Indian Journal of Critical Care Medicine

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2023 | August | Volume 27 | Issue 8

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EDITORIAL

Umadri Singh, Indubala Maurya, Mohan Gurjar

Who Cares About Me? The Need of the Hour is to Improve Awareness and Quality of End-of-life Care Practices in Indian Intensive Care Units

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:3] [Pages No:523 - 525]

Keywords: Awareness, Educational program, End-of-life care, Ethical issues, Legal issues, Practice, Quality care, Terminal care

   DOI: 10.5005/jp-journals-10071-24512  |  Open Access |  How to cite  | 

377

EDITORIAL

Rekha Solomon

Predicting Pediatric ICU Outcomes: Yet Another SOFA (Study) on the PODIUM?

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:3] [Pages No:526 - 528]

Keywords: Intensive care unit, Pediatric, Sequential organ failure assessment

   DOI: 10.5005/jp-journals-10071-24513  |  Open Access |  How to cite  | 

302

EDITORIAL

Virinchi Sanapala, Vijaya P. Patil

Revamping Communication Strategies: Emphasizing Emotional Connect in Times of Crisis

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:2] [Pages No:529 - 530]

Keywords: COVID-19, Communication, Critical illness

   DOI: 10.5005/jp-journals-10071-24515  |  Open Access |  How to cite  | 

358

Original Article

A Survey for Assessment of Practical Aspects of End-of-life Practices across Indian Intensive Care Units

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:6] [Pages No:531 - 536]

Keywords: Decision-making, End-of-life care, India, Intensive care units, Surveys and questionnaires

   DOI: 10.5005/jp-journals-10071-24500  |  Open Access |  How to cite  | 

Abstract

Background: The end-of-life (EOL) decisions continue to be debated for their moral and legal standing. The acceptance of these decisions varies, based upon the perceptions and personal choices of the intensivists. Materials and methods: An online questionnaire-based survey was designed and circulated among the practicing intensivists via Indian Society of Critical Care Medicine (ISCCM) e-mail. Results: Out of 200 responses, 165 (82.5%) affirmed that EOL decisions are routinely undertaken in their intensive care units. The most prevalent reasons expressed for avoidance of EOL decisions are moral and ethical dilemmas and fear of litigation. There is notable variability in the practice of withholding (47.7%) vs withdrawal (3.5%) of therapies. A good proportion of intensivists follow do-not-intubate (91%) and do-not-resuscitate (86%) orders, whereas only 18% affirmed to be practicing terminal extubation. About 93% of the respondents acknowledged the use of monitoring toward the EOL, and 49% reported the use of preformatted documents. A meager 2% admitted to facing a medicolegal issue after taking an EOL decision. Conclusion: The survey establishes a general acceptance among the Indian intensivists regarding providing compassionate care to terminally ill patients, especially toward the EOL. The pattern of responses, however, indicates significant dilemmas and hesitancy with regard to the decision-making process.

476

Original Article

Mammen Philip Varghese, Tryphena Selwyn, Shalini Nair, Shobha Samuel, Binila Chacko, Kishore Pichamuthu

Assessment of Family Satisfaction with Remote Communication for Critically Ill COVID-19 Patients: An Observational Cohort Study

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:8] [Pages No:537 - 544]

Keywords: Communication, Coronavirus disease-2019, Empathy, Intensive care unit visitation, Trust, Satisfaction

