Indian Journal of Critical Care Medicine

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2020 | March | Volume 24 | Issue 3

EDITORIAL

Is It All Clear if Procalcitonin Clears in Acute Pancreatitis?

[Year:2020] [Month:March] [Volume:24] [Number:3] [Pages:2] [Pages No:149 - 150]

PDF  |  DOI: 10.5005/jp-journals-10071-23388  |  Open Access |  How to cite  | 

EDITORIAL

Ananya Saha

Trigger Tools for Adverse Drug Events: Useful Addition to the Quality Tool Box

[Year:2020] [Month:March] [Volume:24] [Number:3] [Pages:2] [Pages No:151 - 152]

PDF  |  DOI: 10.5005/jp-journals-10071-23393  |  Open Access |  How to cite  | 

EDITORIAL

Praveen G Kumar

Know Thy Ulcers!!!

[Year:2020] [Month:March] [Volume:24] [Number:3] [Pages:2] [Pages No:153 - 154]

PDF  |  DOI: 10.5005/jp-journals-10071-23389  |  Open Access |  How to cite  | 

Original Article

R Ravichandran, Deepak Amalnath, Kusa K Shaha, BH Srinivas

Paraquat Poisoning: A Retrospective Study of 55 Patients From a Tertiary Care Center in Southern India

[Year:2020] [Month:March] [Volume:24] [Number:3] [Pages:5] [Pages No:155 - 159]

Keywords: Paraquat, Paraquat poisoning, Toxicology

PDF  |  DOI: 10.5005/jp-journals-10071-23369  |  Open Access |  How to cite  | 

Abstract

Background: In India the data on paraquat (PQ) poisoning are limited to case reports and small case series. Hence, this study was carried out to understand the clinical features and outcomes of PQ poisoning. We also briefly report the relevant Indian studies on PQ poisoning. Materials and methods: This was a retrospective case record-based study of PQ poisoning victims admitted over a period of 5 years. Results: Of the 55 patients included in this study, the in-hospital mortality rate was 72.7%. Acute kidney injury was the most common manifestation. The use of cyclophosphamide did not affect the clinical outcome. Hemoperfusion (HP) was not done for any patient. Pulmonary edema and acute tubular necrosis were the most common histopathological findings. Conclusion: In India, this is one of the most comprehensive studies of PQ toxicity. Hence, we hope that this information would be of use to clinicians who deal with PQ poisoning.

Original Article

Divya Gupta, Anju R Bhalotra, Rahil Singh

Audit on Practices of Stress Ulcer Prophylaxis in Intensive Care Unit Patients

[Year:2020] [Month:March] [Volume:24] [Number:3] [Pages:8] [Pages No:160 - 167]

Keywords: Critical care, H2 receptor locker, Proton pump inhibitor, Stress ulcer bleeding, Sucralfate

PDF  |  DOI: 10.5005/jp-journals-10071-23368  |  Open Access |  How to cite  | 

Abstract

Background: This audit was aimed at studying current practices regarding the use of stress ulcer prophylaxis (SUP) in the Indian critical care setup, with the background aim of raising awareness regarding the use and indications of SUP in critically ill patients. Materials and methods: After registering the trial with the clinical trial registry, India, a structured audit questionnaire containing 26 questions pertaining to SUP was distributed through electronic media among clinicians working in the intensive care units (ICUs) across India. Responses obtained were statistically analyzed. Results: The questionnaire was sent to 550 clinicians. Only 197 responded, of whom 91.4% were anesthesiologists, 5.6% were physicians, and 3% were intensivists. The audit revealed that 33% respondents were unaware of the existing SUP guidelines and around 32% did not have protocols for SUP in their ICU. Sixty-nine percent of respondents felt that all ICU patients must receive SUP and 44.7% opined that it should be started on ICU arrival. Almost 94% knew that early enteral feeding is protective against stress ulceration. Only 24.9% responders agreed that there must be clear indications for SUP, and most of them were unaware of all the potential side effects. Once initiated, 43.7% respondents would stop prophylaxis when no indication was left, whereas 69 respondents would stop on ICU discharge. Conclusion: There is a lack of awareness regarding initiation, choice of agent, adverse effects as well as termination of SUP in ICU and guidelines for the same. Institutional protocols should be in place and steps need to be taken to prevent unwarranted use.

