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1.
Anaesthesia ; 72(12): 1467-1475, 2017 Dec.
Article in English | MEDLINE | ID: mdl-28703290

ABSTRACT

Acute risk change has been described as the difference in calculated mortality risk between the pre-operative and postoperative periods of cardiac surgery. We aimed to assess whether this was associated with long-term survival after cardiac surgery. We retrospectively analysed 22,570 cardiac surgical patients, with minimum and maximum follow-up of 1.0 and 6.7 years. Acute risk change was calculated as the arithmetic difference between pre- and postoperative mortality risk. 'Rising risk' represented an increase in risk from pre- to postoperative phase. The primary outcome was one-year mortality. Secondary outcomes included mortality at 3 and 5 years and time to death. Univariable and multivariable analyses were undertaken to examine the relationship between acute risk change and outcomes. Rising risk was associated with higher mortality (5.6% vs. 3.5%, p < 0.001). After adjusting for baseline risk, rising risk was independently associated with increased 1-year mortality (OR 2.6, 95%CI 2.2-3.0, p < 0.001). The association of rising risk with long-term survival was greatest in patients with highest baseline risk. Cox regression confirmed rising risk was associated with shorter time to death (HR 1.86, 1.68-2.05, p < 0.001). Acute risk change may represent peri-operative clinical events in combination with unmeasured patient risk and noise. Measuring risk change could potentially identify patterns of events that may be amenable to investigation and intervention. Further work with case review, and risk scoring with shared variables, may identify mechanisms, including the interaction between miscalibration of risk and true differences in peri-operative care.


Subject(s)
Cardiac Surgical Procedures/mortality , Postoperative Complications/mortality , Aged , Australia/epidemiology , Databases, Factual , Female , Follow-Up Studies , Humans , Male , Middle Aged , New Zealand/epidemiology , Postoperative Period , Preoperative Period , Retrospective Studies , Risk Assessment/methods , Risk Factors , Survival Analysis
2.
Anaesth Intensive Care ; 44(6): 734-741, 2016 11.
Article in English | MEDLINE | ID: mdl-27832561

ABSTRACT

Rapid response systems have been mandated for the recognition and management of the deteriorating patient. Increasing medical emergency team (MET) dose may be associated with improved outcomes. Large numbers of MET calls may divert resources from the program providing the service unless additional personnel are provided. To describe the implementation and outcomes of a multifaceted rapid response system (RRS) in a teaching hospital, we conducted an observational study. The RRS consisted of the introduction of a MET together with 1) redesign of the ward observation chart with the vital sign variables colour-coded to identify variation from normal; 2) mandated minimum frequency of vital sign measurement; 3) three formal levels of escalation based on the degree of physiological instability as measured by a modified early warning score (MEWS); 4) COMPASS© education and e-learning package with a two-hour face-to-face small group tutorial; 5) practise in escalation and communication using the ISBAR (Identify, Situation, Background, Assessment, Response/Recommendation) communication tool. The primary outcome measures were all-cause hospital mortality rate and hospital standardised mortality ratio (HSMR) compared to peer hospitals calculated by the Health Round Table. There were 161,153 separations and 1,994 hospital deaths from July 2008 to December 2012. The MET call rate was 11.3 per 1000 separations in 2012. There was a decline in all-cause hospital mortality from 13.8 to 11 deaths/1000 separations. The HSMR decreased from 95.7 in 2008 to 66 in the second half of 2012 (below the three standard deviation control limit). A low MET dose may be associated with improved hospital mortality when combined with a MEWS and an intervention to improve communication.


Subject(s)
Communication , Hospital Mortality , Hospital Rapid Response Team , Vital Signs , Hospitals, Teaching , Humans , Intensive Care Units , Middle Aged
3.
Br J Anaesth ; 117(2): 164-71, 2016 08.
Article in English | MEDLINE | ID: mdl-27440627

