JCPM2025.01.28

The following is an edited transcript of the Journal Club with Pearls & Marketing (JCPM) of January 28, 2025, with Charles Runels, MD.  

>-> The PDF transcript of this live journal club can be seen here <-<

Topics Covered

• The Role of PRP in Facial Rejuvenation
• The O-Shot® for Interstitial Cystitis
• The Need for a Higher Concentration PRP When Treating Orthopedic Problems
• A Variety of Procedures to Make the Eyes Look Younger
• Optimizing the Regenerative Potential of Vaginal Fibroblasts
• Ways to Improve the Quality of PRP (that have nothing to do with the centrifuge)
• Fat vs. PRP for OA of the Knee
• Do PRP Device Manufacturers Bias Research?
• Does Age, Gender, or BMI Influence PRP?
• Why You Need Your Own Room, with a Lock on the Door, Without a Cell Phone
• The Five Rules of a Scientific Revolution (and how to lead one with minimal bloodshed)

Charles Runels, MD
Author, researcher, and inventor of the Vampire Facelift®, Orchid Shot® (O-Shot®), Priapus Shot® (P-Shot®), Priapus Toxin®, Vampire Breast Lift®, and Vampire Wing Lift®, & Clitoxin® procedures.

Transcript

Welcome to our Journal Club. Thank you for coming at this new time [2 pm New York time]. It seems that we really are missing some of our people in Europe, New Zealand, and Australia when we do the 9:00 p.m. Eastern Time; it puts us in the wee hours of the morning (3:00 a.m., 4:00 a.m. time when you’re in Europe). This new time allows us to be around lunchtime across the U.S. and around bedtime throughout most of the rest of the world. So, thank you for adapting to that.

This was a crazy week. We had eight inches of snow in one day here in the southern part of Alabama near the Gulf Coast, the most we’ve had since the 1800s. We also had the most research regarding PRP that I’ve seen come out in a week in a long time. Usually, I have 10 or 20 papers come out per week that relate to what we do. It’s over 40 relevant papers out this week.

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So, I had more to go through to find what I think would help you most. I wound up with a little bit longer list, but I’m still going to try to run through it in 30 minutes or less. So, let’s jump in and see if we can do it. My goal is to find papers that will help you better take care of your people or help you better educate your people on what you’re doing.

Oh, at the end I’m going to show you a couple of things out of a book by Virginia Woolf, and one that’s considered a classic on starting a revolution that I think will help you both with your marketing and your reading.

The Role of PRP in Facial Rejuvenation

Let’s start with this one: the role of platelet concentrations in facial rejuvenation.^[1] It’s a review series. And everything in here is old hat, but it’s nice to have it all in one place. It’s also open source, so it’s a great one to show your patients.

I’ll send you the link in the upcoming email. And most of those papers I’m talking about are in your handout section.

They compare PRP and PRF and they acknowledge that when you complement them with an HA filler or lasers, you get a different effect that can be very helpful. So that’s the main point of that. It’s a beautiful review article that you can share with your people to help them understand what you’re doing.

The O-Shot® Procedure for Interstitial Cystitis

This one is another one that reinforces the idea that you can help people who are suffering from interstitial cystitis.^[2] Now we’re up to probably two dozen papers and they’re all (except for one) focusing on injecting into the bladder. I’m still waiting for one of our urologists or one of our members to do the paper that shows you do not need to do that. But we are finding repeatedly; remember, I have 3,000 doctors telling me what they’re seeing. So, I do not have to be smart; I need to be a good note-taker. I have repeatedly received excited phone calls and text messages telling me that just doing a regular O-Shot procedure by our usual protocol makes interstitial cystitis go away often in people who have suffered for many, many years.

This paper is a good confirmation that the idea is viable, and we’re just making the technique more simple.^[3] 

You could argue that, depending on the woman’s anatomy, you’re practically in the bladder when you’re injecting the anterior vaginal wall, which we recommend. You could approach and inject into the bladder by that approach if you want, but it’s not necessary.

Again, we’re seeing it over and over again. If you want some low-hanging fruit, do a study of interstitial cystitis and just do our regular O-Shot® procedure without injecting into the bladder.