Original Article

Poorna Priya, T Rajendran, VG Geni

Mucormycosis in a Tertiary Care Center in South India: A 4-Year Experience

[Year:2020] [Month:March] [Volume:24] [Number:3] [Pages:4] [Pages No:168 - 171]

Keywords: Amphotericin B, Mucorales, Surgical debridement

PDF  |  DOI: 10.5005/jp-journals-10071-23387  |  Open Access |  How to cite  | 

Abstract

Background: Mucormycosis is an emerging fungal infection in both developed and developing countries with different target population. Unusual isolates and unusual clinical presentations have been reported from India in recent times. Objectives: The present study was done to know the epidemiology, risk factors, diagnostic modalities, and treatment outcome of mucormycosis patients in our hospital. Materials and methods: The study was carried out over a period of 4 years from October 2015 to October 2019. This is a retrospective observational chart review of patients diagnosed with proven and probable mucormycosis. Information on demography, clinical features, risk factors, laboratory and radiological findings, treatment (including medical and surgical treatment), and outcome was extracted from the records. Primary outcome at 42 days was determined. Results: Thirty-eight patients were diagnosed with mucormycosis based on microbiological and/or histopathological examination (HPE) of the clinical samples. Most commonly affected age-group was between 41 years and 60 years. More number of cases were reported during the months of post rainy season (September to December). A large number of patients (77%) presented with uncontrolled diabetes mellitus. Rhino-orbito-cerebral mucormycosis was the most common presentation followed by cutaneous infection. Antifungal treatment was started in around 80% of the cases. Twenty patients were managed by combined medical and surgical intervention. Eight patients died while the outcome of nine was unknown, as they left the hospital against medical advice and could not be followed up. Conclusion: Mucormycosis, an insidious killer, should be an important differential diagnosis in progressive soft tissue infections and deep organ infection.

RESEARCH ARTICLE

Amee D Pandya, Kalan Patel, Devang Rana, Sapna D Gupta, Supriya D Malhotra, Pankaj Patel

Global Trigger Tool: Proficient Adverse Drug Reaction Autodetection Method in Critical Care Patient Units

[Year:2020] [Month:March] [Volume:24] [Number:3] [Pages:7] [Pages No:172 - 178]

Keywords: Adverse drug reactions, Emergency department, Pharmacovigilance, Trigger tool

PDF  |  DOI: 10.5005/jp-journals-10071-23367  |  Open Access |  How to cite  | 

Abstract

Background: Emergency department (ED) being the most crucial part of hospital, where adverse drug reactions (ADRs) often go undetected. Trigger tools are proficient ADR detection methods, which have only been applied for retrospective surveillance. We did a prospective analysis to further refine the trigger tool application in healthcare settings. Objective: To estimate the prevalence of ADRs and prospectively evaluate the importance of using trigger tools for their detection. Materials and methods: A prospective study was conducted in the ED for the presence of triggers in patient records to monitor and report ADRs by applying the Institute for Healthcare Improvement (IHI) trigger tool methodology. Results: Four hundred sixty-three medical records were analyzed randomly using 51 trigger tools, where triggers were found in 181 (39.09%) and ADRs in 62 (13.39%) patients. The prevalence of ADR was 13.39%. According to the World Health Organization (WHO)-Uppsala Monitoring Centre (UMC) causality scale, 47 (75.8%) were classified as probable and 15 (24.2%) as possible, wherein 39 (62.9%) were predictable and 8 (12.9%) were definitely preventable. Most common triggers were abrupt medication stoppage (34.98%), antiemetic use (25.91%), and time in ED >6 hours (17.49%). The positive predictive values (PPVs) of triggers such as international normalized ratio (INR) > 4 (p = 0.0384), vitamin K administration (p = 0.002), steroid use (p = 0.0001), abrupt medication stoppage (p = 0.0077), transfusion of blood or blood products (p = 0.004), and rash (p = 0.0042) showed statistically significant results, which make the event detection process more structured when these triggers are positive. Presence of five or more triggers has statistically significant chances of developing an ADR (p < 0.05). Conclusion: Trigger tool could be a viable method to identify ADRs when compared to the traditional ADR identification methods, but there is insufficient data on IHI tool and its use to identify ADRs in the general outpatient setting. Healthcare providers may benefit from better trigger tools to help them detect ADRs.

