Is my MRI accurate? Is it Reliable?
Ross Hauser, MD
MRI or Magnetic Resonance Imaging is a science of rapidly developing technology. Every day new wonders are discovered. So when commenting on current MRI accuracy, one needs to make sure that the latest research is cited to give accurate updates. This helps us answer patients’ questions on MRI accuracy.
- Abnormal MRIs did not always display an abnormality causing pain.
- “Magnetic resonance imaging (MRI) is commonly used for diagnosis and as a research tool, but its accuracy is questionable.”
- After the MRI only 1 out of 6 received appropriate treatment.
- MRI confirms what you already told your doctor, you have knee pain.
- Research says 43% of Knee MRIs are arguably useless.
- Prior surgery and cartilage volume are problems typically seen with MRI accuracy.
- Weight-bearing MRI of the knee – is the upright MRI better?
- CT Scan better for Patellofemoral pain?
- MRI accuracy in ACL readings.
- What do researchers say about going to ACL surgery? Let a doctor examine your knee NOT the MRI.
- False positives sending the British sailors to surgery.
- MRI will send you to knee replacement, a doctor after physical examination may have other thoughts.
- The study interpretation cast doubts that MRI technology is actually helping the patient’s situation.
- MRI or physical examination? A comparison study.
- MRI or Ultrasound for knee injuries?
- Ankle MRIs.
- In some cases, MRI delivers insufficient results
- How can talking and taking a patient history be more effective than technology in preventing spinal surgery.
Let’s start then with an April 2022 study
Let’s start then with an April 2022 study in the Annals of physical and rehabilitation medicine (1) from La Trobe University researchers in Australia. In this paper the researchers addressed the problem of what an MRI shows and its relevance to the pain the patient feels. Here is what they wrote:
“Assessment of pain location is an essential component of the differential diagnosis of knee pain because pain location is thought to indicate pathology. (If you can find out where the pain is coming from accurately, you can diagnosis it and treat it). Previous studies have questioned whether abnormal (MRI) imaging findings are related to the presence of pain, but none has systematically reviewed the association between knee pain location and the location of abnormal imaging or arthroscopic findings.” In other words, a patient has knee pain and they get and MRI. The patient then has knee arthroscopy surgery. There is limited research comparing the MRI to what was found during surgery. The reason for doing this is to assess the MRI findings.
Objective: To systematically review the association between the location of knee pain and the location of abnormal imaging or arthroscopic findings.
- There were 2034patients in this study. The MRIs and arthroscopic surgery assessments of patellar tendinopathy, knee osteoarthritis, and degenerative meniscal tears.
- Pain location was not associated with the location of abnormal imaging findings in knee osteoarthritis or to abnormal arthroscopic findings in degenerative meniscus tears.
Summary: Abnormal MRIs did not always display an abnormality causing pain.
“Magnetic resonance imaging (MRI) is commonly used for diagnosis and as a research tool, but its accuracy is questionable.”
The difference between a patient history and an MRI is that the MRI can be interpreted subjectively, open to interpretation, and often be a “roadblock,” in helping the patient heal. Our patients are incredibly well educated when it comes to pain. Good patient histories are more important than looking at films. Some of the most common surgeries, such as arthroscopy for meniscal tears, are based on MRI findings, which have an increasingly high percentage of false-positive rates as we age.
MRI does not match up well with arthroscopic discoveries in meniscus tears. In support of the above findings, previous research also noted problems with MRI revealing the true nature of the patent’s problems.
In April 2021, doctors writing in the Australian and New Zealand Journal of Surgery (2) wrote: “Magnetic resonance imaging (MRI) is commonly used for diagnosis and as a research tool, but its accuracy is questionable.” They further wrote that the goal of their study was to compare the accuracy of knee MRI with clinical (in surgery) assessment for diagnosing meniscal tears and to determine the accuracy of MRI for grading chondral lesions. What did they find? “MRI has relatively poor correlation with arthroscopic findings for grading the chondral damage and was less accurate than clinical assessment for the diagnosis of lateral meniscal tears.”
When discussing MRI accuracy or reliability, people will often point to the age of the study. Why? because there is a belief that technology is moving so rapidly that anything more than a few years, months, or even weeks old is already outdated. That is a misnomer. Look at this recent research and we will bring it current.
