Bio

Bio


Sara M. Krzyzaniak, MD FACEP is a Clinical Associate Professor in the Department of Emergency Medicine. She joined the Stanford University family after 8 years at the University of Illinois College of Medicine Peoria where she served in multiple education roles including EM Clerkship Director and Residency Assistant/Associate Program Director. While in these roles she received several awards recognizing her excellence in teaching and education including "Mentor of the year", "Teacher of the year", and "Outstanding Junior Faculty". She was also recognized nationally by the American College of Emergency Physicians with the "National Emergency Medicine Junior Faculty Teaching Award".

Dr. Krzyzaniak's scholarly work has included curriculum development for pediatric stabilization and resuscitation for low-middle income countries, development and implementation of an augmented reality application for pediatric code cart instruction, and best practices in social media for physicians. Presently her scholarly work focuses on the remediation of struggling learners and gender issues in academic medicine. She has also been a course director for Residents as Teachers curriculum as well as an Intern Preparatory Course for medical students.

Beyond her scholarly endeavors and residency leadership roles, Dr. Krzyzaniak also serves as the Chief Operating Officer for the national faculty development program Faculty Incubator which is supported by the medical education startup Academic Life in Emergency Medicine.

Clinical Focus


  • Emergency Medicine
  • Pediatric Emergency Medicine
  • Medical Education

Academic Appointments


Honors & Awards


  • National Junior Faculty Teaching Award, American College of Emergency Physicians (2019)
  • Mentor of the Year, University of Illinois College of Medicine Peoria, Emergency Medicine Residency (2018)
  • Curriculum Innovation Award "Intern Preparedness Course", University of Illinois College of Medicine Peoria (2014)
  • Teacher of the Year Award, University of Illinois College of Medicine Peoria, Emergency Medicine Residency (2014)
  • Outstanding Junior Faculty Award, University of Illinois College of Medicine Peoria, Emergency Medicine Residency (2013)

Professional Education


  • Residency: Denver Health Medical Center (2012) CO
  • Medical Education: Northwestern University Feinberg School of Medicine (2008) IL
  • BA, Saint Louis University, German Studies (2004)
  • BA, Saint Louis University, Psychology (2004)

Community and International Work


  • Pediatric Acute Surgical Support (PASS), Vietnam

    Topic

    Management of acutely ill and injured pediatric patients

    Partnering Organization(s)

    Pham Ngoc Thach University

    Populations Served

    Physicians caring for pediatric patients in southern Vietnam

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

Publications

All Publications


  • Rethinking the Approach to Continuing Professional Development Conferences in the Era of COVID-19. The Journal of continuing education in the health professions Gottlieb, M., Egan, D. J., Krzyzaniak, S. M., Wagner, J., Weizberg, M., Chan, T. 2020

    Abstract

    The COVID-19 pandemic has required a substantial change to the approach used for traditional, in-person continuing professional development (CPD) conferences. Running a virtual CPD conference will necessitate consideration of digital platforms and conversion of large group and small group sessions, abstract presentations, and networking events to a digital medium. This paper will discuss these challenges and present strategies to address them for CPD conference planning in the era of COVID-19.

    View details for DOI 10.1097/CEH.0000000000000310

    View details for PubMedID 32658014

  • Emergency Medicine Gender in Resident Leadership Study (EM GIRLS): The Gender Distribution among Chief Residents Academic Emergency Medicine Education & Training Mannix, A., Parsons, M., Krzyzaniak, S. M., Black, L. P., Alvarez, A., Mody, S., Michael, G. 2020; 4 (3)
  • Sex Distribution of Editorial Board Members Among Emergency Medicine Journals. Annals of emergency medicine Gottlieb, M., Krzyzaniak, S. M., Mannix, A., Parsons, M., Mody, S., Kalantari, A., Ashraf, H., Chan, T. M. 2020