ABSTRACT

BACKGROUND: With improvements in short-term mortality after cardiac surgery, the sensitivity of the standardized mortality ratio (SMR) as a performance-monitoring tool has declined. We assessed acute risk change (ARC) as a new and potentially more sensitive metric to differentiate overall cardiac surgical unit performance. METHODS: Retrospective analysis of the Australian and New Zealand Society of Cardiac and Thoracic Surgeons database and Australian and New Zealand Intensive Care Society Adult Patient Database was performed. The 16 656 patients who underwent coronary artery bypass grafting or cardiac valve procedures during a 4 yr period were included. The ARC was generated using the change between preoperative and postoperative probability of death. Outlier institutions were those with higher (outside 99.8% confidence intervals) ARC or SMR on annual and 4 yr funnel plots. Outliers were grouped and compared with non-outliers for baseline characteristics, intraoperative events, and postoperative morbidity. RESULTS: No outliers were identified using SMR. Two outliers were identified using ARC. Outliers had higher rates of new renal failure (5.7 vs 4.5%, P=0.017), stroke (1.6 vs 0.9%, P=0.001), reoperation (9 vs 6.0%, P<0.001), and prolonged ventilation (15.3 vs 9.5%, P<0.001). Outliers transfused more blood products (P<0.001) and had longer cardiopulmonary bypass times (P<0.001) and less senior surgeons operating (P<0.001). CONCLUSIONS: Acute risk change was able to discriminate between units where SMR could not. Outliers had more adverse events. Acute risk change can be calculated before mortality outcome and identifies outliers with lower patient numbers. This may allow early recognition and investigation of outlier units.


Subject(s)
Cardiac Surgical Procedures/mortality , Cardiology Service, Hospital/standards , Perioperative Care/standards , Postoperative Complications/mortality , Quality of Health Care , Surgery Department, Hospital/standards , Acute Disease , Aged , Australia , Cardiac Surgical Procedures/standards , Female , Humans , Male , Middle Aged , New Zealand , Retrospective Studies , Risk Assessment/methods , Risk Assessment/standards
7.
Anaesth Intensive Care ; 40(4): 648-55, 2012 Jul.
Article in English | MEDLINE | ID: mdl-22813493

ABSTRACT

Critically ill patients receiving extracorporeal membrane oxygenation (ECMO) are often noted to have increased sedation requirements. However, data related to sedation in this complex group of patients is limited. The aim of our study was to characterise the sedation requirements in adult patients receiving ECMO for cardiorespiratory failure. A retrospective chart review was performed to collect sedation data for 30 consecutive patients who received venovenous or venoarterial ECMO between April 2009 and March 2011. To test for a difference in doses over time we used a regression model. The dose of midazolam received on ECMO support increased by an average of 18 mg per day (95% confidence interval 8, 29 mg, P=0.001), while the dose of morphine increased by 29 mg per day (95% confidence interval 4, 53 mg, P=0.021) The venovenous group received a daily midazolam dose that was 157 mg higher than the venoarterial group (95% confidence interval 53, 261 mg, P=0.005). We did not observe any significant increase in fentanyl doses over time (95% confidence interval 1269, 4337 µg, P=0.94). There is a significant increase in dose requirement for morphine and midazolam during ECMO. Patients on venovenous ECMO received higher sedative doses as compared to patients on venoarterial ECMO. Future research should focus on mechanisms behind these changes and also identify drugs that are most suitable for sedation during ECMO.


Subject(s)
Extracorporeal Membrane Oxygenation , Heart Failure/therapy , Hypnotics and Sedatives/administration & dosage , Midazolam/administration & dosage , Respiratory Insufficiency/therapy , APACHE , Adolescent , Adult , Aged , Female , Humans , Male , Middle Aged , Retrospective Studies
8.
Heart Lung Circ ; 19(11): 655-9, 2010 Nov.
Article in English | MEDLINE | ID: mdl-20813584