After the MRI only 1 out of 6 received appropriate treatment.
A July 2021 paper published in the BMJ open quality (22) suggested a problem with overreliance of MRIs in the United Kingdom. As you can see from the associated research presented here, a very similar problem to that seen here in the United States. In this study the researchers saw that the musculoskeletal injury or pain was the cause for the largest proportion of general practitioner recommended magnetic resonance imaging (MRI). This comes still with “limited supporting evidence and potential harms from early imaging overuse.” In other words, too many MRIs too many unneeded surgeries, too many instances where the patient’s situation was made worse.
Here are some of the summary points:
- Only 4.9% of ordered MRIs appeared to be clearly indicated and only 16.0% received appropriate prior therapy.
- Take home point: 19 out of 20 people were sent to get an MRI that was not clearly needed or indicated. Of these people, after the MRI only 1 out of 6 received appropriate treatment.
- 37.0% documented patient imaging request. (The patient demanded the MRI).
- The researchers noted that most had chronic symptoms, pain and disability, and half had psychosocial flags (catastrophizing being one). Mental health was addressed in only 11.8% of chronic sufferers with psychiatric illness, suggesting a solely pathoanatomical approach (mental wellbeing not addressed) to musculoskeletal care.
- Only 7.8% of all patients were appropriately managed without additional referral.
- 1.3% of scans revealed diagnoses leading to change in treatment (therapeutic yield).
- Take home point: If 1000 people have an MRI, only 13 will have a treatment alteration.
- Most imaged patients received pathoanatomical explanations to their symptoms, often based on expected age or activity-related changes.
- Only 16.7% of results appeared correctly interpreted by general practitioner, with spurious over-perception of surgical targets in 65.4% who suffered ‘low-value’ (ineffective, harmful or wasteful) post-MRI referral cascades due to misdiagnosis and overdiagnosis.
- Typically, 20%-30% of general practitioner specialist referrals convert to a procedure, whereas MRI-triggered referrals showed near-zero conversion rate.
MRI confirms what you already told your doctor, you have knee pain.
In September 2017, doctors at Yale-New Haven Health at Bridgeport Hospital and Boston University School of Medicine write in the journal Radiologic Clinics of North America (3) that:
- With technological advances and the availability of sophisticated computer software and analytical strategies, imaging plays an increasingly important role in understanding the disease process of osteoarthritis.
- Radiography has limitations in that it can visualize only limited features of osteoarthritis, such as osteophytes (bone spurs) and joint space narrowing, but remains the most commonly used modality for establishing an imaging-based diagnosis of osteoarthritis.
- The clinical relevance of MRI findings related to osteoarthritic joints remains unclear due to the high prevalence in asymptomatic patients.
In other words, MRIs are showing damage that do not cause pain in the patient.
In a 2016 study doctors writing in the Archives of Physical Medicine and Rehabilitation (4) made this observation: (we saw) evidence that weight-bearing MRI evaluations based on (current) imaging protocols are compatible with patients reporting mild to moderate knee osteoarthritis-related pain.
The simple understanding of that research is: A patient reports knee pain, a doctor sends him/her to get an MRI. The finding? MRI confirms what you told your doctor, you have knee pain. This is the kind of research that indirectly confirms research like this: 43% of Knee MRIs are arguably useless.
Ross Hauser, MD discusses some very common MRI findings in asymptomatic patients and why MRI can lead to surgery even when that may not be the true pain-producing structure.
Research says 43% of Knee MRIs are arguably useless
What are we seeing in this image?
The MRI is demonstrating confusion. As noted in this MRI report, surgical changes are demonstrated in medial meniscus with smaller than the expected size of the body of medial meniscus altered signal intensity in body and posterior horn of medial is extending to inferior articular surface demonstrates similar appearance to previous outside MRI to see the represents residual changes from prior surgery and meniscus tear or recurrent are persistent from prior examination. Now, what does this mean?
MRI of the knee without contrast noted or changes in the medial meniscus. Even the radiologist cannot determine whether this represents recurrent meniscus tear or is just post-surgical changes.