    Abstract

    Previous studies have demonstrated that a sex disparity exists in the editorial boards of select specialties. However, there are limited data with respect to emergency medicine. We seek to determine the sex distribution of editors in chief and editorial board members among emergency medicine journals.In this cross-sectional survey, we compiled a list of all emergency medicine journals, using the Scimago Journal & Country Rank on August 13, 2019. We excluded journals that were no longer published, were not emergency medicine journals, had rotating editorial boards for each issue, or had no first names listed. We obtained the sex and editorial board role by using publicly available data on the journal Web sites. We assigned sex according to knowledge of the member or his or her online faculty profile and used the Genderize program (Genderize.io, Roskilde, Denmark) when sex could not be determined with the above-mentioned approach. We report descriptive statistics for the categoric data, stratified by position (editor in chief, editorial board member, social media editor, resident/fellow member) and country.We identified 73 journals in Scimago; 37 met inclusion criteria, with data available to determine the sex in 99.5% of cases. There were 46 total editors in chief, with only 4 (8.7%) being women. Of 1,477 total editorial board members, only 241 were women (16.3%), with a range of 0% to 33.3% per journal. We found that 28.6% of social media editors (2/7) at 4 journals and 70% of resident or fellow editors (7/10) at 5 journals were women.There is a notable sex disparity among emergency medicine journals' editors in chief and editorial board members. Efforts should be made to improve sex distribution among editorial boards.

    View details for DOI 10.1016/j.annemergmed.2020.03.027

    View details for PubMedID 32376090

  • In Reply to Boucharel. Academic medicine : journal of the Association of American Medical Colleges Gottlieb, M., Krzyzaniak, S. M., Chan, T. M. 2019; 94 (9): 1261

    View details for DOI 10.1097/ACM.0000000000002840

    View details for PubMedID 31460906

  • Simulation-based Remediation in Emergency Medicine Residency Training: A Consensus Study. The western journal of emergency medicine Nadir, N. A., Hart, D., Cassara, M., Noelker, J., Moadel, T., Kulkarni, M., Sampson, C. S., Bentley, S., Naik, N. K., Hernandez, J., Krzyzaniak, S. M., Lai, S., Podolej, G., Strother, C. 2019; 20 (1): 145?56

    Abstract

    Resident remediation is a pressing topic in emergency medicine (EM) training programs. Simulation has become a prominent educational tool in EM training and been recommended for identification of learning gaps and resident remediation. Despite the ubiquitous need for formalized remediation, there is a dearth of literature regarding best practices for simulation-based remediation (SBR).We conducted a literature search on SBR practices using the terms "simulation," "remediation," and "simulation based remediation." We identified relevant themes and used them to develop an open-ended questionnaire that was distributed to EM programs with experience in SBR. Thematic analysis was performed on all subsequent responses and used to develop survey instruments, which were then used in a modified two-round Delphi panel to derive a set of consensus statements on the use of SBR from an aggregate of 41 experts in simulation and remediation in EM.Faculty representing 30 programs across North America composed the consensus group with 66% of participants identifying themselves as simulation faculty, 32% as program directors, and 2% as core faculty. The results from our study highlight a strong agreement across many areas of SBR in EM training. SBR is appropriate for a range of deficits, including procedural, medical knowledge application, clinical reasoning/decision-making, communication, teamwork, and crisis resource management. Simulation can be used both diagnostically and therapeutically in remediation, although SBR should be part of a larger remediation plan constructed by the residency leadership team or a faculty expert in remediation, and not the only component. Although summative assessment can have a role in SBR, it needs to be very clearly delineated and transparent to everyone involved.Simulation may be used for remediation purposes for certain specific kinds of competencies as long as it is carried out in a transparent manner to all those involved.

    View details for DOI 10.5811/westjem.2018.10.39781

    View details for PubMedID 30643618

    View details for PubMedCentralID PMC6324703

  • Curated Collections for Educators: Five Key Papers about Receiving Feedback in Medical Education. Cureus Natesan, S., Stehman, C., Shaw, R., Story, D., Krzyzaniak, S. M., Gottlieb, M. 2019; 11 (9): e5728