ABSTRACT

INTRODUCTION: Despite the advances in modern medicine, cardiac surgery remains associated with significant amounts of blood transfusion and is responsible for nearly 20% of all transfusions in Australasia. Progressive advances in perfusion technology and perioperative supportive management have made it possible for members of the Jehovah's Witnesses (JW) religious group to undergo open cardiac operations with remarkable safety. This study systematically compares the operative mortality and early clinical outcome after cardiac surgery in JWs. METHODS AND MATERIALS: Data was obtained from the cardiac surgery and intensive care unit databases from January 2002 to December 2005. A total of 5353 patients who underwent cardiac surgical procedures including coronary artery bypass grafting with cardiopulmonary bypass (n=4041) and valvular heart surgery (n=2287) were assessed in this study. Of the 5353 patients 49 patients refused blood and blood products because of their religious beliefs. Models were constructed to determine the association between JWs and non-JWs and three outcomes: (1) operative mortality, (2) postoperative variables and (3) length of stay in intensive care unit. Propensity scores were computed from these models and used to match JWs with non-JWs. RESULTS: There were minimal differences in the baseline patient demographic characteristics between the two groups. Haemoglobin and haematocrit levels were higher in JWs both before (13.7g/dL vs 12.8g/dL; P=0.01, and 40.0% vs 39.2%; P=0.08) and after (10.8g/dL vs 9.9g/dL; P=.003, and 34.0% vs 30.9%; P=.001) surgery. Jehovah's Witnesses experienced significantly less bleeding, almost half compared to the control group, with P<0.001. No differences were found in the adjusted and unadjusted operative mortality or intensive care unit and postoperative length of stay between the two groups. CONCLUSION: This study concurs with the international published data that outcomes for JW patients who undergo cardiac surgery are similar to those who receive transfusion. Every appropriate opportunity to reduce the use of allogeneic blood products.


Subject(s)
Cardiac Surgical Procedures/adverse effects , Cardiac Surgical Procedures/mortality , Jehovah's Witnesses , Religion and Medicine , Aged , Analysis of Variance , Australia , Blood Transfusion , Critical Care/statistics & numerical data , Female , Humans , Length of Stay/statistics & numerical data , Male , Middle Aged , Postoperative Complications , Regression Analysis , Retrospective Studies , Treatment Outcome , Treatment Refusal
10.
Vox Sang ; 98(4): 531-7, 2010 May.
Article in English | MEDLINE | ID: mdl-19878495

ABSTRACT

BACKGROUND AND OBJECTIVES: Recombinant activated factor VIIa (rFVIIa) is increasingly being used in non-haemophiliac patients for the treatment of severe bleeding refractory to standard interventions. Optimal dosing regimens remain debated in cardiac surgery. Therefore, this study investigated the use of different rFVIIa dosing practices on response to bleeding and patient outcomes in cardiac surgery patients using data from the Haemostasis Registry. METHODS: Data were extracted from the Haemostasis Registry that records cases of off-licence rFVIIa use in participating institutions. Univariate analyses compared patients receiving < or =40 microg/kg, 41-60 microg/kg, 61-80 microg/kg, 81-100 microg/kg and >100 microg/kg of rFVIIa on key parameters. Logistic regression models investigated the relationship between independent variables and 28-day mortality. RESULTS: Complete data was available on 804 cardiac surgery patients who received rFVIIa. Of these, 42 (5.2%) were treated with doses < or =40 microg/kg, while the dose group containing the most patients was 81-100 microg/kg (368, 45.77%). Results demonstrated no significant differences in the rate of thromboembolic adverse events, response to bleeding or 28-day mortality. CONCLUSIONS: These findings raise the important question of whether lower doses of rFVIIa may be as effective as higher doses in the treatment of severe bleeding in cardiac surgery patients.


Subject(s)
Cardiac Surgical Procedures/adverse effects , Factor VIIa/administration & dosage , Hemorrhage/drug therapy , Postoperative Hemorrhage/drug therapy , Aged , Female , Hemorrhage/etiology , Humans , Male , Middle Aged , Postoperative Hemorrhage/etiology , Recombinant Proteins/administration & dosage , Treatment Outcome
11.
J Heart Lung Transplant ; 26(8): 850-6, 2007 Aug.
Article in English | MEDLINE | ID: mdl-17692791