The Need for a Higher Concentration When Treating Orthopedic Problems

For some reason, you couldn’t get to the paper, but it’s a meta-analysis that looked at the actual concentration of platelets. There are probably at least 10 studies that show that treating orthopedic problems helps to increase concentration.^[4] 

A Variety of Procedures to Make the Eyes Look Younger

This guy did a beautiful summary of all the things you can do around the eyes.^[5] Not just platelet-rich plasma but lasers, surgeries, and everything else. And, of course, one reason this is so important is studies show that when you look at someone, your first impression of their identity and their age is the eye from around the brow to the mid-cheek. It is not just the eye or periorbital region but also the mid-cheek, which is why treating the eye is so important.

When I do a facial consult, I always start with the eyes.

People have only so much time, even if they have unlimited funds, and they can only tolerate so many things being done to their bodies in one session. And so, if I have unlimited time and unlimited money to take care of someone, I still start with the eyes. So, this is a really important paper, I think, because it focuses on all the things that you can do for the most important part of the face when it comes to the wow factor or, “Wow, I really do look younger.”

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And it’s worth downloading and reading. It’s amazing to me. They still call this an “emerging” technique. We’ve been injecting PRP into the face for almost 20 years, a good solid 15 years. But I guess that’s still emerging when it comes to the medical literature. It usually takes 20 to 40 years for something to go mainstream. We’re still towards the end of the first 20.

Also, I noticed that they came up with a different abbreviation for platelet-rich plasma, which I have not seen before. But this is what makes the whole paper worth reading because they give references to treating the dark circles under the eyes, which works. They give you references for that, and then they give you some other helpful references about using platelet-rich plasma periorbital.

Now, the protocol for that—we have quite a number of people who do it—is underutilized by our group. Anytime you have to spin platelet-rich plasma because of the time involved and the expense, it should be a minimum of $600. Most people do one treatment every six to eight weeks, injecting it periorbitally, and then let the person decide if they want another treatment at the end of that timeframe.

Most people need two to three treatments to get satisfaction. So, the person who’s dark Mediterranean, African Indian descent with those dark circles under the eyes, which I think can be attractive, it can look like eye shadow, but if they want it to go away, you have a way that works. It’s being done a lot. And, of course, you could use it in combination with these other ideas.

When you put filler in the cheek for those of you who are new, for example, if you put filler in this gentleman’s cheek, when you expand the tissue there, it’s going to have the effect of pulling taut all the surrounding tissue. You could imagine if you just took your fingers and pinched right there over the anterior part of his zygoma and pulled it towards you, it would tighten everything around it, which is what happens, of course, when you inject an HA filler.

When you see someone with this flattening of the cheek, as this woman does here (see video) and this woman does there, that’s someone who can benefit tremendously from our Vampire Facelift®, where you combine filler with PRP, which has a surrounding tightening effect, even on the eye. If you have a lot of extra tissue, redundant tissue in the lower lid is usually the best for that.

Even though you can help mild redundant tissue or crepe papering, if they get it to that extent, blepharoplasty is the way to go. You’ll still make their face look younger without the blepharoplasty.

But I will sometimes tell people, “Save your money, go get a blepharoplasty, and come back. And then I’ll do your filler,” if that’s the main thing bothering them. Okay, so I have that one, and we have 20 minutes. That’s good. We’re on schedule.

Optimizing the Regenerative Potential of Vaginal Fibroblasts

All right, this one I love this study.^[6] It is used in one of the Regen kits. Regen has been very supportive of our group. It’s still the kit that I’ll probably reach for most, depending on the procedure. I still use it. I have Selphyl in my office, and I have PureSpin and EmCyte, and I think there’s a Harvest around somewhere and the Magellan centrifuge in the back room. And others have come and gone. But PRP from the Regen kits is the one I probably use the most. No doubt about it; it’s the one I use the most these days. They also have a kit that comes with an HA as the activator. It’s non-cross-linked, and this was the kit that Dr. Virag used to study Peyronie’s disease.^[7] Now, HA can activate platelet-rich plasma just like calcium chloride and calcium gluconate. So, when you have the HA there, it is the activator.

They took women who were having surgery and got a full-thickness sample of the vaginal mucosa, and cultured it, and then they exposed the culture to a control group. And then one group got just plain platelet-rich plasma from a Regen kit.