Prior surgery and cartilage volume are problems typically seen with MRI accuracy
In July 2017 doctors at Queen Elizabeth Hospital in the United Kingdom and the University Medical Centre, Rotterdam, The Netherlands write in the European Journal of Orthopaedic Surgery and Traumatology: (5)
The assessment of a patient with chronic hip pain can be challenging. Magnetic resonance imaging (MRI) arthrography of the hip has been widely used now for the diagnosis of articular pathology of the hip. Our study conclusions are MRI arthrogram is a useful investigation tool in detecting hip labral tears, it is also helpful in the diagnosis of femoro-acetabular impingement. However, when it comes to the diagnosis of osteoarthritis’ chondral changes, defects, and cartilage delamination, the sensitivity and accuracy are low.
In the above illustration, we demonstrated the difficulty in understanding what was going on in this patient’s knee. Was the meniscus damage from previous surgery or the continued and new degenerative changes in the knee?
Let’s look at 2019 study researchers at Loma Linda University Medical Center, Wake Forest University Baptist Medical Center, Penn State Health Milton S. Hershey Medical Center published in the journal Clinical medicine insights. Arthritis and musculoskeletal disorders. (6)
“Over the past decade, the use of magnetic resonance imaging (MRI) as a diagnostic tool has been increasing significantly in various fields of medicine due to its wide array of applications. As a result, its diagnostic efficacy and reliability come into question. Specifically, in the field of orthopedics, there has been little discussion on the problems many physicians face while using MRIs in practice.
To gauge the perceived limitations of MRI, (the researchers) designed a study to assess the utility of MRIs and estimate the number of inconclusive MRIs ordered within an orthopedic practice to explore potential alternative avenues of diagnosis. A survey was given to 100 board-certified practicing orthopedic surgeons asking about the value, reliability, and diagnostic utility of MRIs in preoperative planning in shoulder and knee surgery.
Of those surveyed, 93% reported that there was believed to be a problem with the accuracy of an MRI in the setting of prior surgery and/or if previous hardware was present specifically pertaining to the knee or shoulder. (Prior surgery would limit the diagnostic accuracy including hardware distortions). The surgeons also questioned the problems of identifying cartilage defects.
In addition, when asked how many MRIs were believed to be inconclusive based on previous surgery/hardware alone in the last 6 months of practice, an average of 19 inconclusive MRIs was reported by each of the 100 surgeons.
In 2015 doctors at leading medical universities in South Korea were published in the medical journal Knee Surgery and Related Research. (7) The paper reviewed 185 knee MRIs and evaluated them as:
- too difficult to interpret,
- and arguably useless as a means of recommending a treatment program.
- 43% were useless
- 18% were too difficult to interpret
- 39% were useful especially when it came to obvious injury as in sports injury and advanced degenerative joint disease.
The conclusion of this research:
- approximately one-quarter of patients visiting a knee clinic (after visiting other clinics) had pre-obtained knee MRI (came to the clinic with an MRI).
- The doctors at the clinic viewed the MRIs and deemed more than 40% of them useless in selecting treatment options.
- In particular, knee MRI was less likely to be useful in patients with degenerative joint disease or nonspecific knee pain.
- This study suggests clinicians need to reconsider and consult with patients on the expected usefulness of knee MRI in making the correct diagnosis and selecting proper treatment options before getting an MRI.
The above research should not be particularly shocking to a patient with chronic knee pain. We see many patients with MRIs, and for many of those patients, the MRI has failed to come up with a good treatment plan for them. That is why they are visiting us.
Not shocking, it agrees with early research published in 2014 (8) from Mount Sinai Hospital and Women’s College Hospital researchers who say while knee MRI is highly accurate in the evaluation of internal derangements (structural damage) of the knee, a variety of potential pitfalls in the interpretation of abnormalities related to the knee have been identified, particularly in the evaluation of the meniscus, ligaments, and articular cartilage.”
In other words – the MRI pointed out the obvious, but it had difficulty pointing out the less obvious. It could not offer help if the image was too difficult to interpret, or were of no use at all for recommending a treatment plan.
One of the most common things that we hear from potential patients is:
I have this chronic pain but my MRI and/or X-ray says that everything is normal. What’s going on? What we often see when those patients come to our office and we do an evaluation is even though their MRI may be normal we actually can pick up on joint instabilities and ligament laxity is with ultrasound evaluation
MRIs are often done with you laying down with you being as still as possible to get these images so if you’re someone that maybe has no pain laying down but a lot of pain with stairs or with walking or with tennis it may not give us all the information that we need again because you are not moving, you are in your painless position.