ABSTRACT

BACKGROUND: Ischemia-reperfusion injury (IRI) is a prominent cause of primary graft failure after lung transplantation and is associated with an altered surfactant profile. Experimental animal studies have found that replacement with exogenous surfactant administered via fiber-optic bronchoscopy (FOB) enhanced recovery from IRI with improved pulmonary compliance and gas exchange after lung transplantation. We report our clinical experience with FOB instillation of surfactant in severe IRI after human lung transplantation. METHODS: This study is a retrospective review of 106 consecutive lung or heart-lung transplants performed at a single institution. Severe IRI was defined as diffuse roentgenographic alveolar infiltrates, worsening hypoxemia and decreased lung compliance within 72 hours of lung transplantation. One vial of surfactant (20 mg/ml phospholipid) was instilled into each segmental bronchus upon diagnosis of IRI. RESULTS: Six patients (5 bilateral sequential and 1 re-do heart-lung transplant), mean age 46 years, were diagnosed with IRI and surfactant was administered at a mean of 37 hours (range 2.3 to 98) post-transplant. Mean graft ischemia time was 376 minutes (range 187 to 625) and cardiopulmonary bypass time 174 minutes (range 0 to 210). Mean Pao(2) [mm Hg]/Fio(2) ratio before and 48 hours after surfactant instillation was 70 and 223, respectively. Significant resolution of radiologic infiltrates was evident in all cases within 24 hours. Successful extubation occurred at a mean of 13.5 days and survival is presently 100% at 19 months (range 3 to 54). CONCLUSIONS: Bronchoscopic instillation of surfactant improves oxygenation and prognosis after severe IRI in lung transplant recipients. It represents a cost-effective, relatively non-invasive therapeutic alternative to extracorporeal membrane oxygenation.


Subject(s)
Biological Products/administration & dosage , Lung Transplantation , Lung/blood supply , Pulmonary Surfactants/administration & dosage , Reperfusion Injury/drug therapy , Adult , Bronchoscopy , Female , Fiber Optic Technology , Follow-Up Studies , Humans , Instillation, Drug , Male , Middle Aged , Optical Fibers , Radiography, Thoracic , Reperfusion Injury/complications , Reperfusion Injury/diagnostic imaging , Respiratory Insufficiency/surgery
12.
Anaesth Intensive Care ; 35(1): 13-9, 2007 Feb.
Article in English | MEDLINE | ID: mdl-17323660

ABSTRACT

The aim of this study was to review and describe indications for intraaortic balloon counterpulsation (IABP) use and identify the impact these have on outcomes at an Australian cardiothoracic tertiary referral hospital. A secondary aim was comparison of the Australian practice with a large multinational IABP data registry. Patient demographics, IABP indication, IABP complication rate and mortality in 662 patients treated with IABP at The Prince Charles Hospital (TPCH), Brisbane, between January 1994 and December 2004 inclusive were compared with The Benchmark Counterpulsation Outcomes Registry. Data were collected between 1994 and 2000 by retrospective patient record review and prospectively using the Benchmark database from 2001 to 2004. Statistical analysis was undertaken using SAS (v8.2) software. The mean age of patients managed with IABP at TPCH (71.6% male) was 63.4 years (SD 12.4). In-hospital mortality rate was 22% and the complication rate was 10.3%. TPCH indications for IABP were: weaning from cardiopulmonary bypass (34.2%); cardiogenic shock (24.4%); preoperative support (13%); catheter laboratory support (10.6%); refractory ventricular failure (7.3%); ischaemia related to intractable ventricular arrhythmias (4.5%); unstable refractory angina (4%); mechanical complications due to acute myocardial infarction (1.2%) and other (0.4%) (0.4% not reported). In comparison to Benchmark, IABP at TPCH demonstrated a prejudice toward intraoperative use (34.2% versus 16.6%; P < or = 0.0001) and an aversion to catheter laboratory support (10.6% versus 19%; P < or = 0.0001). TPCH and Benchmark IABP outcomes demonstrated comparable mortality (22% versus 20.8%; P = ns) but increased TPCH complications (10.3% vs. 6.2%; P < or = 0.0001) owing to a 2% difference in observed insertion site bleeding.


Subject(s)
Benchmarking/organization & administration , Intra-Aortic Balloon Pumping/trends , Practice Patterns, Physicians'/standards , Adolescent , Adult , Aged , Aged, 80 and over , Australia/epidemiology , Cardiac Catheterization/methods , Female , Heart Diseases/therapy , Hospital Mortality , Humans , Intra-Aortic Balloon Pumping/adverse effects , Intra-Aortic Balloon Pumping/mortality , Male , Middle Aged , Practice Patterns, Physicians'/statistics & numerical data , Prospective Studies , Registries , Retrospective Studies , Risk Factors , Survival Rate , Treatment Outcome , United States/epidemiology
13.
Anaesth Intensive Care ; 34(6): 736-45, 2006 Dec.
Article in English | MEDLINE | ID: mdl-17183891

