Citation Nr: 21002298 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 15-06 545 DATE: January 13, 2021 ORDER Entitlement to benefits pursuant to 38 U.S.C. § 1151 for postoperative residuals of right total knee replacement surgery, post staph infection, to include back and hip disabilities with right leg shortening is denied. FINDINGS OF FACT 1. The Veteran provided informed consent for all of the knee procedures that are the subject of this appeal. 2. The evidence of record is against a finding that the Veteran sustained any additional residual disability resulting from carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA in performing and treating the postoperative residuals of right total knee replacement surgery, post staph infection, to include back and hip disabilities with right leg shortening or resulting from an event not reasonably foreseeable.   CONCLUSION OF LAW The criteria for entitlement to benefits pursuant to 38 U.S.C. § 1151 for postoperative residuals of right total knee replacement surgery, post staph infection, to include back and hip disabilities with right leg shortening have not been met. 3 8U.S.C. §§ 1151, 5107; 38 C.F.R. §§ 3.361, 3.1000. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran, who had active service from August 1960 to July 1964, appeals a July 2013 rating decision. In April 2018, the Veteran testified at a videoconference hearing before one of the undersigned Veterans Law Judges (ML). The Board remanded the matter in July 2018 to the Agency of Original Jurisdiction (AOJ) for development. It was thereafter returned to the Board. The Board then denied the claim in May 2019. The Veteran appealed the May 2019 decision to the United States Court of Appeals for Veterans Claims (Court). In a December 2019 order, the Court remanded the case to the Board for action consistent with a December 2019 Joint Motion for Remand (JMR). In February 2020, the Veteran, through his attorney, requested another Board hearing. In November 2020, the Veteran testified at a videoconference hearing before another of the undersigned Veterans Law Judges (HS). On the record at the November 2020 hearing, the Veteran, through his attorney, waived his right to testify before a third Veterans Law Judge on the above issue pursuant to Arneson v. Shinseki, 24 Vet. App. 379 (2011) (a veteran must be provided the opportunity to testify before all members of a Board panel deciding the case). Thus, no further hearing will be held, and this adjudication constitutes the panel decision on the single issue common to the April 2018 and November 2020 hearings. The sole articulated reason for remand in the JMR is that the Board erred in May 2019 when it did not provide an adequate statement of reasons or bases to support its finding that Appellant provided informed consent for his procedures. The JMR includes the following: The Board stated that “VA received the Veteran’s informed consent to perform the procedures dated October 13, 2005, October 31, 2005, and January 19, 2006, as indicated by the January 2019 examiner and no contraindication for surgery was found.” [R. at 11-12 (4-16)]. However, at his April 2018 hearing Appellant testified that he could not recall being informed that a staph infection was a possible complication from his surgery. [R. at 3071 (3061-85)]. He stated: “I wasn’t aware of that and I wouldn’t have consented to it.” Id. In a March 2019 statement, Appellant stated that “there was no informed consent given.” [R. at 23 (22-23)]. “I went through three surgeries where I was not informed of the alternatives and risks.” Id. Because the Board did not discuss Appellant’s statement that he did not provide informed consent or weigh them against the other evidence of record, the parties agree that remand is warranted for the Board to do so in the first instance. McNair v. Shinseki, 25 Vet. App. 98, 105 (2011) (the Board is required to weigh the claimant’s statements regarding lack of informed consent against the other evidence of record).”   Compensation under 38 U.S.C. § 1151 The law provides that compensation may be paid for a qualifying additional disability that is 1) not the result of the Veteran’s willful misconduct; 2) was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by VA either by a VA employee or in a VA facility; and 3) the proximate cause of the disability was A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination or (B) an event not reasonably foreseeable. 38 U.S.C. § 1151. VA regulations provide that benefits under 38 U.S.C. § 1151 (a) for claims received by VA on or after October 1, 1997 for additional disability due to hospital care, medical or surgical treatment, examination, require actual causation not the result of continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished, unless VA’s failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361. If additional disability is shown to exist, the next consideration is whether the causation requirements for a valid claim have been met. To establish actual causation, the evidence must show that the medical or surgical treatment rendered resulted in the Veteran’s additional disability. 