   DOI: 10.5005/jp-journals-10071-24504  |  Open Access |  How to cite  | 

Abstract

Background: During the pandemic, traditional family meetings were replaced by remote telecommunications. We assessed the families’ satisfaction with these communications using a survey-based questionnaire. Methods: The study involved 20-minute telephonic surveys conducted with the family member who was updated during the hospitalization of the patient. A thematic-based questionnaire with responses on a scale of 5 ranging from very dissatisfied to very satisfied was used. The responses were dichotomized into bad and good reports for analysis. Results: A total of 196 patients were eligible. Only 154 patients’ family representatives consented to the study. The frequency and content of the telephonic updates were satisfactory. The bad report was assigned to 5% of families only. Among features assessing empathy of communication providers, the satisfaction rate was much higher with 3% of families alone providing a bad report. The response was significantly biased against the final outcome of the patient with poor review often provided by relatives of patients who had succumbed to the illness. The dissatisfaction rate was much higher, above 12% for the trust of communication and ICU visitation. However, the final outcome of the patient did not affect the trust in the information conveyed by the physician. Interpretation: This study highlights several drawbacks in the communication strategy during the second surge of coronavirus disease-2019 (COVID-19). The final outcome of the patient was the key decisive factor for the response to most of the questionnaire. Sustained faith in communication by the physician despite the final outcome of the patient, re-emphasizes the need for emotional connection and training for breaking bad news.

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Original Article

Munna Lal Patel, Radhey Shyam, Anurag Chaudhary, Rekha Sachan, Wahid Ali

Urinary Neutrophil Gelatinase-associated Lipocalin as a Diagnostic and Prognostic Marker for Acute Kidney Injury in Hospitalized Cirrhotic Patients: A Study from North Indian Population

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:7] [Pages No:545 - 551]

Keywords: Acute kidney injury, Biomarker, Liver cirrhosis, Model for end-stage liver disease, Outcome, Urinary neutrophil gelatinase-associated lipocalin

   DOI: 10.5005/jp-journals-10071-24497  |  Open Access |  How to cite  | 

Abstract

Background: A serious problem in cirrhosis is acute renal injury. The study aimed to examine the urinary neutrophil gelatinase-associated lipocalin (uNGAL) as a diagnostic and prognostic marker of acute kidney injury (AKI) in cirrhotic patients. Methods: A prospective study was carried out over a period of 1 year. A total of 490 patients suffering from cirrhosis who visited an indoor hospital were screened, and after the exclusion, a total of 90 subjects admitted to the medicine intensive care unit (MICU) fulfilling inclusion criteria were enrolled. Those having a history of renal diseases, on nephrotoxic drugs, in septic shock, peritonitis, UTI, and no urine output were excluded. On admission, for the estimation of uNGAL, urinary levels of sodium, creatinine, fresh urine samples were obtained, and blood samples were taken for serum creatinine estimation. Results: Out of 90 patients, 33.3% did not develop AKI, and 66.7% developed AKI. Urinary neutrophil gelatinase-associated lipocalin levels were six times higher in patients with acute tubular necrosis (259.08 ± 118.41 ng/mL) and three times higher in Hepatorenal syndrome (HRS)-AKI (124.97 ± 16.38) as compared with patients with normal kidney function (39.76 + 5.7). Those who died had a higher uNGAL (171.6 ng/mL) in comparison to those who survived (133.7 ng/mL). At a cutoff value of ≥114.9 (ng/mL), urinary NGAL represents a sensitivity of 86.92% and specificity of 100% to diagnose AKI and AUC 0.966 (95% CI: 0.919–0.990) in cirrhotic patients. Conclusion: Urinary NGAL is good for diagnosing AKI and is a marker to distinguish the types of AKI in liver cirrhosis.

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Original Article

Kamal Kajal, Karan Singla, Goverdhan Dutt Puri, Ashish Bhalla, Aparna Mukherjee, Gunjan Kumar, Alka Turuk, Madhumita Premkumar, Varun Mahajan, Naveen B Naik, Thrilok Chander Bingi, Pankaj Bhardwaj, Mary John, Geetha R Menon, Damodar Sahu, Samiran Panda, Vishnu Vardhan Rao, National Clinical Registry for COVID-19 Team

Analysis of Predictors and Outcomes of COVID-19 Patients Requiring ICU Admission from COVID-19 Registry, India

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:11] [Pages No:552 - 562]

