healthdata.org/infographic/hi…
🫀 RHD = 1 of the most underfunded diseases
👉 academic.oup.com/trstmh/article…
#WHA75
(7/75) Implication of underfunding of #GlobalCardiacSurgery?
Lack of 💰 = limited research capacity & interest (few grants):
🫀 #RHD is nearly eradicated in HICs ⏩ neglected in #GlobalHealth discourse.
🫀 #CHD research is dominated by HICs ↔️ gaps in care in LMICs.
#WHA75
(8/75) Limited funding also means insufficient capacity.
High-income countries have 180 times (!) as many 🫀 surgeons per million people as low-income countries.
👉 jtcvs.org/article/S0022-… @AATSJournals
Numbers of other #HeartTeam members unknown but likely even fewer.
#WHA75
(9/75) Resulting gap in #GlobalCardiacSurgery?
~1.5 million 🫀 operations each year, far below what is needed:
❤️🩹 >90% w/ #CHD do not get care they need
❌ <1 in 10 w/ #RHD receive needed surgery
📉 Even less for revasc., dissections, #HF, etc
thieme-connect.com/products/ejour…
#WHA75
(10/75) What is the need in #GlobalCardiacSurgery?
Unmet need highest in #LMICs; 🫀 surgical need 📶 with socioeconomic development:
#RHD, #EMF, #Chagas, etc. ⏩ #IHD, degenerative valvular disease, etc.
Note: #CHD remains!
👉 sciencedirect.com/science/articl…
#WHA75
(11/75) What does all that scarcity mean for #GlobalCardiacSurgery?
SIX BILLION PEOPLE lack access to safe, timely, and affordable cardiac surgical care when needed. 🫀🌐
👉 annalsthoracicsurgery.org/article/S0003-… @annalsthorsurg
#WHA75
(12/75) #GlobalCardiacSurgery is just too expensive.. Right?
Narayana Health 🇮🇳 performs 🫀 operations at as little as US$1,500 per surgery.
🇻🇳 ~US$2,000-3,000
🇬🇭🇳🇬 ~US$5,000-8,000
BUT w/o financial risk protection, costs still insurmountable.
acc.org/latest-in-card…
#WHA75
(13/75) Does it make $ sense to invest in #GlobalCardiacSurgery?
Pediatric 🫀 surgery = ⬆️ cost-effective ($171/DALY averted) in LMICs 👉 jamanetwork.com/journals/jaman…
Even more so than several other (already cost-effective) #GlobalHealth priorities 👉 link.springer.com/article/10.100…
#WHA75
(14/75) Does it make socioeconomic sense to invest in #GlobalCardiacSurgery?
Expanding integrated secondary and tertiary prevention & care for #RHD in the African Union may result in a net benefit of US$2.8 BILLION through 2030.
👉 thelancet.com/journals/langl…
#WHA75
(15/75) REMEMBER: #GlobalCardiacSurgery = #HealthSystems, not another operative silo.
Similarly, #CTSurgery is not about the surgeon, but about #HeartTeams.
🫀 surgical care is not about clinicians, but patients, families, and communities.
Partnerships are key.
#WHA75
(16/75) #GlobalCardiacSurgery is no longer only about disparities.
In recent decades, 🫀 surgeons initiated 🌐 partnerships.
In recent years, #GlobalSurgery momentum ⏩ discussions within #CTSurgery.
In recent months, societal commitment 📈 attention for the field.
#WHA75
(17/75) Do examples of #GlobalCardiacSurgery prioritization exist?
In 🇬🇭, 🫀 surgeon & government leadership shifted financing from #CTSurgery abroad to local program:
💰 Lower costs
💪 Strengthened #HealthSystem
🏥 Treatment closer to home
👉 sciencedirect.com/science/articl…
#WHA75
(18/75) Are there other #GlobalCardiacSurgery success stories?