Whereas ultrasound evaluation allows us to move the joint while we’re evaluating the soft tissue of that joint. Ultrasound also allows us and the patient to see the problems in real-time. So the patient can see their examination in real-time and for instance, compare the “bad” knee to the “good” or “not so bad knee.”
Weight-bearing MRI of the knee – is the upright MRI better?
A January 2018 review study in the journal Acta Biomedica (9) suggested that despite several limitations (typical of MRI, one is that they are static), imaging in non-recumbent position under physiological stress allows detection of load-induced physiological and pathological variations (Simply, by standing up you can see how the weight of the patient is causing stress on the knee). The most relevant results up to date showed that this new diagnostic instrument allows recognizing both the meniscal tear stability and a latent instability, making it possible to correctly guide the orthopedic surgeon towards the treatment management. (This is seen as being helpful to understand how to proceed with surgery). Moreover, upright MRI allows to accurately understand patellofemoral kinematics during painful activities, helping to differentiate mal-trackers from non-maltrackers and to improve treatment for patellofemoral pain.
CT Scan better for Patellofemoral pain?
In a September 2020 study (10) on knee multi-position CT images, researchers from Ewha Woman’s University in Seoul, Korea teamed with researchers from the Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Stanford University to assess the benefits of CT scans of the knee in Patellofemoral pain patients to compare weight-bearing images to non-weight-bearing images. Three images were taken. Non-weight bearing flat on the back. Standing knee straight Squatting at 30-degree angle. The findings were that when the CT scans in all three positions had their readings combined a description of the patient’s patella problems were better understood by way of patellar motion and patella tracking.
MRI accuracy in ACL readings
In a 2015 study, (11) University researchers in Turkey published their research calling into question MRI accuracy in ACL readings.
They found that ACL damage in degenerated knees was much more difficult to determine than an acute injury and in fact were:
- Moderately successful in GRADE 1 damage – intact ligament;
- POOR for Grade 2, partial tear with less than half of the ligament substance disrupted;
- POOR for Grade 3, partial tear with more than half of the ligament substance disrupted;
- FAIR for Grade 4, complete tear.
The researchers concluded: “In cases where there is uncertainty regarding ACL integrity in degenerative knees, although standard MRI provides additional information on ACL status, it is not of sufficient diagnostic value.”
So as you can see an MRI can sometimes be detrimental to designing a treatment program for the patient, especially a surgical treatment program.
What do researchers say about going to ACL surgery? Let a doctor examine your knee NOT the MRI
We usually advise new patients that we do not require an MRI before his/her visit as when they do come in we will do a physical examination and talk to them about their pain challenges. Asking the patient questions about their pain has always been a primary component of our initial consultation. Now it is considered a sound scientific device in recent research comparing taking a patient history to MRI accuracy.
Doctors in Korea writing in BioMed Central Musculoskeletal Disorders (12) examined whether MRI findings are of value in predicting the degree of knee joint laxity as measured using two typical physical examinations, i.e., the Lachman (physical manipulation to test the laxity of the ACL) and pivot shift tests (physical manipulation to test the ACL and PCL Posterior Cruciate Ligament).
- They concluded that their analysis of the associations between MRI findings and the grade on physical examinations in patients with symptomatic ACL injury suggests that MRI has limited value for predicting the grade of laxity.
False positives sending the British sailors to surgery
Now here is another study on the problems of surgery selections based on MRIs. This comes from doctors of the British Navy publishing in their Journal of the Royal Naval Medical Service. (13)
- False-positive MRI scans may lead to unnecessary surgery for meniscus damage.
- The false-positive patients who went to surgery prevented those with real meniscal tears from getting more prompt surgery because of a backlog.
- And by the way, the false-positive patients should have never been sent to surgery.
- It is also important for the surgeon to review the MRI scan itself, as well as the report. (Some surgeons did not even look at the MRI).
MRI will send you to knee replacement, a doctor after physical examination may have other thoughts
Getting back to the discussion of MRI for knee osteoarthritis and the subsequent use of MRI imaging to send patients to possible unnecessary knee replacement surgery, we find that a lot of research suggests that the decision to have knee replacement surgery should be made after a physical examination and consultation. Unfortunately many times the decision is left to the interpretation of a scan or X-ray that may not provide the doctor with an accurate assessment.