    Abstract

    Introduction Feedback is a complex, multi-component interaction that is essential for academic development and advancement. Successful feedback requires active involvement from both the giver and receiver. However, research and guidance on the subject mostly center on the role of the provider of feedback. But the receiver of feedback holds the true power in this interaction, choosing how to interpret the information and deciding whether or not to incorporate the feedback to instill behavioral change. In this article, the authors aim to summarize five key papers related to receiving feedback, in order to outline both relevant information for emerging clinician-educators and discern ways to use this information for faculty development. Methods In order to generate a list of key papers that describe the importance of receiving feedback, the authors conducted a consensus-building process informed by social media sources. Key articles on receiving feedback were aggregated through a literature search. This list was further augmented via an open call on Twitter for important papers regarding receiving feedback. Through these processes, a list of 43 papers was created on the topic of receiving feedback in medical education. After compiling this preliminary list, the authorship group engaged in a modified Delphi approach to build consensus on selecting papers that best described the process of receiving feedback. Results We present the group's five most highly rated papers on the topic of receiving feedback in medical education. These papers were deemed essential and have also been summarized based on their relevance to junior faculty members and faculty developers. Conclusion While giving and receiving feedback are both vital for growth and development, much of the research focuses solely on giving feedback. However, receiving feedback is equally, if not more, important for instilling change in the learner. We explore the power of receiving feedback in medical education through five key papers that analyze the subject. We believe these papers can serve as great learning resources for both junior faculty members and faculty developers. They can assist the junior faculty to cultivate the ability to receive feedback and also serve as resources to aid senior faculty in building faculty-development sessions.

    View details for DOI 10.7759/cureus.5728

    View details for PubMedID 31723492

    View details for PubMedCentralID PMC6825441

  • What Emergency Medicine Rewards: Is There Implicit Gender Bias in National Awards? Annals of emergency medicine Krzyzaniak, S. M., Gottlieb, M., Parsons, M., Rocca, N., Chan, T. M. 2019; 74 (6): 753?58

    Abstract

    Multiple studies have demonstrated a gender gap in the percentage of women recognized in national awards, but to our knowledge this gap has not been studied within emergency medicine. This study is designed to evaluate the presence of a gender gap in female representation in awards from national emergency medicine organizations in the United States and Canada.The awards from 5 national organizations during the past 5 years were reviewed. We developed a data extraction tool to identify and categorize the awards and recipients. Data were grouped according to gender distribution and assessed with respect to emergency medicine organization, year of award, category of award, and career phase specified by award.The overall percentage of female awardees across all 5 organizations from 2014 to 2018 was 28%. Only 16% of all named awards were named after women, and female awardees were more likely to be recognized early in their career for advocacy and work pertaining to the advancement of women, whereas men were favored for awards recognizing mentorship and organizational contributions.Emergency medicine is unique among other specialties in that the percentage of women represented in national awards (28%) closely mirrors the overall representation of women in emergency medicine (27.6% in the United States, 31% in Canada). This is in contrast to the documented leadership gap in academic medicine and emergency medicine, which may reflect a lag time between receiving national awards and earning academic and professional promotion. Although some organizations had significantly lower representation of female awardees, the overall trends indicate that women have closed the gender gap in award representation. This may signal a forthcoming change in other domains with established gaps in emergency medicine; specifically, in leadership and pay.

    View details for DOI 10.1016/j.annemergmed.2019.04.022

    View details for PubMedID 31229389

  • Curated Collections for Educators: Eight Key Papers about Feedback in Medical Education. Cureus Natesan, S. M., Krzyzaniak, S. M., Stehman, C., Shaw, R., Story, D., Gottlieb, M. 2019; 11 (3): e4164

    Abstract

    Feedback is an essential part of learning, growth, and academic success. Junior faculty members are often unfamiliar with the grounding literature that defines feedback. Many times they receive little education on providing and receiving feedback, resulting in unhelpful "feedback" for both learners and program leadership alike. This article aims to summarize eight key papers on feedback, to outline relevant information for emerging clinician educators, and identify ways to use these resources for the faculty development.  In order to generate a list of key papers that describes the importance and significance of feedback, the authors conducted a consensus-building process to identify the top papers. In August and September, 2018, the 2018-2019 Academic Life in Emergency Medicine (ALiEM) Faculty Incubator program discussed the topic of feedback in medical education. A number of papers on the topic was highlighted. This list of papers was further augmented using the suggestions and expertise of guest experts who are leaders in the field of medical education and feedback. The authors also used social media to conduct an open call on Twitter for important papers regarding feedback (utilizing #meded, #Feedback hashtags). Via this process, a list of 88 key papers was identified on the topic of feedback in medical education. After compiling these papers, the authorship group engaged in a modified Delphi approach to build consensus on the top eight papers on feedback. These papers were deemed essential by the authors and have been summarized with respect to their relevance to junior faculty members and to faculty developers. In this manuscript, we present eight key papers addressing feedback in medical education with discussions and applications for junior faculty members and faculty developers. This list of articles that can serve to help junior clinician educators grow in their ability to give effective feedback and also serve as resources upon which senior faculty can design the faculty development sessions.