Keywords: COVID-19, COVID-19 registry, ICU patients, Outcome

   DOI: 10.5005/jp-journals-10071-24496  |  Open Access |  How to cite  | 

Abstract

Background: Patients admitted to intensive care units (ICUs) with severe coronavirus disease (COVID-19) are associated with high mortality. The present retrospective, multicenter study describes the predictors and outcomes of COVID-19 patients requiring ICU admission from COVID-19 Registry of Indian Council of Medical Research (ICMR), India. Materials and methods: Prospectively collected data from participating institutions were entered into the electronic National Clinical Registry of COVID-19. We enrolled patients aged >18 years with COVID-19 pneumonia requiring ICU admission between March 2020 and August 2021. Exclusion criteria were negative in RT-PCR report, death within 24 hours of ICU admission, or incomplete data. Their demographic and laboratory variables, ICU severity indices, treatment strategies, and outcomes were analyzed. Results: A total of 5,865 patients were enrolled. Overall mortality was 43.2%. Non-survivors were older (58.2 ± 15.4 vs 53.6 ± 14.7 years; p = 0.001), had multiple comorbidities (33.2% vs 29.5%, p = 0.001), had higher median D-dimer (1.56 vs 1.37, p = 0.015), higher CT severity index (16.8 ± 5.2 vs 13.5 ± 5.47, p = 0.001) and longer median hospital stay (10 vs 8 days, p = 0.001) and ICU stay (5 vs 4 days, p = 0.001), compared with survivors. On multivariate analysis, high CRP (HR 1.008, 95% CI: 1.006–1.010, p = 0.001) and high D-dimer (HR 1.089, 95% CI: 1.065–1.113, p < 0.001) were associated with invasive mechanical ventilation while older age (HR 1.19, CI: 1.001–1.038, p = 0.039) and high D-dimer (HR-1.121, CI: 1.072–1.172, p = 0.001) were independently associated with mortality and while the use of prophylactic low molecular weight heparin (LMWH) (HR 0.647, CI: 0.527–0.794, p = 0.001) lowered mortality. Conclusion: Among 5,865 COVID-19 patients admitted to ICU, mortality was 43.5%. High CRP and D-dimers were independently associated with the need for invasive mechanical ventilation while older age and high D-dimer were associated with higher mortality. The use of prophylactic LMWH independently reduced mortality.

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Original Article

Jerry Jacob

ChatGPT: Friend or Foe?—Utility in Trauma Triage

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:4] [Pages No:563 - 566]

Keywords: Comorbidities, Intensive care specialist, Treatment guideline

   DOI: 10.5005/jp-journals-10071-24498  |  Open Access |  How to cite  | 

Abstract

Artificial intelligence (AI) has been growing rapidly in the health and production industry. The most recent AI program that has caught everyone's eye is, Chat Generative Pre-trained Transformer (ChatGPT). It is a program based on Open AI and was released in November 2022 to the public. It is a chatbot that helps with analyzing and learning data from the net, based on human literature and data.

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Original Article

Nikhil Narayanaswamy, Narendra Prasad Chandregowda

Communication Skill Training Levels among Critical Care Doctors in India

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:5] [Pages No:567 - 571]

Keywords: Communication skills, End of life, Faculty development, Family meeting checklist, Intensive care unit communication, Medical interviewing, Violence against doctors