The other group had the region PRP with an HA. And then they looked to see, and really, to me, is the best, the most dramatic picture. This is the control group, and you can see the fibroblasts (see the video). It’s an in-vitro study. The fibroblasts are growing at the same magnification much more dramatically with the PRP and the PRP with the HA.

Then, they have this way of measuring senescence with an enzyme or a chemical. And when they looked for that marker, though, the control group had a biochemically older group of cells. Dramatically so compared with the PRP or the PRP with HA.

So, the first in-vitro study that I’ve seen that looked at this, there was a similar study in menopause, not in-vitro, but they injected platelet-rich plasma with a Regen kit into the vaginal wall of women who had dyspareunia from dryness after being treated for breast cancer.^[8] 

They also demonstrated that dyspareunia improved dramatically.

So that’s the people study. This is the in-vitro study. This, again, is one you could at least send the link to your people. I don’t think it was open source. I’ll put the link in the chat box. Give me a second. You can send this to your people as well.

I talk to my people as if they’re doctors. If you’re new to the group, maybe you’re wondering what you’re going to send with cultures and all this to your patients. Yes, they read it.

So if you took that link and you send it to your patients, and you say, “Here’s research showing that platelet-rich plasma makes the cells of the vagina healthier,” they’ll read it, and they will understand most of it and thank you for not talking down to them.

So that’s an important study because I haven’t seen a good in vitro study that backs up what we’re doing in people.

Ways to Improve the Quality of PRP (that have nothing to do with the centrifuge)

This one is crazy good.^[9] 

I’ve heard people talk about this a lot; I know Jeff Piccirillo did a book about this called Perfect PRP. You can find it on Amazon, and I’ve heard and seen scattered papers about things you can do to make your platelet-rich plasma work better. But this is the first paper I’ve seen where they just make it easy for you and they put it all in one paper. The best part of this paper I think is the chart.

Before I get to that, though, I thought it was interesting the way they describe what happens with exercise, which is one of the things you can do to increase the activity and the number of platelets that epinephrine and norepinephrine increase with exercise, which I knew, but I never thought about the spleen contracting. I guess I missed that. It seems obvious, I suppose, to everybody on the call, but I didn’t think about it; just physically contracting to release platelets into the circulation.

But dramatic. If they do intense exercise, that’s a 25% bump.

So if you’re using a gel kit, which increases platelets by 1.5 to two times the concentration of whole blood, well, that’s a 10% boost in your effectiveness, 10% to 15% depending on the person’s hematocrit. So that I thought was important. And if you want to know exactly, they’ve figured that out for you, too, and think it needs to happen five minutes to an hour before the blood is drawn.

And it can be moderate exercise. I think sometimes people get too complicated. They think, “Well, I don’t have a treadmill.” If you live in a place with a reasonable climate and a sidewalk outside, then you have that. You can ask your person to walk around the block or I guess you could ask them to jog in place, but I always thought that’s the most boring thing. That’s torment. I know when I was doing a weight loss/diabetes clinic back in my general internal medicine days, when people would come in and I would check their sugar and it would be a little high, to prove the point, rather than making them obese by giving them an insulin injection and driving the sugar, force-feeding the body, which is what you’re doing, and you’re decreasing insulin receptors and increasing insulin resistance by doing that, I would tell them, “Okay, your blood sugar is,” whatever it was, “now go walk five minutes away from my office. Come back. That’ll be a 10-minute walk and let’s redo your blood sugar.”

This doesn’t have to be complicated. If they have a jacket or the weather’s reasonable, it can just go for a walk, come back, and let’s draw your blood. Now, the different foods, and when I was reading this and saw these different foods and supplements, I’m thinking, okay, I need to make a list, and then finally got down here and saw, okay, thank goodness they made the list for me, the other thing though, before I show you that list, is this idea about hypoxia and hyperbaric both helping, which is interesting. There was an article that came out probably eight years ago in one of the journals talking about how our modern-day lifestyle leads to the diseases of modern-day people, which is not walking, too easy to get food, and too many calories. And so, they did a study where they did the things that a caveman, person, or woman would’ve been exposed to a couple 1,000 or more years ago. What would an Indigenous person have to experience?^[10]

And that was fasting, some dehydration, some, of course, VO2 max enhancement or VO2 enhancement by aerobic exercise because you’re walking. The fasting is increasing insulin sensitivity. But on that list was also hot and cold and hypoxia, which I never thought of something that people would be exposed to, but in a way you do expose yourself to it if you go past your anaerobic threshold. And, of course, if you are living at altitude, there would be even more possibilities of that. If you look at some of the techniques that are taught in types of Kriya and other types of yoga by hyperventilating, followed by relaxation, if you put a pulse oximeter on your finger while you do that, which I’ve done, because you’re blowing off your CO2, you’ll often have some mild hypoxia before you have the urge to breathe again. And those exercises have been shown to help focus.