    View details for DOI 10.7759/cureus.4164

    View details for PubMedID 31065470

    View details for PubMedCentralID PMC6497184

  • Curated Collections for Educators: Five Key Papers about Residents as Teachers Curriculum Development. Cureus Krzyzaniak, S. M., Cherney, A., Messman, A., Natesan, S., Overbeck, M., Schnapp, B., Boysen-Osborn, M. 2018; 10 (2): e2154

    Abstract

    The Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to prepare residents to teach and assess medical students and other learners. In order to achieve this, many programs develop formal residents as teachers (RAT) curricula. Medical educators may seek the guidance of previously published literature during the development of RAT programs at their institutions. The authors sought to identify key articles published on the subject of RAT programs over the last 10 years. The authors utilized a formal literature search with the help of a medical librarian and identified additional articles from virtual discussions among the author group and an open call for articles on Twitter using the hashtag #MedEd. Virtual discussions occurred within an online community of practice, the Academic Life in Emergency Medicine (ALiEM) Faculty Incubator. The lead author conducted a four-round modified Delphi process among the author group in order to narrow the broad article list to five key articles on RAT programs. The authors summarize each article and provide considerations for junior faculty as well as faculty developers. Curriculum development and program evaluation should utilize established frameworks and evidence-based approaches. The papers identified by this Delphi process will help faculty use best practices when creating or revising new RAT curriculum. In addition, faculty tasked with guiding junior faculty in this process or creating faculty development programs around curriculum development will find these articles to be a great resource for building content.

    View details for DOI 10.7759/cureus.2154

    View details for PubMedID 29637035

    View details for PubMedCentralID PMC5884573

  • Education Theory Made Practical Vol. 2 edited by Gottlieb, M., Chan, T. M., Krzyzaniak, S. M., Grossman, C., Robinson, D., Papanagnou, D. 2018
  • A qualitative study of medical educators' perspectives on remediation: Adopting a holistic approach to struggling residents. Medical teacher Krzyzaniak, S. M., Wolf, S. J., Byyny, R., Barker, L., Kaplan, B., Wall, S., Guerrasio, J. 2017; 39 (9): 967?74

    Abstract

    During residency, some trainees require the identification and remediation of deficiencies to achieve the knowledge, skills and attitudes necessary for independent practice. Given the limited published frameworks for remediation, we characterize remediation from the perspective of educators and propose a holistic framework to guide the approach to remediation.We conducted semistructured focus groups to: explore methods for identifying struggling residents; categorize common domains of struggle; describe personal factors that contribute to difficulties; define remediation interventions and understand what constitutes successful completion. Data were analyzed through conventional content analysis.Nineteen physicians across multiple specialties and institutions participated in seven focus groups. Thirteen categories emerged around remediation. Some themes addressed practical components of remediation, while others reflected barriers to the process and the impact of remediation on the resident and program. The themes were used to inform development of a novel holistic framework for remediation.The approach to remediation requires comprehensive identification of individual factors impacting performance. The intervention should not only include a tailored learning plan but also address confounders that impact likelihood of remediation success. Our holistic framework intends to guide educators creating remediation plans to ensure all domains are addressed.

    View details for DOI 10.1080/0142159X.2017.1332362

    View details for PubMedID 28562135

  • Transition of Care Practices from Emergency Department to Inpatient: Survey Data and Development of Algorithm. The western journal of emergency medicine Lee, S., Jordan, J., Hern, H. G., Kessler, C., Promes, S., Krzyzaniak, S., Gallahue, F., Stettner, T., Druck, J. 2017; 18 (1): 86?92