In Nepal, Dr. @KoiralaBhagawan pioneered the "Poor Patients Relief" program, a microinsurance program by the government to finance 🫀 surgery for children, the elderly, & the poor.
👉 asj.amegroups.com/article/view/5…
#WHA75
(19/75) Any other notable #GlobalCardiacSurgery examples in #LMICs?
The Salam Centre in Sudan 🇸🇩
👉 frontiersin.org/articles/10.33…
The Shisong Center in Cameroon 🇨🇲
👉 frontiersin.org/articles/10.33…
The Maputo Heart Institute in Mozambique 🇲🇿
👉 ncbi.nlm.nih.gov/pmc/articles/P…
+dozens more! #WHA75
(20/75) Can #GlobalCardiacSurgery be scaled?
Narayana Health in India performs one of the *highest* number of 🫀 operations per year at the *lowest* cost anywhere in the world.
Their operative outcomes are *highly* favorable.
👉 link.springer.com/chapter/10.100…
#WHA75
(21/75) What are #GlobalCardiacSurgery NGOs doing?
🫀 86 NGOs: 56 pediatric, 5 adult, 25 both
🔪 Median volume: 82 cardiac operations per year
🌐 Active in 96 LMICs
🏥 Care delivery, capacity building, supplies, & more
👉 semthorcardiovascsurg.com/article/S1043-…
#WHA75
(22/75) How do #GlobalCardiacSurgery NGOs influence policy?
@CHeartLink is a leading voice in #CHD & #GlobalSurgery advocacy in Brazil, China, India, Malaysia, Vietnam, & on the 🌐 stage.
The Invisible Child: childrensheartlink.org/the-invisible-…
@TheLancet: thelancet.com/journals/lance…
#WHA75
(23/75) How do organizations ⬆️ #GlobalCardiacSurgery capacity-building?
@heartuni_org = #OpenAccess e-learning on #CHD & pediatric #CVD:
📚 Training curriculum
📽️ Conference/Grand Round recordings
👀 heartuniversity.org @JustinTretterMD
👉 cambridge.org/core/journals/…
#WHA75
(24/75) How are patients & families engaged in #GlobalCardiacSurgery discourse?
@globalarchorg = 🌐 alliance of patient-family organizations, providing voice at the 🫀 of cardiovascular discourse.
#DeclarationOfRights for People with #CHD & #RHD: secure.lglforms.com/form_engine/s/…
#WHA75
(25/75) How are policymakers engaged in #GlobalSurgery & 🫀 medicine?
@surgfoundation provides innovative platform for entire ecosystem to ⬆️ global surgical interventions.
@worldheartfed unites #CVD voices 🌐 to tackle the leading cause of death.
#WHA75 #GlobalCardiacSurgery
(26/75) How is the next generation of #GlobalCardiacSurgery engaged?
@GlobalCardiac is a global network of trainees interested in #CTSurgery, #GlobalSurgery, & #HealthEquity:
📢 Advocacy & webinars
🔍 Research & conference presentations
🌐 Social & mentorship networks
#WHA75
(27/75) How is industry engaged in #GlobalSurgery?
@JNJGlobalHealth has been a strong and vocal supporter of #Surgery4All: jnj.com/global-public-…
@EdwardsLifesci supports #GlobalCardiacSurgery through @CTSurgeryFdn Every Heartbeat Matters Award: thoracicsurgeryfoundation.org/awards/edwards/
#WHA75
(28/75) How are societies engaged in #GlobalCardiacSurgery?
The #CSIA by @worldheartfed @AATSHQ @STS_CTsurgery @EACTS #ASCVTS resembles societal commitment to expanding #RHD surgical care capacity and delivery in Mozambique, Rwanda, & beyond.
👉 world-heart-federation.org/cardiac-surger…
#WHA75
(29/75) How are 🫀 surgeons themselves engaged in #GlobalCardiacSurgery?