   DOI: 10.5005/jp-journals-10071-24495  |  Open Access |  How to cite  | 

Abstract

Medical training programs outline the necessity of communication skills but there is likely a dearth of teaching at the bedside in part due to prioritization of other skills over communication or due to lack of opportunity. In India, the majority of critical care units are open in nature, and communication lead is likely to be taken by the primary specialty rather than the critical care doctors themselves. In the majority of the cases, the root cause analysis shows a lack of clear communication as a barrier. The sicker the patient, the higher the chance for anxiety and miscommunication among healthcare professionals as well as the family. The current project aims to find the training levels in Indian critical care settings and draw conclusions to see if there are avenues to improve the process. This study was based on a web-based questionnaire that was sent out to 1,000 critical care doctors across India. Educational experience and learning of communication techniques/concepts were assessed using a modified educational experience and attitudes questionnaire. Baseline demographic data were obtained and results were tabulated across 193 complete responses, which consistently showed a disparity in perceived levels of competence across different mandatory aspects of communication. Further, we find that though communication is a trainable skill, the mode of training has been largely reactive and has remained so for the last 20 years hinting at poor training in communication. Our survey suggests an urgent need for improvement of the training processes to reduce the burden of ethical, clinical, and legal dilemmas in critical care.

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SYSTEMATIC REVIEW

Bhavna Gupta, Pallavi Ahluwalia, Nidhi Gupta, Anish Gupta

Role of Nebulized Heparin in Clinical Outcome of COVID-19 Patients with Respiratory Symptoms: A Systematic Review

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:8] [Pages No:572 - 579]

Keywords: Acute respiratory distress syndrome, Coronavirus disease-2019, Nebulized heparin, Pandemic, Randomized study, Randomized controlled trial, Respiratory failure, SARS, SARS-CoV-2, Unfractionated heparin

   DOI: 10.5005/jp-journals-10071-24511  |  Open Access |  How to cite  | 

Abstract

Coronavirus disease-2019 (COVID-19) is an extremely contagious illness caused by the SARS-CoV-2 virus and has been declared a pandemic by the World Health Organization (WHO). There are currently no particular treatments, however, nebulized heparin has been offered as a viable therapy. The purpose of this systematic review is to assess the efficacy of nebulized heparin in COVID-19 patients with respiratory symptoms. Methods: Relevant studies were identified through a systematic search of the PubMed, Medline, Embase, Cochrane Library and Web of Science, and Scopus databases. The search terms included “nebulized heparin,” “COVID-19,” and “SARS-CoV-2.” Studies that evaluated the use of nebulized heparin in COVID-19 patients with respiratory symptoms were included. The rest of the studies along with those that were not published in English were excluded. The systematic review was registered under PROSPERO-CRD42023413927. Observations: Five studies have been included in this systematic review. Case reports, case series, observational studies, and randomized controlled trial (RCT) comprised the studies. The patient sample sizes ranged from 2 to 98. The studies assessed the efficacy of nebulized heparin in COVID-19 patients with variable disease severity. The evaluated outcomes included mortality, hospital stay duration, oxygen requirements, and laboratory parameters. Conclusion: Based on the clinical studies included in this systematic review, nebulized heparin may be useful in the management of COVID-19. Oxygen saturation was greater, inflammatory indicators were lower, and hospital stays were shorter in these patients. However, the studies had limitations, including inconsistent sample sizes, varying dosages of nebulized heparin, and no control groups. Nebulized heparin in patients with COVID-19 needs to be studied further to determine its safety and effectiveness.

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BRIEF RESEARCH COMMUNICATION

Shinto Bosco, Neeru Sahni, Arihant Jain, Pankaj Arora, Vipin Raj, Lakshminarayana Yaddanapudi

Delayed Transfer of Critically Ill Patients from Emergency Department to Intensive Care Unit

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:3] [Pages No:580 - 582]

Keywords: Critically ill adults, Emergency service, Intensive care unit, Patient admission