38 C.F.R. § 3.361 (c)(1). In addition, the proximate cause of the disability claimed must be the event that directly caused it, as distinguished from a remote contributing cause. 38 C.F.R. § 3.361 (d). It must be shown that the hospital care, medical or surgical treatment, or examination caused the Veteran’s additional disability, and that VA failed to exercise the degree of care that would be expected of a reasonable health care provider or that VA furnished the hospital care, medical or surgical treatment, or examination without the informed consent of the Veteran or the Veteran’s representative. To establish the proximate cause of an additional disability or death, it must be shown that there was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA’s part in furnishing hospital care, medical or surgical treatment, or examination. Whether the proximate cause of a Veteran’s additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. 38 C.F.R. § 3.361 (d). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA’s part in furnishing medical treatment proximately caused the additional disability, it must be shown that the medical treatment caused the additional disability; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) VA furnished the medical treatment without the veteran’s informed consent. 38 C.F.R. § 3.361 (d) (1). Benefits may also be paid where residuals result in an event that was not reasonably foreseeable. Id. To determine whether there was informed consent, VA will consider whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. Informed consent may be express (i.e., given orally or in writing) or implied under the circumstances specified in 38 C.F.R. § 17.32 (b), such as in emergency situations. 38 C.F.R. § 3.361 (d) (1). Minor deviations from the requirements of 38 C.F.R. § 17.32 that are immaterial under the circumstances of a case will not defeat a finding of informed consent. Failure to advise a patient of a foreseeable risk can be considered a minor, immaterial deviation under the regulation if a reasonable person in similar circumstances would have proceeded with the medical treatment even if informed of the foreseeable risk. See McNair v. Shinseki, 25 Vet. App. 98 (2011). VA regulations provide that informed consent is the freely given consent that follows a careful explanation by the practitioner to the patient or the patient’s surrogate of the proposed diagnostic or therapeutic procedure or course of treatment. The practitioner, who has primary responsibility for the patient or who will perform the particular procedure or provide the treatment, must explain in language understandable to the patient or surrogate the nature of a proposed procedure or treatment; the expected benefits; reasonably foreseeable associated risks, complications or side effects; reasonable and available alternatives; and, anticipated results if nothing is done. The patient or surrogate must be given the opportunity to ask questions, to indicate comprehension of the information provided, and to grant permission freely without coercion. The practitioner must advise the patient or surrogate if the proposed treatment is novel or unorthodox. The patient or surrogate may withhold or revoke his or her consent at any time. 38 C.F.R. § 17.32 (c). Entitlement to benefits pursuant to 38 U.S.C. § 1151 for postoperative residuals of right total knee replacement surgery, post staph infection, to include back and hip disabilities with right leg shortening is denied. As discussed below, upon fully considering the entire record, to include all of Appellant’s statement(s) that he did not provide informed consent, and weighing those statements against the other evidence of record in the first instance, we conclude that he did indeed provide informed consent. The record reflects that the Veteran developed a staph infection following a right total knee replacement (TKR) that was performed on October 13, 2005. He underwent a tibial liner replacement and debridement on October 31, 2005. The staph infection remained and on January 19, 2006, the Veteran underwent hardware removal and fusion. A second right TKR was performed on June 19, 2006. The record also reflects that the Veteran has a leg length discrepancy, which was first noted on June 15, 2006. The Veteran contends that he has limited motion of the right knee due to scar tissue from the staph infection. He also contends that the leg length discrepancy was caused by the staph infection and/or the right knee surgeries that he underwent at the Palo Alto HCS between October 2005 and June 2006. At the first Board hearing, the Veteran testified that, after undergoing the initial right TKR on October 13, 2005, he developed a staph infection that ultimately required additional surgeries on October 31, 2005, January 19, 2006, and June 19, 2006. He also contends that he was not