The cardiac surgeon-advocate commits to:
📜 Health policy
🌐 Local & global disparities
🫂 Community engagement
💡 (Un)conscious bias education
👉 sciencedirect.com/science/articl…
#WHA75
(30/75) Much happened in #GlobalCardiacSurgery in recent years!
In 2015, #DCP3 @WorldBank had dedicated #GlobalSurgery volume:
🫀 #CHD = 66% of preventable deaths of common surgical conditions
🏥 #CTSurgery could prevent 58% of said mortality
👉 dcp-3.org/surgery
#WHA75
(31/75) Have there been political #GlobalCardiacSurgery commitments?
In 2018, the WHA71.14 Resolution “Rheumatic fever and rheumatic heart disease” was passed at #WHA71, an important political statement to tackle #RHD worldwide 🫀🌐.
👉 apps.who.int/gb/ebwha/pdf_f…
#WHA75
(32/75) Have there been multidisciplinary #GlobalCardiacSurgery commitments?
In 2020, @NCDIpoverty Commission reframed discussion surrounding #NCDs & injuries as part of #UHC for the poorest billion, including many neglected #CVD (e.g., #RHD).
👉 thelancet.com/commissions/NC…
#WHA75
(33/75) What #GlobalCardiacSurgery resources have become available?
Dr. @jacqueskpodonu released his textbook "Global Cardiac Surgery Capacity Development in #LMICs," compiling chapters from #GlobalSurgery leaders from across disciplines & 🌐.
👉 link.springer.com/book/10.1007/9…
#WHA75
(34/75) What #GlobalCardiacSurgery efforts have societies made?
Pre-2021: one #GlobalSurgery session at #CTSurgery conference (#AATS2019).
October ’21 – May ’22: ALL major 🫀 surgery conferences had GCS sessions (#EACTS2021, #CCC2021, #STS2022, #AATCVS2022, #AATS2022).
#WHA75
(35/75) What academic #GlobalCardiacSurgery efforts have been made?
Although #OpenAccess publishing remains 💰 (scielo.br/j/rbccv/a/hNtP…), @ctsnetorg's new #CTSNetGlobal platform promotes free & dedicated #GlobalSurgery in #CTSurgery publishing.
👉 ctsnet.org/article/ctsnet…
#WHA75
(36/75) What #GlobalCardiacSurgery 🔍 efforts have arisen?
In Nov 2021, @nih_nhlbi hosted 3-day public workshop on prevention & care for #RHD with experts from across 🌐.
👉 @NIH commitment to eradicating RHD:
ℹ️ nhlbi.nih.gov/events/2021/er…
📽️ vimeo.com/651148197
#WHA75
(37/75) What governmental #GlobalCardiacSurgery leadership has paved the way for a better future?
In Malaysia, the government has recognized the importance of 🫀 surgical care for children with #CHD. @DGHisham
👉
#WHA75 @bzheleva @CHeartLink
(38/75) What #GlobalCardiacSurgery models have been successfully replicated elsewhere?
Narayana Health started Health City Cayman Islands to ⬆️ #CTSurgery and other complex care for Caribbean & at ⬇️💰 for US.
👉 hbr.org/2018/06/is-thi…
👉 hbs.edu/faculty/Pages/…
#WHA75
(39/75) What data-oriented #GlobalCardiacSurgery initiatives are ⬆️ #CTSurgery outcomes across settings?
@IQICforCHD convenes >70 🫀 programs in >25 countries (mostly #LMICs) to track #CHD surgery outcomes in a standardized fashion.
👉 iqic.chboston.org
#WHA75
(40/75) What training opportunities exist in #GlobalCardiacSurgery?
#CTSurgery training programs limited in #LMICs.
Differing licensing processes in HICs 🛑 international training.
But, several countries leave many 🫀 surgery spots unfilled.
👉 jtcvs.org/article/S0022-…
#WHA75
(41/75) What training opportunities may arise for #GlobalCardiacSurgery?
No int'l accreditation/standardization ➡️ 🫀#GlobalSurgery residency?