RESEARCH ARTICLE

Srikar Adhikari, Elaine Situ-LaCasse, Josie Acuña, Steven Irving, Christina Weaver, Kara Samsel, David E Biffar, Mahsaw Motlagh, John Sakles

Integration of Pre-intubation Ultrasound into Airway Management Course: A Novel Training Program

[Year:2020] [Month:March] [Volume:24] [Number:3] [Pages:5] [Pages No:179 - 183]

Keywords: Airway, Cricothyroid membrane, Echocardiography, Emergency medicine, Hemodynamic, Pre-intubation, Ultrasound

PDF  |  DOI: 10.5005/jp-journals-10071-23370  |  Open Access |  How to cite  | 

Abstract

Objectives: To determine the feasibility of integrating pre-intubation ultrasound into airway course and assess emergency medicine (EM) residents’ confidence and comfort level in using ultrasound for pre-intubation hemodynamic stabilization and identifying cricothyroid membrane after the training session. Materials and methods: This is a retrospective study. Pre-intubation ultrasound training was delivered with the following ultrasound components (didactics and hands-on sessions using human models) to EM residents: (1) sonoanatomy and scanning technique to identify cricothyroid membrane and (2) pre-intubation echocardiography for recognition of acute right ventricular failure and pre-intubation hemodynamic stabilization. Results: A total of 56 EM residents participated in this study. Only 21% [95% confidence interval (CI), 10–31%] reported using ultrasound for pre-intubation hemodynamic stabilization. After the training session, 89% (95% CI, 81–97%) reported that ultrasound-based teaching increased their knowledge of pre-intubation hemodynamic stabilization compared with traditional teaching methods. On a scale of 1 (low) through 10 (high), the average comfort level for integrating ultrasound findings into medical decision making for pre-intubation hemodynamic stabilization was 6.8 (95% CI, 6.3–7.3). Seventy-nine percent (95% CI, 68–89%) reported that focused training in airway ultrasound is adequate to identify cricothyroid membrane. On a scale of 1 (low) through 10 (high), the average confidence level for identifying cricothyroid membrane using ultrasound was 6.6 (95% CI, 6.1–7.1). Conclusion: At our institution, we successfully integrated pre-intubation ultrasound into an airway course. Emergency medicine residents had a moderate level of comfort and confidence level using ultrasound for pre-intubation hemodynamic stabilization and identifying cricothyroid membrane after the training session.

RESEARCH ARTICLE

Laura Beard, Billy Holt, Catherine Snelson, Chetan Parcha, Fang Gao Smith, Tonny Veenith

Analgesia of Patients with Multiple Rib Fractures in Critical Care: A Survey of Healthcare Professionals in the UK

[Year:2020] [Month:March] [Volume:24] [Number:3] [Pages:6] [Pages No:184 - 189]

Keywords: Analgesia, Critical care, Pain relief, Rib fractures, Thorax trauma

PDF  |  DOI: 10.5005/jp-journals-10071-23375  |  Open Access |  How to cite  | 

Abstract

Introduction: Good analgesia has been shown to reduce the risk of pneumonia, chronic pain, and mortality in patients with multiple rib fractures (MRFs). This survey explores the current analgesic practice in the UK, protocol use, barriers to provision, and physician preferences. Materials and methods: A web-based survey was distributed nationally to an enriched cohort of clinicians working in UK trauma units with an interest in MRF management. Results: Seventy-nine healthcare professionals responded. A third (31.4%) reported that their department had a rib fracture pain protocol, 52.9% did not, and 15.7% were unsure. Significantly more respondents reported adequate pain control when a hospital protocol was present compared to when not (χ2, p < 0.01). Inadequate analgesia, a poor cough, and inability to breathe deeply were the commonest complications reported by 81.4, 78.6, and 65.7%, respectively. Patient-controlled analgesia (PCA) was the most commonly used form of analgesia (38.6%) followed by thoracic epidural (TEA) (30.0%) and continuous opioid infusion (18.6%). However, TEA was the preferred method of analgesia among respondents (37.1%) followed by serratus block (21.4%), paravertebral block (17.1%), and PCA (14.3%). Discussion: There is considerable variation among physicians in their current use of analgesic modalities, with opiate-based methods predominating despite a physician preference for regional techniques. Thoracic epidurals are preferred by physicians but of limited use as a result of contraindications, time pressures, and staff skill mix. Pain control is reported to be better handled when protocols are present. Further research focusing on currently utilized regional techniques is required in order to produce a validated standardized national protocol that is informed by the current practice, the evidence base, and limitations to service provision. Key messages: There is considerable variation among physicians in their current use of analgesic modalities. Opiate-based methods dominate for thoracic trauma despite a physician preference for regional techniques, which can be challenging in this cohort due to contraindications, staff skill mix, and time pressures. Inadequate analgesia is common but is better managed when pain management protocols are available.