informed of the extent of the actual leg length discrepancy until many months after the fourth surgery. He claims back and hip disabilities also as a result of the surgery and residuals. At his second Board hearing, the Veteran reiterated his statements with regard to lack of informed consent regarding the knee surgeries. It was acknowledged by the Veteran’s attorney that the only issue is whether there was informed consent. The crux of the argument is that the Veteran was never advised the leg could be shortened as a result of the surgery. He stated he would never have consented to such a consequence. As to the first surgery in October 2005, he stated there was just a general consent. He reported he signed the request for anesthesia and surgical procedure, not a more detailed form like he signed for the very last surgery. He also recalls a consent form for a transfusion and a consent form for a hepatitis and AIDS testing. He testified that there were no risks explained as to any of these procedures, but he signed those because he felt it was like, “your way or the highway” on VA’s part. He stated he was not counseled on any of the risks or benefits or advantages or alternatives, possible outcomes or anything else like that. When asked by the VLJ why he had the first surgery and what was he expecting from the surgery, he responded that he was expecting to get a knee replacement. He told the undersigned (HS) he did not know that he could get a Staph infection. He stated he had to continue with the subsequent surgeries after the first surgery since he got the Staph infection from the first surgery. He urged that the corrective wedge VA gave him to wear in his shoe for five years led to ankle and hip problems. A VA opinion was obtained in June 2013. The examiner noted that the Veteran had unexpected complications from the October 2005 surgery, but also noted that these complications do happen in the general population. He further noted that there was no carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of the VA in furnishing care. Pursuant to the Board’s July 2018 remand, the Veteran underwent an examination by a VA physician in January 2019. The examiner reported the Veteran’s medical history as follows: [The Veteran] is accompanied by his work friend who testifies to his claimed condition and limitation during this “face to face” encounter. [The Veteran] in summary underwent a right total knee arthroplasty on 10/13/2005. He had an immediate postoperative infection Methicillin-resistant Staphylococcus aureus (MRSA), and on 10/31 underwent an Incision and Drainage (I&D). This failed to control the MRSA infection, and he had prolonged course of antibiotic treatment. On 01/19/06 he underwent a resection arthroplasty and then had the total knee arthroplasty re-implanted in 06/2006. He reports as annotated in his 1151 claim of postoperative residuals of right total knee replacement surgery, post staph infection, to include back and hip disabilities with right leg shortening as diagnosed leg length discrepancy was caused by or contributed to by any of the Veteran’s four right knee surgeries (October 13, 2005, October 31, 2005, January 19, 2006, and June 19, 2006). He has worn a shoe lift after his right knee surgeries due to leg length discrepancy or shortening. This has made his back and hips more painful. Veteran can do all of his routine activities of daily living with pain and difficulty. He lives alone and drives a tow truck. His friend who is present testifies to his work difficulties. He avoids all kneeling and squatting when towing vehicles. He has to get down, and usually will lie down to his side. Of note, he also had a left total knee arthroplasty done in VAPA [VA Palo Alto] in 12/2006, and he has done very well. Also, he contends that “medical battery” was done by VAPA during (October 13, 2005, October 31, 2005, and January 19, 2006 as there was no evident of informed consent had been evident in his medical records that were performed by the Orthopedic service from VAPA. Lastly, he had prior lumbar spine surgery (laminectomy) done at VA Cincinnati around late 1990s with no complication. With regards to the consent forms of record, the examiner provided the following remarks, which are transcribed below: VBMS was reviewed. This is done as a “face to face” encounter with the Veteran. Firstly, the informed consents dated October 13, 2005, October 31, 2005, and January 19, 2006 were found from VAPA. These records were sent to the author of this AMIE from AMC. I had asked her to input these informed consents in VBMS for everyone to access. The Remanded document dated July24, 2018 annotates: “....Thus, the claim must be remanded for the AOJ to conduct a complete search for any consent forms obtained with respect to the Veteran’s four right knee surgeries...”The January 19, 2006 informed consent was easily identified and Veteran acknowledged its existence in VAPA health records (Vista Imaging). Furthermore, he claims during this “face to face” encounter