Late 2012 and 2013 research recommended to doctors that the determination of a patient’s knee pain was best left in the hands of an experienced examining physician – as opposed to patient scans. Before you say to yourself, this study is ten years old, we remind you that the research presented in this article that is supportive of these finding are from the last year or two.
The study interpretation cast doubts that MRI technology is actually helping the patient’s situation
Writing in the medical journal Arthritis, (14) doctors in Turkey wrote:
“The use of MRI techniques to investigate tissue pathology (damage) has become increasingly widespread in osteoarthritis research. Semiquantitative assessment (this is defined as non-precise – or subject to interpretation) of the joints by expert interpreters of MRI data is a powerful tool that can increase our understanding of the natural history of this complex disease.
Several reliable and validated semiquantitative scoring systems now exist and have been applied to large-scale, multicentre, cross-sectional, and longitudinal observational epidemiological studies.
Such approaches have advanced our understanding of the associations of different tissue pathologies with pain and improved the definition of joint alterations that lead to disease progression. . . Although these new scoring systems offer theoretical advantages over pre-existing systems, whether they offer actual superiority with regard to reliability, responsiveness and validity remain to be seen.”
The study interpretation cast doubts that the latest MRI technology is actually helping the patient’s situation. In other research, MRI-based diagnosis was given another setback when doctors summarized: “Knee pain, stiffness, and duration of disease may affect the level of disability in the patients with knee osteoarthritis. Therefore treatment of knee osteoarthritis could be planned according to the clinical features and functional status instead of radiological findings.”
- The interpretation of the research suggests that it is better to ask the patient what hurts them as compared to telling them what hurts them based on scans.
In both our opinion and that of certain researchers, physical examination and patient history are superior to the current MRI technology.
MRI or physical examination? A comparison study
Research from Boston University School of Medicine (15) suggests that assessing the patient’s symptoms through a physical examination is likely to be more informative for understanding, treating, and potentially preventing functional limitations than radiographic assessments in osteoarthritic patients.
In looking at the widespread use of MRI to identify joint disease, the study says that semiquantitative assessment (which is a non-precise – subject to interpretation reading) of the joints by expert interpreters of MRI data is a powerful tool that can increase understanding of joint disease in osteoarthritis.
Using a tried and testing scoring system for different joint diseases, doctors can precisely diagnose problems of the joint as seen on the MRI. BUT, the researchers warn – it is still not accurate!
“Although these new scoring systems offer theoretical advantages over pre-existing systems, whether they offer actual superiority with regard to reliability, responsiveness and validity remain to be seen.”
The entire study points to the use of MRI as a valuable tool until the end, which states, in theory, this should work, but that remains to be seen. In other words – there is a doubt that the latest in MRI enhancements help the patient’s situation.
Supporting this finding is another research paper: Incredibly the paper cites that there is not much by way of published literature to help a doctor to have a proper consultation.
Listen to what Arthritis Research United Kingdom Primary Care Centre doctors had to say:(16)
“Osteoarthritis is a common condition managed in general practice, but often not in line with published guidance. The ideal consultation for a patient presenting with possible Osteoarthritis is not known. The aim of the study was to develop the content of a model Osteoarthritis consultation for the assessment and treatment of older adults presenting in general practice with peripheral joint problems.”
There is a lack of consensuses of how to perform the proper consultation in determining how to help a patient. Here is what these researchers came up with: The model Osteoarthritis consultation included 25 tasks to be undertaken during the initial consultation between the doctor and the patient presenting with peripheral joint pain. The 25 tasks provide detailed advice on how the following elements of the consultation should be addressed:
- assessment of chronic joint pain,
- patient’s ideas and concerns,
- exclusion of red flags,
- provision of the diagnosis and written information,
- promotion of exercise and weight loss,
- initial pain management and
- arranging a follow-up appointment.
This study has enabled the priorities of the doctors and patients to be identified for a model Osteoarthritis consultation.
The study did not say – look at the film and treat.
MRI or Ultrasound for knee injuries?