RESEARCH ARTICLE

Sakshi Duggal, Partha S Biswas

A Comparison of Acute Physiology and Chronic Health Evaluation II Score and Serum Procalcitonin Change for Predicting Mortality in Acute Pancreatitis

[Year:2020] [Month:March] [Volume:24] [Number:3] [Pages:5] [Pages No:190 - 194]

Keywords: Acute pancreatitis, Acute physiology and chronic health evaluation II, Procalcitonin

PDF  |  DOI: 10.5005/jp-journals-10071-23377  |  Open Access |  How to cite  | 

Abstract

Introduction: The prediction of mortality in acute pancreatitis (AP) is a useful estimate for effective treatment. Scoring systems such as acute physiology and chronic health evaluation (APACHE) II, computed tomography (CT) severity index (CTSI), bedside index of severity in acute pancreatitis (BISAP), etc., are used for prediction. Biomarkers like C-reactive protein (CRP) and procalcitonin (PCT) are also considered useful for prognostication. The aim of this retrospective study was to correlate the changes in serum PCT level with APACHE II score between admission and 48 hours as mortality predictor in AP. Materials and methods: The observational study was conducted in a cohort of 42 patients admitted consecutively in the seven-bedded general intensive care unit (ICU) of our institute between June 2016 and May 2018, with the diagnosis of AP. The APACHE II score and serum PCT level at admission and 48 hours were retrieved from the hospital database. The change in APACHE II and PCT level was compared between ICU “survivors” and “nonsurvivors.” The predictive accuracy of APACHE II and PCT was measured using area under receiver–operator characteristics (ROC) curve. A p value <0.05 was considered as significant. Results: Of the 42 patients enrolled, 30 patients (71.42%) were survivors and 12 (28.58%) were nonsurvivors. The median APACHE II score in nonsurvivors increased from 16 (7–19) to 23 (11–29) and remained unchanged at 16 (9–19 at admission; 10–22 at 48 hours) in survivors. The median PCT levels increased from 3.8 (1.2–5.6) to 6.2 (1.9–12.5) in nonsurvivors and decreased from 3.8 (1.2–5.6) to 2.2 (0.6–2.9) in survivors. Serum PCT change compared better than the APACHE II score change among survivors (r = 0.455, p = 0.011) with a mean (±standard deviation SD) change of 1.41 (±1.59). Conclusion: The change in serum PCT and APACHE II between admission and 48 hours correlates well and is useful for mortality prediction in AP. Serum PCT change compares better than APACHE II score change in survivors.

CASE REPORT

Sushmita RS Upadhya, Chakrapani Mahabala, Jayesh G Kamat, Jayakumar Jeganathan, Sushanth Kumar, Mayur V Prabhu

Plasmapheresis in Sepsis-induced Thrombotic Microangiopathy: A Case Series

[Year:2020] [Month:March] [Volume:24] [Number:3] [Pages:5] [Pages No:195 - 199]

Keywords: Gram negative, Management, Microangiopathic hemolytic anemia, Peripheral smear, Plasmapheresis, Schistocyte, Sepsis, Sepsis and intensive care unit, Thrombotic microangiopathy