with me that Veteran does not recall signing the informed consents dated October 13, 2005, October 31, 2005, and January 19, 2006 thus “medical battery” was done by VAPA. Clearly, informed consents dated October 13, 2005, October 31, 2005, and January 19, 2006 are present and signed by Veteran. These were properly counter signed by the operative surgeon and witnessed to further testify that consent was not done under duress or coercion. Clinical notes had indicated operative risks, benefits, and alternative care were discussed prior to all surgeries in contention. Regards to Staphylococcus infection or MRSA, Veteran had MRSA prior to any knee surgeries and properly identified and treated as seen in microbiology report in July 07, 2005 from VAPA. The Staphylococcus bacteria is ubiquitous in all human skin. And as reported by [Dr. I.W.] (C&P Examination dated 2013 from VA Omaha) “...it must be one that a reasonable healthcare provider would not consider an ordinary risk of the treatment provided....” for claimed postoperative residuals of right total knee replacement surgery, post Staphylococcus infection, to include back and hip disabilities with right leg shortening as diagnosed leg length discrepancy was caused by or contributed to by any of the Veteran’s four right knee surgeries (October 13, 2005, October 31, 2005, January 19, 2006, and June 19, 2006). These infections and leg shortening as diagnosed leg length discrepancy are well known Orthopedic surgical complications. These are medical facts. The examiner also provided the following medical opinions, which are transcribed in italics below: (a) Does the Veteran have a currently diagnosed staph infection residual, to include scar tissue? There is surgical scar to the right knee as I have annotated above but by no means this is solely from the right knee infection. Of note, his unrelated abdominal scar from aortobifemoral bypass is longer and just as wide in comparison to his right knee scar. In essence, Veteran does NOT have a currently diagnosed Staphylococcus infection residual. (b) Is it at least as likely as not (50 percent probability or greater) that any currently diagnosed staph infection residual or the Veteran’s currently diagnosed leg length discrepancy was caused by or contributed to by any of the Veteran’s four right knee surgeries (October 13, 2005, October 31, 2005, January 19, 2006, and June 19, 2006)? Again, there is NO currently diagnosed Staphylococcus infection residual in my opinion. But Veteran’s currently diagnosed leg length discrepancy is at least as likely caused by or contributed to by Veteran’s four right knee surgeries. (c) If any of the surgeries caused or contributed to a currently diagnosed staph infection residual or the currently diagnosed leg length discrepancy, what is the likelihood that there was carelessness, negligence, lack of proper skill, error in judgment or similar instances of fault on VA’s part in performing this surgery? There is NO carelessness, negligence, lack of proper skill, error in judgment or similar instances of fault on VA’s part in performing this surgery. His infection was identified immediately post-operative. Proper intervention to include I&D and prolonged antibiotic course and eventual removal of infected knee hardware were done to counter this MRSA infection. (d) If any of the surgeries caused or contributed to a currently diagnosed staph infection residual or the currently diagnosed leg length discrepancy, was the disorder an event not reasonably foreseeable? These complications arising from right total knee replacement surgery and residuals of right total knee replacement surgeries with post Staphylococcus infection, to include back and hip disabilities with right leg shortening as diagnosed leg length discrepancy were medically known complications. The risk is small (and known) but the benefits outweighed such known surgical risks. Therefore, surgeries caused infection & residual and diagnosed leg length discrepancy, was an event reasonably foreseeable. (e) After reviewing treatment records, was the staph infection timely found and appropriately treated? Yes. (f) If the answer to (c) or (d) is yes, is it at least as likely as not (50 percent probability or greater) that any currently noted hip disability, or back disability is caused by or aggravated by the Veteran’s currently diagnosed leg length discrepancy? Veteran of note had prior lumbar disease that required laminectomy years prior to his bilateral knee condition and s/p bilateral knee replacement. I see that he has not required further surgical intervention or care specifically to his lumbar spine. Thus, Veteran’s claimed back disability is less likely aggravated by the Veteran’s currently diagnosed leg length discrepancy. And finally, Veteran’s claimed back disability is NOT caused by the Veteran’s currently diagnosed leg length discrepancy as his back condition pre-existed to his diagnosed leg length discrepancy. Also X-ray from VA Cincinnati identifies bilateral