🌐 Different & changing disease burdens
📚 Shared learning
🏥 #HealthSystems understanding
👉 ctsnet.org/article/opport…
#WHA75
(42/75) What educational tools may support #GlobalCardiacSurgery?
Simulation training & #VR = underutilized in #CTSurgery beyond high-income country settings.
But, opportunities to ⬇️💰 (e.g., e-learning; VR: cardboard headset + smartphone).
👉 onlinelibrary.wiley.com/doi/abs/10.111…
#WHA75
(43/74) How can #GlobalCardiacSurgery capacity-building 📶 further?
Early in pandemic: virtual conferences = elevating voices previously left unheard & ⬆️ access to learning, research, networking.
Now: many back to in-person only.
⏩ Hybrid?
👉 jtcvs.org/article/S0022-…
#WHA75
(44/75) How can #GlobalCardiacSurgery training be expanded?
Human factors ~ patient outcomes ⏩ up to 60% of surgery-related adverse events.
Non-technical skills (#NOTSS) = under-leveraged in #CTSurgery, yet ✅ across settings.
👉 jtd.amegroups.com/article/view/3…
#WHA75
(45/75) How can #GlobalCardiacSurgery care delivery be further improved?
Quality improvement #QI initiatives (e.g., @ERASCardiac) ⏩ optimize perioperative outcomes.
Essential: #HeartTeam collaboration throughout #CTSurgery care continuum.
👉 jamanetwork.com/journals/jamas…
#WHA75
(46/75) How may #GlobalCardiacSurgery outcomes further improve?
The @WHO Surgical Safety Checklist & #CTSurgery-specific checklists ~ ⬇️ operative mortality.
📽️ lifebox.org/thechecklistef… @SaferSurgery
👉 sciencedirect.com/science/articl…
#WHA75
(47/75) How can #GlobalCardiacSurgery care delivery be optimized across settings?
Randomized controlled trials (RCTs) are cornerstone of evidence-based medicine.
Cardiovascular RCTs remain limited in #LMICs, especially for #CTSurgery ⏩ opportunity for 🌐 collaboration.
#WHA75
(48/75) How can #GlobalCardiacSurgery care delivery be optimized?
🫀 research in LMICs limited & must be scaled:
▶️ HICs: 8.1% of #CVD DALYs ↔️ 81.1% of research
⚠️ Low-income/lower-middle-income countries: 59.5% of DALYs ↔️ 2.8% of research
👉 globalheartjournal.com/articles/10.53…
#WHA75
(49/75) Why should #GlobalCardiacSurgery research be ⬆️?
🫀 guidelines cannot be generalized across populations.
🌐 Different settings, systems, resources, etc = different care needs/outcomes.
⚠️ Country income group & inequality ~ mortality
👉 hal.univ-lorraine.fr/hal-02516015/d…
#WHA75
(50/75) What should be done to facilitate #GlobalCardiacSurgery research scaling?
#OpenAccess publishing = increased dissemination, citations, etc.
But:
💵 Median 🫀 APCs = US$3,000
❌ Discounts & waivers limited
👉 ncbi.nlm.nih.gov/pmc/articles/P…
👉 ghspjournal.org/content/9/4/733
#WHA75
(51/75) How can #GlobalCardiacSurgery 🔍 be facilitated further?
#CTSurgery journals: female (10.5%) & LMIC (5.2%) underrepresentation on editorial boards.
👉 semthorcardiovascsurg.com/article/S1043-…
LMIC editorial board representation ~ LMIC publications.
👉 jamanetwork.com/journals/jaman…
#WHA75
(52/75) How can #GlobalCardiacSurgery interventions be financed beyond traditional 💰?
Innovative financing instruments (e.g., social impact bonds) may be explored following ✅️✅️ examples:
👉 #NCDs: gh.bmj.com/content/6/3/e0…
👉 #GlobalSurgery: gh.bmj.com/content/5/6/e0…
#WHA75
(53/75) How can #GlobalCardiacSurgery interventions be facilitated?