ABSTRACT

Near-hanging is an increasing presentation to hospitals in Australasia. We reviewed the clinical management and outcome of these patients as they presented to public hospitals in Queensland. A retrospective clinical record audit was made at five public hospitals between 1991 and 2000. Of 161 patients enrolled, 82% were male, 8% were indigenous and 10% had made a previous hanging attempt. Chronic medical illnesses were documented in 11% and previous psychiatric disorders in 42%. Of the 38 patients with a Glasgow Coma Scale score (GCS) of 3 on arrival at hospital, 32% returned to independent living and 63% died. Fifty-two patients received CPR, of whom 46% had an independent functional outcome. Independent predictors of mortality were a GCS on hospital arrival of 3 (AOR 150, CI 95% 12.4-1818, P<0.001), taking plain X-rays of the cervical spine (AOR 0.06, CI 95% 0.004-0.97, P=0.047) and contact with the ground (AOR 0.03, CI 95% 0.002-0.62, P=0.02). Only 66% had imaging of the cervical spine performed with other imaging performed infrequently. There were three laryngeal, two hyoid bone and three cervical spine injuries and one carotid dissection. The number of cervical spine X-rays required to find a significant cervical spine fracture was 54. Near-hanging presenting to hospital with a poor conscious state or even cardiac arrest can have a favourable clinical outcome. Radiological investigations are infrequently performed despite a low GCS precluding early accurate assessment. Given the general favourable outcome, an aggressive approach to searching for correctable injuries is recommended.


Subject(s)
Mental Disorders/therapy , Neck Injuries/etiology , Suicide, Attempted/psychology , Adolescent , Adult , Aged , Aged, 80 and over , Australasia , Female , Glasgow Coma Scale , Humans , Male , Mental Disorders/diagnosis , Mental Disorders/prevention & control , Middle Aged , Neck Injuries/diagnostic imaging , Neck Injuries/therapy , Practice Guidelines as Topic , Queensland , Radiography , Retrospective Studies , Suicide, Attempted/statistics & numerical data , Treatment Outcome
14.
Crit Care Resusc ; 8(1): 46-9, 2006 Mar.
Article in English | MEDLINE | ID: mdl-16536720

ABSTRACT

Fungal endocarditis represents both a diagnostic and therapeutic challenge to the treating team. The critical care physician will see a rising incidence as older and more immuno-compromised patients are being supported in their intensive care units. Aspergillus sp. endocarditis represents less than 25% of all cases of fungal endocarditis and is associated with a mortality of around 80%. Early diagnosis may assist with definitive management. We review a case of Aspergillus endocarditis, and review the literature as to optimal methods of detection, imaging modalities of choice, and management, both surgical and medical.


Subject(s)
Aspergillus flavus , Endocarditis, Bacterial/diagnosis , Endocarditis, Bacterial/therapy , Aspergillosis , Endocarditis, Bacterial/diagnostic imaging , Endocarditis, Bacterial/surgery , Fatal Outcome , Female , Humans , Middle Aged , Ultrasonography
15.
Anaesth Intensive Care ; 34(1): 13-20, 2006 Feb.
Article in English | MEDLINE | ID: mdl-16494143

ABSTRACT

We reviewed the outcome following use of recombinant activated factor VII (rVIIa) in patients with major bleeding post cardiothoracic surgery in our unit between January 2002 and July 2004. The unit consists of 16 cardiothoracic intensive care beds in a public metropolitan teaching hospital which serves as a referral centre for heart and lung transplant surgery. Patients with refractory bleeding following cardiothoracic surgical procedures who were treated with rVIIa were identified. A total of 12 episodes of rVIIa use were recorded in ten patients, including three episodes with ventricular assist devices, and 5 heart and/or lung transplants. The median dose used was 85 microg/kg. Chest tube drainage decreased in all patients following administration of rVlIIa; median chest tube drainage decreased from 445 ml/h to 171 ml/h (P = 0.03). Despite cessation of bleeding, mortality was high when rVIIa was used after more than 24 hours. In six episodes, despite early rVIIa use (within six hours), continued bleeding necessitated return to theatre, where a surgical source of bleeding was found. In this small retrospective study, rVIIa significantly reduced bleeding that was refractory to standard blood product transfusion. In this series of patients, those that did not respond to rVIIa early in the postoperative phase were found to have a surgical source of bleeding.