hip pain and X-ray identifies hypertrophic scarring in 1999. X-ray from VAPA in 2018 identifies for right hip pain and X-ray identifies “Stable mild DJD”. This transition of hip pain from 1999-2018 is under stable normal senescent physiologic process of a hip pathology. Clearly there was pathology in 1999 and current. So, Veteran’s claimed hip disability is NEITHER caused nor aggravated by the Veteran’s currently diagnosed leg length discrepancy. The VA physician further supported his opinions with references to medical journals. Per VA policy, an event is considered “not reasonably foreseeable” if it is not the type of risk that would be disclosed as part of the informed consent procedures shown in 38 C.F.R. § 17.32. We note that VA received the Veteran’s consent to perform the procedures dated October 13, 2005, October 31, 2005, and January 19, 2006, as indicated by the January 2019 examiner. We also note the aforementioned statements of the Veteran that he did not provide informed consent. He has placed particular emphasis on the first surgery from which the complications arose. Ultimately, we conclude there was informed consent as to all the knee procedures. First, the Veteran consented to the actual procedures to include the first procedure as pointed out at the second hearing. Second, the October 6, 2005 pre-operative notes include the following explicit reference to risks, benefits, alternatives and outcomes of surgery: PLAN: 1. The patient is scheduled for a right total knee arthroplasty on 10/13/05. 2. The risks, benefits, alternatives and outcome of surgery were explained and discussed with the patient. 3. Postoperative care and rehabilitation were discussed with the patient. 4. The risks, benefits, alternative of blood transfusion and the OrthoPAT machine were also explained and discussed with the patient. Also noted was the following: Education discussed with the patient today was as above. He demonstrated satisfactory understanding of the instructions and verbalized compliance. All of his questions were answered to his satisfaction. The above plan, including patient education, was reviewed with the patient/family who demonstrated satisfactory understanding. Anesthesia pre-op appointment October 6, 2005 also provides the following in the plan: GA vs RA vs LA with the benefits and risks (including the remote possibility of death) of each technique discussed. The patient consents to proceed. The Veteran’s assertions that there was insufficient information or discussion as to risks, benefits, alternatives and outcomes of surgery are outweighed by the documented records made by health care personnel at the time of the surgery. This is because the clear meaning of the documents and logical inference from these documents is that the Veteran was fully informed and consented to the surgery. The record is replete with reference to explanations and to his repeated desire to proceed after being informed of known risks and benefits. We note that the October 31, 2005 plan for when he had surgery for the infected knee noted the following: The patient was explained the risks, benefits, and alternatives of the surgery. He elects to proceed, as well as the possibility of potential hardware removal and cement spacer implantation with potential revision total knee arthroplasty in the future versus knee fusion if we are unable to clear his infection. It was also explained that he will likely need to have six weeks of IV antibiotics and we will establish a PICC line for him after the washout. This was all discussed with the patient and he understands. He will be admitted from clinic today. The Veteran’s assertions that there was insufficient information or discussion as to risks, benefits, alternatives and outcomes are outweighed by the documented record made by health care personnel at the time of this surgery as well, for the same reason. The record is replete with reference to his desire to proceed after being informed of known risks and benefits. As to the January 2006 hardware removal, the record reflects risks and benefits were explained and the Veteran agreed to proceed. Here, it was noted that his questions about general anesthesia were answered. The Veteran’s assertions that there was insufficient information or discussion as to risks, benefits, alternatives and outcomes of surgery are outweighed by the documented record made by health care personnel at the time of this surgery as well, again for the same reason. As to the June 2006 revision, the record documents that the Veteran “understood the risks and benefits of reimplantation and wished to proceed.” See June 22, 2006 interdisciplinary assessment. Anesthesia pre-op appointment June 7, 2006 also provides the following in the plan: GA vs RA vs LA with the benefits and risks (including the remote possibility of death) of each technique discussed. The patient consents to proceed. A June 2006 Informed consent form is of record for that revision. It is undisputed that this form indicates that