Anyway, I guess I’m on a sidetrack, but the point is that low oxygen level can be a stimulant to regenerative effects. I think that could be what’s happening, at least part of the effect of our penis pump when it’s used appropriately. Anyway, so here, this paper is open source and it’s worth it. It’s in your handout section. It’s worth it just for this list of things you can do. And if you look at the list, it’s a pretty nice list just for being a healthy person. But specifically, there are things on here that would make your PRP work better. So you could decide what you think makes sense and choose from that menu for your patients when they’re going to have one of our procedures.

Fat vs. PRP for OA of the Knee

When you do micro fragments and adipose tissue and compare it with PRP for osteoarthritis to the knee, they’re about the same.^[11] 

However, as in other studies looking at cortisone, there is a similar thing here in that the adipose tissue micro-fragmented fat injected into the knee had better short-term pain relief. The PRP was better long-term. This was a meta-analysis.

So more evidence. And you don’t see many studies comparing the two. And I love the chief author’s name. His first name is X, abbreviated X, and his last name is E. That’s just B-A, like Musk naming his son X. X-E, I don’t know. If X-E was showing up with a six-gun, I’d be afraid of it. I think that’s a cool name.

Do PRP Device Manufacturers Bias Research?

How much time? Seven minutes. This one, I can summarize very quickly. Surprise, these people. They looked at, I think, 26 studies and lots of people. They were looking to see if studies of platelet-rich plasma were influenced when they were financed by one of the manufacturers, and they found that there was no influence.

This probably happens because just about every PRP study I look at shows benefit. Well, how would you know the difference?

However, they conclude that you should pay attention to who’s paying for the research but that they could not find any bias in the studies they had looked at, even when the manufacturer was paying for the research.

Does Age, Gender, or BMI Influence PRP?

This one, last one, and I’ll get back to how to do a scientific revolution based on one of the classics ever written and about Virginia Woolf, but here they looked at, what happens with plate-rich plasma with age and BMI and sex? And there’s some difference, but not that much.

The biggest point I see, or the biggest helpfulness of this paper is that they give you a range, which we know, but just so you have it. Effectiveness, they say, is still enigmatic, but probably between 200,000 and a million cells per microliter is therapeutic.

My clinical bet is that it will be shown that a higher level is needed for orthopedic cases with avascular tissue, as the genitalia and face have lots of blood flow.

But they also point out that it’s not a linear response, and when you get to too high a concentration, effectiveness drops off. 

But the other usefulness of this study I think is they give you a beautiful summary of what the problem is, which is that it’s really hard to come to an absolutely definitive conclusion to what platelet-rich plasma even is.

This introduction is worth reading if you’re in our space just to be aware of it. We always want to be aware of our weaknesses when it comes to our research, and that’s a good way to do that.

Okay, so I have four minutes to talk about these two books, and then we’ll call it a day unless you guys have questions, in which case I’ll stay over. But I thought of these books.

Why You Need Your Own Room, with a Lock on the Door, Without a Cell Phone

One of them is A Room of One’s Own by Virginia Woolf.^[12] I’ll show; let me swap what you’re looking at so you can… Oh, here’s the link. And this is what she wrote back in the time when women barely had the right to vote. This was written in the ’20s, and she was an independent thinker. and in this essay, A Room Of One’s Own, she talks about the fact, and probably would be true, that had Shakespeare had a sister who had equal talent, she would probably not have ever been published because she would’ve been too busy taking care of the babies, which at that time was about all you had time to do.

And her idea of feminism is different, I think, than what it’s thought about to be now. I won’t get into the politics of it. Her biggest point was, man or woman, if you intend to be creative, and this is where it affects your practice and your marketing, if you intend to work on your business or write research or create marketing materials or do the next book… I’m still not showing you what I want you to see, hold one second, that’s the book, Virginia Woolf, of course this is an edited and modern version of the old one, but I think the audiobook version of this, audible.com, is really nice because the woman who reads it sounds like she could be Virginia Woolf.