Public-private partnerships (#PPP) have been leveraged across #GlobalHealth and 🫀 medicine, and may be strategically pursued to 📶 global #CTSurgery capacity.
👉 hsph.harvard.edu/health-systems…
#WHA75
(54/75) How can patient outcomes be prioritized within #GlobalCardiacSurgery?
Value-based healthcare (#VBHC) models = ⬆️ patient outcomes whilst ⬇️ resource utilization.
✅️ VBHC is feasible across settings.
👉 catalyst.nejm.org/doi/abs/10.105…
#WHA75
(55/75) How can resource utilization be optimized in #GlobalCardiacSurgery?
Underused costing methods, such as time-driven activity-based costing (#TDABC), may:
✅️ Improve costing
🔍 Highlight inefficiencies
🔄 Promote M&E for $ + quality
👉 annalsthoracicsurgery.org/article/S0003-…
#WHA75
(56/75) How may #GlobalCardiacSurgery efficiency be maximized from the start?
Regionalization of complex health services, such as #CTSurgery:
🤝 Pools resources
🏥 Increases volume
💰 Reduces healthcare costs
✅ Improves outcomes
👉 journals.lww.com/co-cardiology/…
#WHA75
(57/75) How can #GlobalCardiacSurgery fit into national health plans?
#NSOAPs = policy plans to ⬆️ access to surgical healthcare.
#CTSurgery not well incorporated into NSOAPs to date ⏩ get seat at the table & strengthen entire #HealthSystem.
👉 thieme-connect.com/products/ejour…
#WHA75
(58/75) How can #GlobalCardiacSurgery accessibility for patients be 📶?
On the road to #UHC & #NSOAPs, healthcare packages must gradually expand to address most pressing healthcare needs with biggest risks of catastrophic health expenditure.
👉 ncbi.nlm.nih.gov/pmc/articles/P…
#WHA75
(59/75) How can #GlobalCardiacSurgery resources be 📶?
Long, fragmented supply chains hinder availability of surgical equipment & materials (e.g., 🫀 valves), & often ⬆️💰.
Shorter, local, transparent supply chains can ⬇️ costs & stock-outs.
👉 americanjournalofsurgery.com/article/S0002-…
#WHA75
(60/75) Collaboration is 🔑, in #GlobalCardiacSurgery and beyond.
🫀 surgical care spans entire care continuum, from community to hospital & back.
#GlobalSurgery = cross-cutting #HealthSystem intervention, much more than what happens in OR.
👉 bulletin.facs.org/2017/07/latin-…
#WHA75
(61/75) How can #GlobalCardiacSurgery become more collaborative?
There is no #SafeSurgery without #SafeAnesthesia, and #CTSurgery is no exception.
🌐 Anesthesia workforce = limited globally; 🫀 anesthesia even fewer.
👉 wfsahq.org/resources/work… @wfsaorg
#WHA75
(62/75) How can #GlobalCardiacSurgery learn from & grow together w/ other specialties?
Neuro-/cardiovascular & #VascSurg greatly share capacity (e.g., imaging, interventions, critical care) & barriers/opportunities.
👉 link.springer.com/chapter/10.100…
👉 heartasia.bmj.com/content/hearta…
#WHA75
(63/75) How can #GlobalCardiacSurgery benefit from regional collab?
Small Island States (1% 🌐 population): Limited 🫀 surgery ↔️ Burden of #RHD etc. ⬆️
Regional 🤝 (e.g., Asia-Pacific NSOAPs) ⏩ #CTSurgery growth?
👉 annalsthoracicsurgery.org/article/S0003-…
👉 gh.bmj.com/content/2/4/e0…
#WHA75
(64/75) Why should #GlobalCardiacSurgery ⬆️ shared learning & co-development in #GlobalSurgery interventions?