A December 2021 paper (21) from radiologists at Ain Shams University in Cairo examined and tested the diagnostic reliability of a knee ultrasound for the evaluation of meniscus and collateral ligaments damage. They then compared these results with a knee MRI. The research team introduced their study in this way: “Although magnetic resonance imaging (MRI) is often the “gold standard” for diagnosing knee problems, it has many limitations. Therefore, ultrasonography has been suggested as an effective rapid alternative in many knee abnormalities, especially after injuries of the meniscus and collateral ligaments.”
The researchers found slightly better readings for overall accuracy in the ultrasounds.
- Ultrasound overall accuracy for the assessment and diagnosing of meniscus injuries compared to MRI (91.7% vs. 88.3%).
- Ultrasound overall accuracy for the assessment and diagnosing of collateral ligament injures (96.7% vs. 93.3%).
Doctors at The Steadman Philippon Research Institute wrote in the medical journal Foot and Ankle International examined MRI readings in the ankle. Doctors looked at a group of patients: (17)
- 95% reported pain as the primary reason for seeking medical attention
- 44% reported instability
- 42% loss of function
Also, almost as a sub-note, it was reported that 39% reported previous ankle surgery. Since these patients were seeking relief of pain it can be assumed that these were failed ankle surgeries.
The researchers noted that following a radiographic reading and confirmation by arthroscopic surgery – most of the false positives could be eliminated BUT “a high index of suspicion should be maintained in the appropriate clinical setting.”
One could give an opinion that MRI and surgical confirmation must be balanced and checked by a physical examination in the clinical setting. One could also ask the question – why not just get the physical examination in the first place and put off the MRI and arthroscopic intervention?
In some cases, MRI delivers insufficient results
In July 2018 doctors writing in the journal Knee Surgery, Sports Traumatology, Arthroscopy (18) tried to determine the reliability and validity of preoperative magnetic resonance imaging (MRI) scan for the detection of additional pathologies in patients with chronic ankle instability compared to arthroscopic findings. To do this they looked at thirty patients. What did they find in these thirty patients?
“In total, 72 additional pathologies were found arthroscopically compared to 73 lesions gathered from MRI images. (The amount missed were equal to the amount found on MRI – 50%). . . Chronic ankle instability is associated with a high incidence of additional pathologies. In some cases, MRI delivers insufficient results, which may lead to misinterpretation of present comorbidities. MRI is a helpful tool for preoperative evaluation, but arthroscopy remains gold standard in the diagnosis of associated lesions in patients with chronic ankle instability.”
How can talking and taking a patient history be more effective than technology in preventing spinal surgery
In our article, Is your MRI sending you to a back surgery you do not need? we seek to offer one simple piece of information. Your MRI may be sending you to a spinal surgery you do not need. We support this simple idea with a lot of research and our observations in the many patients we have seen after failed back surgery syndrome. Please visit that article for a comprehensive understanding of the role of MRIs in back surgery preparation.
How can talking and taking a patient’s history be more effective than technology in preventing spinal surgery? For one thing, a doctor has to ask the right questions and do a little investigation. When you ask the right questions you get “significant diagnostic value,” as reported in the new medical literature on the diagnostic accuracy of history taking to assess lumbosacral nerve root compression. (19)
Why is talking to a patient considered a “significant diagnostic value,” because a lot of the other diagnostic methods DON’T WORK.
In trying to determine the best testing methods for spinal fusion surgery success prior to the surgery, investigators had this to say:
Spinal fusion is a common but controversial treatment for chronic low back pain. In an effort to test whether any pre-fusion test could be performed to increase satisfactory surgeries and make fusion less controversial, different diagnostic tests including MRI were examined. In the end, no tests in patients with chronic low back pain could be identified for whom spinal fusion is a predictable and effective treatment.
Best evidence does not support the use of current tests for patient selection in clinical practice. (20)
Please see this article on Failed Back Surgery Risks In this article I explain why MRI readings may lead to INCREASED incidents of failed back surgery syndrome.
The difference between a patient’s history and an MRI is that the MRI can be interpreted subjectively, open to interpretation, and often be a “roadblock,” in helping the patient heal. Our patients are incredibly well educated when it comes to their pain. That is why we think it is better to talk than look at films.
Summary and contact us. Can we help you?
We hope you found this article informative and it helped answer many of the questions you may have surrounding issues with MRIs. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
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This article was updated July 22, 2022