Subject(s)
Cardiac Surgical Procedures/adverse effects , Factor VIIa/therapeutic use , Postoperative Hemorrhage/drug therapy , Postoperative Hemorrhage/mortality , Thoracic Surgical Procedures/adverse effects , Adult , Cardiac Surgical Procedures/methods , Cohort Studies , Coronary Care Units , Dose-Response Relationship, Drug , Drainage/methods , Female , Follow-Up Studies , Heart Transplantation/adverse effects , Heart Transplantation/methods , Humans , Infusions, Intravenous , Lung Transplantation/adverse effects , Lung Transplantation/methods , Male , Middle Aged , Postoperative Hemorrhage/diagnosis , Queensland , Reoperation , Retrospective Studies , Risk Assessment , Severity of Illness Index , Survival Rate , Thoracic Surgical Procedures/methods , Treatment Outcome
16.
Crit Care Resusc ; 6(2): 102-4, 2004 Jun.
Article in English | MEDLINE | ID: mdl-16566695

ABSTRACT

Complications associated with external cardiac compression include trauma to the heart, chest wall, lungs and gastrointestinal viscera, with gastrointestinal visceral injury including, ruptured stomach, liver, oesophagus, spleen and colon. However, the use of thrombolytics and anticoagulants in patients with an acute myocardial infarction increases the incidence of a visceral haemorrhage when these patients need cardiopulmonary resuscitation. We report two out-of-hospital cardiac arrest patients whose immediate post-resuscitation phase was complicated by hepatic injury and significant haemoperitoneum. Conservative management in a major intensive care unit of both the liver trauma and the induced coagulopathy was associated with a successful outcome in both cases.

17.
Intensive Care Med ; 27(4): 665-72, 2001 Apr.
Article in English | MEDLINE | ID: mdl-11398692

ABSTRACT

OBJECTIVES: To investigate the pharmacokinetics of intravenous ciprofloxacin 200 mg every 8 h in critically ill patients on continuous veno-venous haemodiafiltration (CVVHDF), one form of continuous renal replacement therapy (CRRT). DESIGN AND SETTING: Open, prospective clinical study in a multidisciplinary, intensive care unit in a university-affiliated tertiary referral hospital. PATIENTS: Six critically ill patients with acute renal failure on CVVHDF. INTERVENTIONS: Timed blood and ultrafiltrate samples were collected to allow pharmacokinetics and clearances to be calculated of initial and subsequent doses of 200 mg intravenous ciprofloxacin. CVVHD was performed with 1 l/h of dialysate and 2 l/h of predilution filtration solution, producing 3 l/h of dialysis effluent. The blood was pumped at 200 ml/min using a Gambro BMM-10 blood pump through a Hospal AN69HF haemofilter. MEASUREMENTS AND RESULTS: Ten pharmacokinetic profiles were measured. The CVVHDF displayed a urea clearance of 42 +/- 3 ml/min, and removed ciprofloxacin with a clearance of 37 +/- 7 ml/min. This rate was 2-2.5 greater than previously published for ciprofloxacin in other forms of CRRT. On average the CVVHDF was responsible for clearing a fifth of all ciprofloxacin eliminated (21 +/- 10%). The total body clearance of ciprofloxacin was 12.2 +/- 4.3 l/h. The trough concentration following the initial dose was 0.7 +/- 0.3 mg/l. The area under the plasma concentration time curves over a 24-h period ranged from 21 to 55 mg.h l-1. CONCLUSIONS: Intravenous ciprofloxacin 600 mg/day in critically ill patients using this form of CRRT produced adequate plasma levels for many resistant microbes found in intensive care units.


Subject(s)
Acute Kidney Injury/metabolism , Acute Kidney Injury/therapy , Anti-Infective Agents/pharmacokinetics , Ciprofloxacin/pharmacokinetics , Hemodiafiltration , Intensive Care Units , Adult , Aged , Anti-Infective Agents/administration & dosage , Anti-Infective Agents/blood , Area Under Curve , Ciprofloxacin/administration & dosage , Ciprofloxacin/blood , Female , Humans , Infusions, Intravenous , Male , Metabolic Clearance Rate , Middle Aged , Prospective Studies , Urea/blood
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