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But another example can be found in the work of Lester Breslow and his colleagues generic 500 mg sumycin amex antibiotics for uti drinking, who surveyed the health behavior of about 7000 Californians for five and a half years purchase 250 mg sumycin amex infection attack 14 alpha. Although it is true that Californians may not be a representative sample (for health habits or anything else) buy sumycin 500mg without a prescription antimicrobial scrubs, the investigators established strong links be tween health habits generic sumycin 500 mg with mastercard antibiotics for uti sulfa, including regular sleep, weight m ainte nance, smoking and alcohol consum ption, and exercise and health. None of this is very shocking, but the im portance of the research is that adherence to health habits are the re 224 The Transform ations of Medicine sponsibility of the individual. As Breslow concludes, “We are reaching the point where individual responsibility is a highly im portant factor in determ ining good health. I have suggested that the professional stran glehold on the provision of services and health inform ation be broken. But since so many of the other reform s will founder unless professionalism is eroded, it is necessary to do so. T here will be some quack ery; it is unavoidable where money is to be m ade out of hum an suffering. But we also know that there are less conventional factors at work, factors that are unlikely to be assessed, or in some cases allowed into the healing equation in the first place. Some of these are the scale o f the facility in which care is rendered; the nature and behavior o f health personnel; the setting for care—home, outpatient, hospital; the powers of healing of those who claim to be healers; and the role o f the family and of the patient. Unless the barriers to practice are lowered to allow the interplay of new m ixtures of personnel and facilities and interpersonal interactions, these factors are un likely to be fully assessed. T he theories and practices on which contem porary medicine is premised are not the only ones. And there is evidence, some of which has been discussed, that these systems of medicine are effective. T he rigorous professionalization o f m odern medicine has succeeded in barring, or at least constraining practitioners employing alternative therapies and tech niques, such as acupuncture and chiropractic. T he opportu nity to learn from alternative practices should not be lost, The Obstacles 225 but will be if the prevailing barriers to practice remain. One example: Sister Justa Smith, a biochemist, has isolated a factor that may be associated with healing. Since her hypothesis is that enzyme activity is related to the healing process, she examined persons who claimed to be healers to determ ine w hether they could accelerate enzyme activity. Some of those who claim to be healers and appear to have had success in heal ing can dramatically elevate enzyme activity in controlled experim ents. First, as inform ation becomes available linking the processes o f care with patient outcomes, inform ation will be available to aid people in making choices about healers. Second, that same inform ation will make it possible to bar some prac titioners from practice at regional health centers, when it is clear that harm is being done to patients. T hird, com munities may also choose to bar some practitioners from association with neighborhood hospitals. T he argum ent is that the reform s I propose are hopelessly unrealistic because they are inconsistent with pre vailing social, political, and economic realities. In addition, it is argued that since some o f the proposals have m erit, they might be achieved step by step, particularly if appropriate incentives to change are utilized. It is true that change oc curs in this gradualist way, and some proposals, such as the regionalization of costly medical care equipm ent and ser vices, could be im plem ented without a titanic struggle. But if the reform s I propose are viewed as a whole, the conclusion is inescapable—a revolution is needed. If we start to think differently about health, the reform s will follow in due course. T he accumulation of “bits” o f data that do not fit the old predictions, or old explanations. T he fact that the change is preceded by widespread dissonance and is followed, when the transform ation takes place, by widespread change. T he change is very sudden and is consum m ated in a relatively short period o f time, contrasted with the “life” of the system which is replaced. The change is often in the direction of “simpli fication”; m ore simple explanations and practices. Finally, and m ore subtle, is the occurrence of interac tions “leaping” across the system level between the old sys tem and the new system in the process o f formation, which precede the transform ation. It is far from self-evident that medicine will change dramatically in the next few years, but there are enough signs and signals to make it a possibility. Finally, it will be argued that insufficient resources would be saved from the truncation of the existing medical care system to establish the program s that are proposed. This may be true in the initial conversion o f the system because of pending commitments and sunk costs, and because existing needs must be met before the long-range benefits of the new program s are experienced. If prevention works, the dem ands on a frozen and partially retreaded personal health care system will T he Obstacles 227 gradually lessen, perm itting reallocation of resources to new program s until some reasonable equilibrium is reached. It will also be argued that we will have enough revenue to preserve medicine and launch new program s as well. T he press o f existing social and domestic needs is so great that substantially more money will be dem anded. T he current system is likely to consume 10 percent or m ore o f the gross national prod uct by the year 2000. But even assuming that sufficient monies could be com m andeered, why should the existing system be preserved at the expense of am elioration o f other problems? As Ivan Illich has said: Each car w hich B razil puts on the road denies fifty people good tran sp o rtatio n by bus. Each m erchandized re frig e rato r reduces th e chance o f building a com m unity freezer. Every dollar spent in L atin A m erica on doctors a n d hospitals costs a h u n d re d lives. H ad each dollar been sp en t on providing safe d rin k in g w ater, a h u n d re d lives could have been saved. In the face o f sharp criticism o f medical care, a solution to the ills of the system is now being sought through the enactm ent o f a national health insurance program. Enactment o f a na 228 The Transform ations of Medicine tional health insurance plan in the United States can proba bly be expected within the next few years. Although the plans differ in their approaches to the means of financing care, the total num ber o f federal and state dollars to be appropriated, and the nature and degree o f public regulation, they all have three things in common. First, all tend to build upon the existing delivery system, although many o f the plans propose further industrializa tion o f the system. Second, they share a failure to address a m ajor alternative to the existing delivery system—a national health service—along the lines o f the medical care systems in Great Britain and Sweden and some other W estern nations. And third, there is no recognition of the limitations of m edi cal care to engender health. And, irrespective of the argum ents for and against a national health service—the second o f the points—its viability in the United States is doubtful. T he reason why there has been no debate about the third point—the limits of medicine—m ust be sought outside the policy-making process. Observers and practitioners o f medi cal care have failed to grasp the implications o f the evidence. As a result, the burning issue of the day is national health insurance, not the end o f medicine. We have tolerated tiers of medical practice paralleling class structure and even have created classes o f medical untouchables. T heir logical exten sion has always been some form o f comprehensive national health insurance that would greatly expand public support of medical care while leaving the delivery system intact. The Obstacles 229 National health insurance was a m ajor issue in the 1972 presidential election, and the debate has continued in Con gress since then. Thus, the assault proposed against inequi table access to care in this country will be m ade with dollars rather than with structural reform. T he solution being ad vanced, despite differences in details, is to increase purchas ing power to a level that presumably would be relatively uniform throughout the population.