known risks of TKA revision include infection as well as possible leg length discrepancy. The Veteran’s assertions that there was insufficient information or discussion as to risks, benefits, alternatives and outcomes of this surgery are outweighed by the actual consent form which includes a documented list of known risks. Furthermore, the Board affords the January 2019 VA examiner’s opinion substantial probative value. After reviewing the Veteran’s electronic claims file and VA treatment, the examiner synthesized the Veteran’s medical history and found no evidence of carelessness, negligence, lack of proper skill, or error in judgement by the VA. We also note that the examiner assessed the complications that arose from the initial surgery and revisions to be medically known complications, adding that the benefits outweighed such known surgical risks. What happened was an event reasonably foreseeable. The Board has no reason to doubt the competency or the veracity of the 2019 VA medical opinion. The assessment is uncontroverted. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wray v. Brown, 7 Vet. App. 488 (1995) (the Board may adopt an independent medical expert’s opinion for its reasons and bases where the expert has fairly considered the material evidence of record). We also reiterate that it is supported by citations to medical literature. Thus, the Veteran’s statements made in connection with this claim filed in November 2011 are outweighed by the documented record which on their face indicate informed consent at the time of the procedures in 2005 and 2006, coupled with the opinion of the 2019 VA physician. As a physician, he found the consent forms in the record to be properly executed and witnessed from a medical standpoint. We note the Veteran’s argument that he would not have agreed to infection and leg length discrepancy. However, we also point out that this is a known risk of such procedure as reflected in the uncontroverted 2019 medical opinion. His acceptance of known risks and benefits is plainly recorded in the record. Thus, we find there was informed consent. Moreover, the January 2019 examiner explained that there is no currently diagnosed Staphylococcus infection residual. Regarding the Veteran’s leg length discrepancy, the examiner stated that there is no carelessness, negligence, lack of proper skill, error in judgment or similar instances of fault on VA’s part in performing the procedures. The examiner reasoned that the Veteran’s infection was identified immediately after the procedure and proper intervention was done to counter the infection. We have already pointed out that the examiner stated that these complications were (1) medically known, but the benefits outweighed such known surgical risks and (2) were reasonably foreseeable events. Significantly, the January 2019 examiner also opined that it was less as likely as not that any currently noted hip disability or back disability was caused by or aggravated by his currently diagnosed leg length discrepancy. Instead, the examiner stated the Veteran’s claimed hip disability is a result of the normal aging process and that the Veteran’s claimed back disability has required no additional treatment and pre-existed his diagnosed leg length discrepancy. The Board observes the Veteran’s assertions that he has experienced additional problems ever since the above described procedures, which he claims to have caused additional disability. We conclude that no current hip disability or back disability is related to the leg length discrepancy. The Board again observes he and his friend’s April 2018 testimony and his 2020 testimony. While he is competent to report symptoms such as knee pain, the testimony is outweighed by the 2019 medical opinion as to the matter of etiology of current conditions or whether there was any potential carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA. While he indeed had a complicated post-operative course, additional disability due to any VA fault, or an event not reasonably foreseeable, has not been demonstrated. Accordingly, the preponderance of the evidence of record, to include the January 2019 VA examination report and opinion, is against finding that carelessness, negligence, lack of proper skill, or error in judgment on the part of VA caused additional disability. In addition, the preponderance of the evidence of record is against a finding that an event not reasonably foreseeable caused additional   disability. Therefore, the claim for entitlement to benefits pursuant to 38 U.S.C.§ 1151 for postoperative residuals of right total knee replacement surgery, post staph infection, to include back and hip disabilities with right leg shortening must be denied and the benefit of the doubt rule enunciated in 38 U.S.C. § 5107 (b) is not for application. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals TBD To Be Determined Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. RIPPEL The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.