    Abstract

    We aimed to assess the current scope of handoff education and practice among resident physicians in academic centers and to propose a standardized handoff algorithm for the transition of care from the emergency department (ED) to an inpatient setting.This was a cross-sectional survey targeted at the program directors, associate or assistant program directors, and faculty members of emergency medicine (EM) residency programs in the United States (U.S.). The web-based survey was distributed to potential subjects through a listserv. A panel of experts used a modified Delphi approach to develop a standardized algorithm for ED to inpatient handoff.121 of 172 programs responded to the survey for an overall response rate of 70.3%. Our survey showed that most EM programs in the U.S. have some form of handoff training, and the majority of them occur either during orientation or in the clinical setting. The handoff structure from ED to inpatient is not well standardized, and in those places with a formalized handoff system, over 70% of residents do not uniformly follow it. Approximately half of responding programs felt that their current handoff system was safe and effective. About half of the programs did not formally assess the handoff proficiency of trainees. Handoffs most commonly take place over the phone, though respondents disagree about the ideal place for a handoff to occur, with nearly equivalent responses between programs favoring the bedside over the phone or face-to-face on a computer. Approximately two-thirds of responding programs reported that their residents were competent in performing ED to inpatient handoffs. Based on this survey and on the review of the literature, we developed a five-step algorithm for the transition of care from the ED to the inpatient setting.Our results identified the current trends of education and practice in transitions of care, from the ED to the inpatient setting in U.S. academic medical centers. An algorithm, which guides this process, is proposed to address the current gap in the standardized approach to ED to inpatient handoffs that were identified in the survey's assessment of needs.

    View details for DOI 10.5811/westjem.2016.9.31004

    View details for PubMedID 28116015

    View details for PubMedCentralID PMC5226771

  • Curated Collections for Educators: Five Key Papers about Program Evaluation. Cureus Thoma, B., Gottlieb, M., Boysen-Osborn, M., King, A., Quinn, A., Krzyzaniak, S., Pineda, N., Yarris, L. M., Chan, T. 2017; 9 (5): e1224

    Abstract

    The evaluation of educational programs has become an expected part of medical education. At some point, all medical educators will need to critically evaluate the programs that they deliver. However, the evaluation of educational programs requires a very different skillset than teaching. In this article, we aim to identify and summarize key papers that would be helpful for faculty members interested in exploring program evaluation. In November of 2016, the 2015-2016 Academic life in emergency medicine (ALiEM) Faculty Incubator program highlighted key papers in a discussion of program evaluation. This list of papers was augmented with suggestions by guest experts and by an open call on Twitter. This resulted in a list of 30 papers on program evaluation. Our authorship group then engaged in a process akin to a Delphi study to build consensus on the most important papers about program evaluation for medical education faculty. We present our group's top five most highly rated papers on program evaluation. We also summarize these papers with respect to their relevance to junior medical education faculty members and faculty developers. Program evaluation is challenging. The described papers will be informative for junior faculty members as they aim to design literature-informed evaluations for their educational programs.

    View details for DOI 10.7759/cureus.1224

    View details for PubMedID 28589073

    View details for PubMedCentralID PMC5453746

  • Academic Primer Series: Eight Key Papers about Education Theory. The western journal of emergency medicine Gottlieb, M., Boysen-Osborn, M., Chan, T. M., Krzyzaniak, S. M., Pineda, N., Spector, J., Sherbino, J. 2017; 18 (2): 293?302

    Abstract

    Many teachers adopt instructional methods based on assumptions of best practices without attention to or knowledge of supporting education theory. Familiarity with a variety of theories informs education that is efficient, strategic, and evidence-based. As part of the Academic Life in Emergency Medicine Faculty Incubator Program, a list of key education theories for junior faculty was developed.A list of key papers on theories relevant to medical education was generated using an expert panel, a virtual community of practice synthetic discussion, and a social media call for resources. A three-round, Delphi-informed voting methodology including novice and expert educators produced a rank order of the top papers.These educators identified 34 unique papers. Eleven papers described the general use of education theory, while 23 papers focused on a specific theory. The top three papers on general education theories and top five papers on specific education theory were selected and summarized. The relevance of each paper for junior faculty and faculty developers is also presented.This paper presents a reading list of key papers for junior faculty in medical education roles. Three papers about general education theories and five papers about specific educational theories are identified and annotated. These papers may help provide foundational knowledge in education theory to inform junior faculty teaching practice.