Reciprocity ➡️ Improve health outcomes everywhere
#CTSurgery examples: #OPCAB, Del Nido cardioplegia, low-cost CT, etc.
👉 jamanetwork.com/journals/jamas… @bc_alkire
#WHA75
(65/75) In which ways should #GlobalCardiacSurgery innovate prior to surgery?
Community-based screening & detection of #CVD remains limited in LMICs + remote ➡️ opportunity for handheld echo, task-sharing, and more?
👉 ncbi.nlm.nih.gov/pmc/articles/P…
👉 sciencedirect.com/science/articl…
#WHA75
(66/75) How do diagnostics fit into #GlobalCardiacSurgery?
Diagnostics = essential part of #HealthSystem.
👉 thelancet.com/journals/lance…
Min. overall needs:
📷 20 radiography units per million population
🏥 1 CT scanner per 10 radiography units
👉 link.springer.com/chapter/10.100…
#WHA75
(67/75) How does critical care availability fit into #GlobalCardiacSurgery?
Critical care capacity = rate-limiting & life-saving in #CTSurgery.
🌐 96+ countries: <5.0 ICU beds per 100,000 population.
Pandemic = ICU capacity innovation?
👉 sciencedirect.com/science/articl…
#WHA75
(68/75) In which ways can & should #GlobalCardiacSurgery innovate after surgery?
🫀 rehabilitation + follow-up often ⬇️ & fragmented in variable-resource contexts & remote settings.
➡️ Opportunity for innovative models, telemedicine, & more.
👉 sciencedirect.com/science/articl…
#WHA75
(69/75) What gaps in knowledge persist in #GlobalCardiacSurgery?
📷 Select gaps & *many* more.
⚠️ Role of/need for clinical epidemiology, health economics, qualitative research, geospatial analysis, anthropology, political science, and more.
👉 ctsnet.org/article/moving…
#WHA75
(70/75) What is unknown re: #GlobalCardiacSurgery workforce?
🏥 How many/where are cardiologists, 🫀 nurses, intensivists, perfusionists, technicians 🌐?
📚 How many training programs exist for all members of #HeartTeam?
⚖️ How far is #CTSurgery from #GenderEquity 🌐?
#WHA75
(71/75) What is unknown re: #GlobalCardiacSurgery care delivery?
🏥 Outcomes in variable-resource contexts
🫀 Treatment for neglected #CVD (e.g., #EMF)
⚖️ Optimal treatment considering patient context (e.g., mitral valve surgery for #RHD)
👉 journals.lww.com/co-cardiology/…
#WHA75
(72/75) What is unknown re: #GlobalCardiacSurgery financing?
💰 Healthcare $ across system
⚖️ Cost-effectiveness across settings
🛑 Financial burdens on patients
🫀 Countries’ #CTSurgery spending
🆕 Innovative financing instruments' impact
👉 link.springer.com/chapter/10.100…
#WHA75
(73/75) What are growing gaps in #GlobalCardiacSurgery?
📶 Increasing access to #CTSurgery ➡️ (lifelong?) follow-up needs into the last mile.
✅ Increased survival ➡️ growing 🫀 care needs.
🌐 #ACHD care capacity limited worldwide.
👉 internationaljournalofcardiology.com/article/S0167-…
#WHA75
(74/75) What can never be forgotten in #GlobalCardiacSurgery?
Global = local.
Disparities exist in EVERY country, even with #UHC:
▶️ Geography
▶️ Sex & gender
▶️ Race, ethnicity, Indigeneity, immigration
▶️ Socioeconomic status
And more.
👉 onlinecjc.ca/article/S0828-…
#WHA75
(75/75) There is still much to do in #GlobalCardiacSurgery.
It's a privilege to contribute to this growing field w/ support of mentors 🌐.
I'm inspired by the #FutureOfTheOR, like @GlobalCardiac & @InciSioNGlobal.
I'm hopeful for a better future.
Action is now needed.
#WHA75
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