Just go for a walk or two and you’ll get through it and it will motivate you. But this is the edited ’89 version. It was written in the ’20s. But back to the lady, her point was, to be able to write, you need to be able to have the time to sit somewhere and be undisturbed, and a place, hence A Room Of One’s Own, a place to sit. Of course, there were no cell phones back then.

She would’ve gone crazy now, ranting about that.

But you need a place to be undisturbed and the money to allow you to sit there and think and read and think about what you’re reading and what’s happened, in our case with your patients. So we mostly thought that every so often, a doctor should take a month off and just read his notes and think about his patients.

And of course, the reason she says that Shakespeare’s sister could have never made it is being independent of a husband and having no children and still having a cash flow and a room to sit in would’ve been nearly impossible in Shakespeare’s day.

And so probably there were women of great genius who we never heard from. But the reason I show this to you is I think there are many physicians of great genius who don’t really have a room of their own because they’re patients. Just like Shakespeare’s sister would’ve been pulled at by children and our husband, we have our family and several thousand patients pulling at us. And so to rope off the place to be undisturbed with a cell phone turned off and to sit down and read a journal, think about what you’re reading, and think about your patients is hard to come by. But reading this, I think, will motivate you to make the space.

The Five Rules of a Scientific Revolution (and how to lead one with minimal bloodshed)

The other book I wanted to show you relates to the same idea: Structure of Scientific Revolutions.^[13] If you just read some of the reviews here, like here’s, of course, this is another old one. There was one by Oxford, the Guardian. Here in Opinion.

The Guardian says, “One of the most influential books of the 20th century. Single-handedly changed the way we think about science basically.”

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I’ve read it a few times, and I wrote down what I thought was most helpful to us.

This book came out in 1962.

We are part of a revolution: a whole new category of therapies that are being ignored by some, made into something stupid by others and embraced in a smart way by a third group.

Here are the five rules for a scientific revolution, which, again, we are part of. Let me read them, and then we’ll call it a day.

One is you keep pointing to the anomalies and failures of the old system. For example, with erectile dysfunction, the old system does not give away to make your penis healthier. PDE5Is, Trimix, of course, penile implants. None of those things make the penis healthier.

So you keep pointing to that and saying, “Hey, guys, you can still keep all that, still use all that. We have a way to make your penis healthier. Why aren’t you using that? And why should that be your last choice? Why not make it the first choice? Or at least along with the other.” 

So you keep pointing that Point out the anomalies and failures of the old system in your emails to your patients, in your talks, and when you give a talk.

With female sexual function, it would be, “Listen, we still just have two FDA-approved drugs to help women with sex. They’re both psych drugs. We have DHEA cream, which has a very limited indication. But other than that, we have really nothing to affect the genitalia of a female to help her have better sex when men have 20-something plus drugs and devices. Why is that?”

So, you keep pointing out the failure of the old system.

Number two is that you keep speaking and acting loudly and with assurance from your new knowledge and conviction. That would be your marketing materials. This is why I say your marketing is not 10% off because it’s Valentine’s Day. It’s showing people what you know and talking with passion about what you know to be best for them.

Number three, keep putting people who are preaching the new paradigm in places of public visibility and power.

That’s you.

You’re a doctor, or you’re a physician extender, and you have a place of recognition and honor. And so keep talking about it.

Number four is you do not waste time with reactionaries.

You cannot argue with a closed mind.

Waste your energy and your time; you might as well donate two pints of blood and hold your breath for 30 minutes because you’re going to feel stupid and tired when you argue with a closed mind. So, you just avoid them.

Number five and the last one is you work with the active change agents and the open-minded middle ground. And that would be us.

Yeah, we have procedures we thought of and protocols that work, and we have a lot of advantages to being in our group. But I think one of the main advantages is that we are in a group: We’re the active change agents, and we’re spending all sorts of research and inspiration.

So, I think I’ll see if there are questions, and if not, we’ll call it a day.

No questions. So thank you for being here. I hope that was helpful to you. I’ll shoot out a summary with links to the research very soon. Bye.