   DOI: 10.5005/jp-journals-10071-24502  |  Open Access |  How to cite  | 

Abstract

Background and aim: Delay in the transfer of critically ill patients from the emergency department (ED) to intensive care units (ICUs) may worsen clinical outcomes. This prospective, observational study was done to find the incidence of delayed transfer. Materials and methods: After approval from the institute ethics committee and written informed consent, all patients admitted to ICU from ED over 6 months were divided into groups I and II as patients getting transferred to ICU within 30 minutes of the decision or not, respectively. The factors affecting the immediate transfer and clinical outcome of all patients were noted. Monthly feedback was given to the ED team. Results: Out of 52 ICU admissions from ED, 35 (67.3%) patients were not transferred within 30 minutes, and the most frequent factor preventing immediate transfer was ED-related (54%). A statistically significant difference was found in acute physiology and chronic health evaluation (APACHE II) score, clinical deterioration during transfer, longer duration of mechanical ventilation and length of stay, and higher mortality with patients transferred immediately to ICU. A reduction of 42.6% was noted in transfer time from the first month to the last month of study. Conclusion: The incidence of delayed transfer of patients from ED to ICU was 67.3% with ED-related factors being the most frequent cause of delay (54.2%).

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BRIEF RESEARCH COMMUNICATION

Supradip Ghosh, Amandeep Singh, Aditya Lyall

Modification of Initial Empirical Antibiotic Prescription and its Impact on Patient Outcome: Experience of an Indian Intensive Care Unit

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:7] [Pages No:583 - 589]

Keywords: Antibiotic stewardship, Culture-negative sepsis, De-escalation, Empirical antibiotic

   DOI: 10.5005/jp-journals-10071-24505  |  Open Access |  How to cite  | 

Abstract

Introduction: Data on the overall impact of antibiotic modification following initial empiric prescription in both culture-positive and culture-negative critically ill patients are exiguous. Materials and methods: In a retrospective analysis of “ANT-CRITIC” study, we classified ICU patients receiving empirical antibiotics who remained in the ICU for >72 hours or till availability of culture results (whichever is longer) into five groups based on culture results and antibiotic modification: negative culture, no change (group I), positive culture, no change (group II), positive culture, de-escalation (group III), positive culture, escalation (group IV) and negative culture, antibiotic modification (group V). Baseline variables and clinical outcomes were compared. Logistic regression analysis was performed to look for independent variables associated with mortality. Results: 276 prescription episodes were analyzed. Group II was associated with worsening organ dysfunction at 72 hours, lower clinical cure rate at day 7, and higher hospital mortality. There was an independent association between group II prescription and hospital mortality [adjusted OR 2.774 (CI 1.178–6.533), p = 0.02]. Group III received longer duration of antibiotic (mean duration = 8.27 ± 4.11 days, median duration = 7 days [IQR 5–11]). Conclusion: Outcomes of critically ill infected patients differ significantly when they are classified based on culture result and antibiotic modification pattern.

378

PEDIATRIC CRITICAL CARE MEDICINE

Amoolya Lois, Sushma Save

Serial Evaluation of Sequential Organ Failure Assessment Score (SOFA) as a Predictor of Outcome in Children Admitted in Pediatric Intensive Care Unit (PICU) at Tertiary Care Hospital

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:6] [Pages No:590 - 595]

Keywords: Morbidity, Mortality, Multiorgan dysfunction syndrome, Pediatric intensive care unit, Sequential organ failure Assessment score

   DOI: 10.5005/jp-journals-10071-24509  |  Open Access |  How to cite  | 

Abstract

Background: Sequential organ failure assessment score (SOFA) is a score to quantify organ system dysfunction. This study was done to evaluate SOFA as a predictor of outcomes in children in pediatric intensive care unit (PICU). Objective: (A) To determine whether initial SOFA, Delta SOFA, and SOFA score at 72 hours are better predictors of outcome in terms of sensitivity and specificity. (B) To compare the initial SOFA, Delta SOFA, and SOFA score at 72 hours. Materials and methods: A prospective observational study was conducted on 160 patients aged from 29 days to 12 years admitted in PICU of a Tertiary Care Hospital in a metropolitan city in India for a period of 1 year. Then, the initial SOFA score, 72-hour SOFA, and Delta SOFA (T0 SOFA - T72 SOFA) were calculated and patients were followed up till discharge from PICU or deceased. Results: The best threshold to differentiate between discharged and deceased corresponds to as initial SOFA of 7.50 with a sensitivity of 64.71%, and specificity of 89.51%. The similar threshold for 72 hours SOFA is 10.50 which correspond to a sensitivity of 76.47% and specificity of 96.50%. The study showed strong evidence (p-value < 0.05) that, patients whose Delta SOFA values increased from the previous value (–1.5), had a greater chance to succumb to illness. Delta SOFA had the best sensitivity (82.35%) and 72-hour SOFA had the best specificity (96.50%) in predicting the outcome of PICU patients. Conclusion: This study emphasizes the use of SOFA score as a prognostic indicator in critically ill children, as variables measured are easily available.