    View details for DOI 10.5811/westjem.2016.11.32315

    View details for PubMedID 28210367

    View details for PubMedCentralID PMC5305140

  • False-Negative FAST Examination: Associations With Injury Characteristics and Patient Outcomes ANNALS OF EMERGENCY MEDICINE Laselle, B. T., Byyny, R. L., Haukoos, J. S., Krzyzaniak, S. M., Brooks, J., Dalton, T. R., Gravitz, C. S., Kendall, J. L. 2012; 60 (3): 326-334

    Abstract

    Focused assessment with sonography in trauma (FAST) is widely used for evaluating patients with blunt abdominal trauma; however, it sometimes produces false-negative results. Presenting characteristics in the emergency department may help identify patients at risk for false-negative FAST result or help the physician predict injuries in patients with a negative FAST result who are unstable or deteriorate during observation. Alternatively, false-negative FAST may have no clinical significance. The objectives of this study are to estimate associations between false-negative FAST results and patient characteristics, specific abdominal organ injuries, and patient outcomes.This was a retrospective cohort study including consecutive patients who presented to an urban Level I trauma center between July 2005 and December 2008 with blunt abdominal trauma, a documented FAST, and pathologic free fluid as determined by computed tomography, diagnostic peritoneal lavage, laparotomy, or autopsy. Physicians blinded to the study purpose used standardized abstraction methods to confirm FAST results and the presence of pathologic free fluid. Multivariable modeling was used to assess associations between potential predictors of a false-negative FAST result and false-negative FAST result and adverse outcomes.During the study period, 332 patients met inclusion criteria. Median age was 32 years (interquartile range 23 to 45 years), 67% were male patients, the median Injury Severity Score was 27 (interquartile range 17 to 41), and 162 (49%) had a false-negative FAST result. Head injury was positively associated with false-negative FAST result (odds ratio [OR] 4.9; 95% confidence interval [CI] 1.5 to 15.7), whereas severe abdominal injury was negatively associated (OR 0.3; 95% CI 0.1 to 0.5). Injuries to the spleen (OR 0.4; 95% CI 0.24 to 0.66), liver (OR 0.36; 95% CI 0.21 to 0.61), and abdominal vasculature (OR 0.17; 95% CI 0.07 to 0.38) were also negatively associated with false-negative FAST result. False-negative FAST result was not associated with mortality (OR 0.89; 95% CI 0.42 to 1.9), prolonged ICU length of stay (relative risk 0.88; 95% CI 0.69 to 1.12), or total hospital length of stay (relative risk 0.92; 95% CI 0.76 to 1.12). However, patients with false-negative FAST results were substantially less likely to require therapeutic laparotomy (OR 0.31; 95% CI 0.19 to 0.52).Patients with severe head injuries and minor abdominal injuries were more likely to have a false-negative than true-positive FAST result. On the other hand, patients with spleen, liver, or abdominal vascular injuries are less likely to have false-negative FAST examination results. Adverse outcomes were not associated with false-negative FAST examination results, and in fact patients with false-negative FAST result were less likely to have a therapeutic laparotomy. Further studies are needed to assess the strength of these findings.

    View details for DOI 10.1016/j.annemergmed.2012.01.023

    View details for Web of Science ID 000308620500014

    View details for PubMedID 22512989

  • Completed suicides in Colorado: differences between Hispanics and non-Hispanic Whites. Suicide & life-threatening behavior Betz, M. E., Krzyzaniak, S. M., Hedegaard, H., Lowenstein, S. R. 2011; 41 (4): 445?52

    Abstract

    All suicides by Hispanics (n = 434) and non-Hispanic Whites (n = 3,370) in Colorado from 2004 to 2008 using the Violent Death Reporting System were examined. Hispanic victims were significantly younger. Adjusting for age and gender, Hispanic victims were less likely to have reported depressed mood [odds ratio (OR) 0.78; 95% confidence interval (CI) 0.63-0.97], mental health diagnosis (OR 0.53; 95% CI 0.41-0.7), or current psychiatric treatment (OR 0.47; 95% CI 0.43-0.77). There were no differences in reports of financial, relationship, job, or legal stresses. Hispanic suicides were equally likely to be by overdose, firearm, or hanging, but more likely to be in jail (OR 2.68; 95% CI 1.55-4.65). To prevent suicides, stronger partnerships are needed among public health, medical, mental health, and criminal justice professionals.

    View details for DOI 10.1111/j.1943-278X.2011.00044.x

    View details for PubMedID 21631574

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