PDF  |  DOI: 10.5005/jp-journals-10071-23374  |  Open Access |  How to cite  | 

Abstract

Introduction: Cytokines and granulocyte elastase produced in sepsis cleave a disintegrin and metalloprotease with thrombospondin type I motif 13 (ADAMTS13) and deplete its levels. By this mechanism, sepsis results in microangiopathic hemolytic anemia (MAHA) with thrombocytopenia. Hence, the hypothesis is that plasmapheresis may help in sepsis-induced thrombotic microangiopathy (sTMA), by removing the factors responsible for low levels of ADAMTS13. In tropical countries like India, the contribution of sepsis to intensive care unit (ICU) mortality is high; and hence, it is essential to look out for newer modalities of sepsis treatment. There is abundant literature on the use of plasmapheresis in sepsis but data on its use in sTMA are limited, thus necessitating further research in this field. Case description: This case series studies the outcomes of five patients admitted with sTMA in the ICU and attempts to evaluate the effectiveness of plasmapheresis in improving their outcomes. All patients diagnosed with sTMA and treated with plasmapheresis, between January 2016 and August 2018 at our tertiary care center, were selected for the study. The diagnosis of sepsis was based on sepsis-3 definition. Results: Four different gram-negative organisms were found to have caused MAHA, with the commonest source being either urinary tract infection (UTI) or lower respiratory tract infection. Three of five patients required hemodialysis and two had disseminated intravascular coagulation (DIC). All five had good outcome and recovered well from the acute episode post plasmapheresis. Discussion: In two of five patients, the initial smear was negative and hence the need for repeated examination of the peripheral blood smear should be kept in mind in cases of sTMAs. The median of the number of plasmapheresis sessions required in sTMA is six, which is lesser than that required for primary thrombotic thrombocytopenic purpura (TTP). Hence, the duration of central line placement and the risk of catheter-related complications are low. Based on the observations made in this case study, further exploratory studies are required to evaluate the efficacy of plasmapheresis in sTMA secondary to tropical infections.

CASE REPORT

Anjali Kalbhande, Uday Gajare, Preeti Shanbag

Peritoneal Dialysis Using a Bicarbonate-buffered Dialysate in a Child with an Inborn Error of Metabolism Presenting with Severe Acidosis

[Year:2020] [Month:March] [Volume:24] [Number:3] [Pages:3] [Pages No:200 - 202]

Keywords: Acute peritoneal dialysis, Bicarbonate-buffered dialysate, Inborn error of metabolism, Severe acidosis

PDF  |  DOI: 10.5005/jp-journals-10071-23372  |  Open Access |  How to cite  | 

Abstract

Metabolic acidosis is observed in the pediatric intensive care unit (PICU) in several conditions including sepsis, intoxications, and severe catabolic states. It is occasionally seen due to acute decompensation in an inborn error of metabolism (IEM). Persistent acidosis results in a decrease in myocardial contractility, cardiac output, and catecholamine responsiveness. The mainstay of treatment of metabolic acidosis has been intravenous sodium bicarbonate infusion. However, the large amounts of sodium bicarbonate sometimes required can be hazardous resulting in hypernatremia, hypervolemia, and hyperosmolality. We report a 3-year child who presented with persistent lactic acidosis due to an IEM whom we treated with peritoneal dialysis (PD) using a bicarbonate-buffered dialysate. The child recovered uneventfully within 72 hours of dialysis. Peritoneal dialysis using a bicarbonate-buffered dialysate is a safe and simple method of treating persistent severe acidosis in the PICU.

CASE REPORT

Kapil Bhalla, Ashish Gupta, Deepak Nehra

Acute Disulfiram Poisoning in a Child: A Case Report and Review of Literature

[Year:2020] [Month:March] [Volume:24] [Number:3] [Pages:3] [Pages No:203 - 205]