References

Berndt, Sarah, Solange Vischer, Antoine Turzi, and Patrick Dällenbach. “Optimizing the Regenerative Potential of Vaginal Fibroblasts: The Role of Autologous Platelet-Rich Plasma and Hyaluronic Acid in Vitro.” Maturitas 194 (March 2025): 108196. https://doi.org/10.1016/j.maturitas.2025.108196.

Hersant, Barbara, Mounia SidAhmed-Mezi, Yazid Belkacemi, Franklin Darmon, Sylvie Bastuji-Garin, Gabrielle Werkoff, Romain Bosc, et al. “Efficacy of Injecting Platelet Concentrate Combined with Hyaluronic Acid for the Treatment of Vulvovaginal Atrophy in Postmenopausal Women with History of Breast Cancer.” Menopause 25, no. 10 (2018): 1. https://doi.org/10.1097/GME.0000000000001122.

Kuhn, Thomas S., and Ian Hacking. The Structure of Scientific Revolutions: 50th Anniversary Edition. Fourth edition. Chicago: University of Chicago Press, 2012.

Malcangi, Giuseppina, Angelo Michele Inchingolo, Alessio Danilo Inchingolo, Laura Ferrante, Giulia Latini, Irma Trilli, Paola Nardelli, et al. “The Role of Platelet Concentrates and Growth Factors in Facial Rejuvenation: A Systematic Review with Case Series.” Medicina 61, no. 1 (January 7, 2025): 84. https://doi.org/10.3390/medicina61010084.

Montagnino, Jami, Matthew W. Kaufman, Maya Shetty, Christopher Centeno, and Michael Fredericson. “Optimizing Orthobiologic Therapies with Exercise, Diet, and Supplements.” PM&R, January 24, 2025, pmrj.13320. https://doi.org/10.1002/pmrj.13320.

Oeding, Jacob F., Nathan H. Varady, Caden J. Messer, Joshua S. Dines, Riley J. Williams, and Scott A. Rodeo. “Platelet Concentration Explains Variability in Outcomes of Platelet-Rich Plasma for Lateral Epicondylitis: A High Dose Is Critical for a Positive Response: A Systematic Review and Meta-Analysis With Meta-Regression.” The American Journal of Sports Medicine, January 27, 2025, 3635465241303716. https://doi.org/10.1177/03635465241303716.

Pruimboom, Leo, and Frits A.J. Muskiet. “Intermittent Living; the Use of Ancient Challenges as a Vaccine against the Deleterious Effects of Modern Life – A Hypothesis.” Medical Hypotheses 120 (November 1, 2018): 28–42. https://doi.org/10.1016/J.MEHY.2018.08.002.

Tao, Brendan K., Fahad R. Butt, Thanansayan Dhivagaran, Michael Balas, Navdeep Nijhawan, Georges Nassrallah, Ahsen Hussain, and Edsel B. Ing. “Periocular Aging Across Populations and Esthetic Considerations: A Narrative Review.” Journal of Clinical Medicine 14, no. 2 (January 16, 2025): 535. https://doi.org/10.3390/jcm14020535.

Virag, Ronald, Hélène Sussman, Sandrine Lambion, and Valérie de Fourmestraux. “Evaluation of the Benefit of Using a Combination of Autologous Platelet Rich-Plasma and Hyaluronic Acid for the Treatment of Peyronie’s Disease.” Sexual Health Issues 1, no. 1 (2017). https://doi.org/10.15761/SHI.1000102.

Woolf, Virginia. A Room of One’s Own. First Edition. San Diego: Mariner Books Classics, 1989.

Ye, X., Z. Shen, X. Li, B. Zhang, G. Shen, and L. Wu. “Microfragmented Adipose Tissue versus Platelet-Rich Plasma in the Treatment of Knee Osteoarthritis: A Systematic Review and Meta-Analysis.” Acta Orthopaedica Belgica 90, no. 3 (September 2024): 549–58. https://doi.org/10.52628/90.3.12669.

Yu, Wan-Ru, Yuan-Hong Jiang, Jia-Fong Jhang, and Hann-Chorng Kuo. “Repeated Intravesical Injections of Platelet-Rich Plasma Are Safe and Effective in the Treatment of Interstitial Cystitis/Bladder Pain Syndrome.” Tzu Chi Medical Journal 37, no. 1 (January 2025): 72–79. https://doi.org/10.4103/tcmj.tcmj_166_24.

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