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LETTER TO THE EDITOR

Sumit Roy Chowdhury, Riddhi Kundu

Commentary on “Prediction of Successful Spontaneous Breathing Trial and Extubation of Trachea by Lung Ultrasound in Mechanically Ventilated Patients in Intensive Care Unit”

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:1] [Pages No:596 - 596]

Keywords: Acute respiratory failure, Combined ultrasound approach, Critical care, Extubation failure, Extubation readiness, Impact assessment, Lung ultrasound, Transthoracic echocardiography

   DOI: 10.5005/jp-journals-10071-24508  |  Open Access |  How to cite  | 

360

LETTER TO THE EDITOR

Lalit Kumar Rajbanshi

Author Reply “Comment on Prediction of Successful Spontaneous Breathing Trial and Extubation of Trachea by Lung Ultrasound in Mechanically Ventilated Patients in Intensive Care”

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:2] [Pages No:597 - 598]

Keywords: Lung ultrasound, Spontaneous breathing trial, Ventilatory weaning

   DOI: 10.5005/jp-journals-10071-24510  |  Open Access |  How to cite  | 

342

LETTER TO THE EDITOR

Rujittika Mungmunpuntipantip, Viroj Wiwanitkit

COVID-19 Vaccine Associated with Cutaneous Involvement: Correspondence

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:1] [Pages No:599 - 599]

Keywords: Adverse drug effects, COVID, Vaccine

   DOI: 10.5005/jp-journals-10071-24499  |  Open Access |  How to cite  | 

358

LETTER TO THE EDITOR

Tapesh Bansal

Antiviral Drugs for Viral Pneumonia

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:1] [Pages No:600 - 600]

Keywords: Acute respiratory distress syndrome, Treatment, Viral pneumonia

   DOI: 10.5005/jp-journals-10071-24506  |  Open Access |  How to cite  | 

407

LETTER TO THE EDITOR

Balaji Vaithialingam, Swaroop Gopal, Dheeraj Masapu

“Locked-in State” Following Anterior Circulation Aneurysmal Subarachnoid Hemorrhage

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:2] [Pages No:601 - 602]

Keywords: Aneurysm, Locked in state, Subarachnoid hemorrhage

   DOI: 10.5005/jp-journals-10071-24501  |  Open Access |  How to cite  | 

323

LETTER TO THE EDITOR

Pallavi Sahoo

Author Reply: Comparison of Norepinephrine and Terlipressin vs Norepinephrine Alone for Management of Septic Shock: A Randomized Control Study

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:2] [Pages No:603 - 604]

Keywords: Sepsis, Septic shock, Terlipressin

   DOI: 10.5005/jp-journals-10071-24514  |  Open Access |  How to cite  | 

357

LETTER TO THE EDITOR

Daisy Khera, Chethan Suresh

Comparison of Norepinephrine and Terlipressin vs Norepinephrine Alone for Management of Septic Shock: Few Concerns

[Year:2023] [Month:August] [Volume:27] [Number:8] [Pages:1] [Pages No:605 - 605]

Keywords: Intensive care unit, Norepinephrine, Sepsis, Shock, Terlipressin

   DOI: 10.5005/jp-journals-10071-24503  |  Open Access |  How to cite  | 

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