Keywords: Child, Disulfiram, Literature, Poisoning, Review

PDF  |  DOI: 10.5005/jp-journals-10071-23371  |  Open Access |  How to cite  | 

Abstract

Aim: To determine the significance of acute disulfiram poisoning in pediatric population. Background: Disulfiram poisoning in children is uncommon, can occur in children who have ingested large amount of drug because of careless and unsafe storage. Only few cases have been reported in literature. Although well tolerated by most patients, severe toxic side effects have been also reported including hepatitis, encephalopathy, psychosis, optic, and peripheral neuropathy. Case description: This is a case report of disulfiram toxicity in a 4.5-year girl who ingested 4–5 tablets of disulfiram (approximately 1–1.25 g) accidentally and presented with hypoglycemia and encephalopathy. After initial stabilization in emergency room, the child was shifted to intensive care unit (ICU) where the child was managed conservatively. Blood sugars normalized after 8 hours of admission. Magnetic resonance imaging (MRI) brain showed bilateral globus pallidus hyperintensity in T2-weighted (T2W) and diffusion-weighted (DW) images and hypointensity in T1-weighted (T1W) images including diffusion restriction. Conclusion: Acute disulfiram poisoning can occur in children who have ingested large amount of drug because of unsafe storage. It can lead to hepatitis, encephalopathy, psychosis, optic, and peripheral neuropathy. Mainstay of treatment is supportive care, airway protection, oxygen, and dextrose-containing intravenous fluid should be given. Clinical significance: Acute disulfiram poisoning should be an important differential in diagnosis of any child presenting with idiopathic encephalopathy along with extrapyramidal symptoms with basal ganglia signal changes in MRI of brain in a previously healthy child.

CASE REPORT

Abhishek Jaiswal, Elizabeth Silver

Extended Continuous Infusion of Methylene Blue for Refractory Septic Shock

[Year:2020] [Month:March] [Volume:24] [Number:3] [Pages:2] [Pages No:206 - 207]

Keywords: Extra corporeal membrane oxygenation, Methylene blue, Refractory shock, Sepsis induced

PDF  |  DOI: 10.5005/jp-journals-10071-23376  |  Open Access |  How to cite  | 

Abstract

Objective: Highlight the utility of methylene blue (MTB) infusion for extended period for refractory vasoplegia. Introduction: Hypotension refractory to vasopressor therapy in sepsis is associated with high mortality and limited therapeutic options. Dysregulated nitric oxide (NO) pathway seems to be a major driver, and, therefore, MTB, which inhibits inducible NO synthase activity and decreases cyclic guanosine monophosphate (GMP) accumulation by directly competing with NO by binding to soluble guanylyl cyclase, has been explored. Case description: We describe a successful reversal of refractory septic shock with prolonged MTB infusion in a patient supported on multiple vasopressors at the highest clinical doses as well as venovenous extracorporeal membrane oxygenation (VV-ECMO). Conclusion and clinical significance: Current report suggests a potential role of MTB infusion in refractory vasoplegia even in advanced vasoplegic shock.

LETTER TO THE EDITOR

Poonam Gupta, Pradeep K Verma

A Rare Cause of Methemoglobinemia: How Safe are So-called Biopesticide?

[Year:2020] [Month:March] [Volume:24] [Number:3] [Pages:2] [Pages No:208 - 209]

Keywords: Biological extract, Insecticide, Methemoglobinemia

PDF  |  DOI: 10.5005/jp-journals-10071-23373  |  Open Access |  How to cite  | 

Abstract

With increasing awareness of “greener” environment, market is flooded with biopesticide. Natural insecticides can be chemical, mineral, or biological. We report an unusual case of methemoglobinemia after deliberate ingestion of an insecticide containing extract of pine oil and azadirachtin oil, Ti oil, and kerosene. On literature search, no such case report has been documented so far.

LETTER TO THE EDITOR

Manju Mary Joseph, Rohit Benjamin, Aswin Padmanabhan, Deepti Bal, Shalini Nair

Successful Management of a Life-threatening Endotracheal Bleed with Angiographic Stenting

[Year:2020] [Month:March] [Volume:24] [Number:3] [Pages:2] [Pages No:210 - 211]

Keywords: Endovascular interventions, Innominate artery, Pseudoaneurysm, Trachea arterial fistula, Tracheostomy

PDF  |  DOI: 10.5005/jp-journals-10071-23366  |  Open Access |  How to cite  | 

Abstract

Several operative and postoperative complications have been reported after tracheostomy, including fatal hemorrhage from erosion of a major vessel. We present here a case of hemorrhage after a surgical tracheostomy. This case is being reported on account of the unusual etiology of the hemorrhage and associated high fatality rates. All concerned need to be aware of this complication and its emergency management.

LETTER TO THE EDITOR

Ambarish Joshi

Cerebral Malaria: Hear before Discharge!

[Year:2020] [Month:March] [Volume:24] [Number:3] [Pages:2] [Pages No:212 - 213]

Keywords: Children, Intensive care, Mechanical ventilation, Survival to discharge

PDF  |  DOI: 10.5005/jp-journals-10071-23378  |  Open Access |  How to cite  | 

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