The word asbes- system trusted sumycin 250mg virus 80, resulting in recent very large class-action tos order sumycin 250 mg fast delivery virus and fever, which is derived from the Greek word for lawsuits (68 purchase sumycin 500mg on-line antibiotics for sinus infection z pack,000 individual claims were made in “inextinguishable” or “unquenchable 250 mg sumycin otc antibiotic resistance related to natural selection,” was ﬁrst the year 2000 alone) and the bankruptcy of many used in the late 1300s. Asbestos is a well-recognized human carcino- All forms of asbestos cause nonmalignant inﬂam- gen, but whether a threshold level exists that does matory pulmonary diseases (ie, pleural effusions, not increase the risk of malignancy is unknown. Asbestos- malignant risks associated with nonoccupational associated bronchogenic carcinoma in patients exposure, especially to chrysotile, which accounts with asbestosis was well-recognized by the mid- for 95% of global asbestos consumption. A large-scale, retrospective pulmonary diseases continue to be a signiﬁcant population study37 of 405 hospital-based patients health concern for multiple reasons. As considerable controversy because tremolite, which reviewed in detail elsewhere,36 several recent stud- is an amphibole, is a frequent contaminant that has ies have documented more precisely an increased been implicated as a contributor to the toxicity of risk from environmental asbestos exposure that chrysotile. Compared with chrysotile, amphibole appears to be approximately 10 times lower than ﬁbers accumulate more readily in the distal lung that observed with occupational asbestos expo- parenchyma, are not cleared as effectively, and are sure. The development of asbestosis of asbestos in animal and in vitro models, the results is directly associated with both the magnitude and of human studies have been less impressive. Airborne asbestos levels in pub- structural characteristics (ie, length, diameter, and lic buildings are generally several orders of mag- aspect ratio) are the basis for lung malignancies. Although asbestos-induced lung cancer and to account for asbestos pulmonary toxicity, but they mesothelioma were well-recognized in the United may partly contribute to lung injury. These coated ﬁbers, Serpentine ﬁbers (eg, chrysotile) are curly-stranded, called ferruginous bodies, can be seen with various curved structures, whereas amphiboles (eg, cro- types of ﬁbers, including asbestos, and as such are cidolite, amosite, and tremolite) are straight, rod- also known as asbestos bodies. The clinical presentation ranges from being asymptomatic with total resolution or a blunted costophrenic angle to pleuritic chest pain associ- ated with fever, dyspnea, and bloody pleural ﬂuid. A diagnosis can be made only after the appropriate exposure history, the exclu- sion of all other causes (especially malignancy), and close follow-up for 2 to 3 years. They consist of cer, 10 of the studies were deemed appropriate to dense collagenous material that develops in the address this issue; in none of the 10 was there a mid-lower ribs and on the diaphragm (Fig 6). In 1997, an International tron microscopic studies may reveal noncoated Expert Meeting45 concluded that the presence of ﬁbers and, rarely, ferruginous bodies. These lesions, which can the yearly incidence of mesothelioma is 2 cases per be unilateral or bilateral, are relatively infrequent million person-years among women and 10 to 30 and, unlike circumscribed plaques, diffuse pleural cases per million person-years among men but as plaques may result in restrictive pulmonary phys- much as 270 to 366 cases per million person-years iology and functional impairment. As pleural ﬁbrosis progresses, it can entrap there is no synergistic interaction between asbestos the underlying healthy lung and bronchovascular and cigarette smoke affecting the incidence of tissue. The mechanisms Physical examination and chest radiographic by which rounded atelectasis occurs are unclear, ﬁndings consistent with a pleural effusion are seen but the pathways implicated include the local in 80 to 95% of patients. It is much more frequent in the pari- The chest radiographic ﬁndings of malignant etal pleura, possibly because inhalation is the pleural mesothelioma, although often very sugges- typical route of pathogenicity. Pleural ﬂuid cytology is diagnostic in Unlike lung cancer, there is no widely accepted only 25 to 33% of patients, closed needle pleural staging system for patients with diffuse malignant biopsy is diagnostic in 21 to 77% of patients, and pleural mesothelioma. The lateral parietal pleura; (3) epithelioid cell type; ﬁndings of these stains typically are negative in (4) good performance status; (5) young age; and mesotheliomas. Mesotheliomas No standard therapeutic regimen has been may also elevate pleural fluid hyaluronic acid clearly shown to substantially alter the median levels, but this test is not always readily available. Multimodality therapy with mesothelin, megakaryocyte potentiating factor, various combinations of chest surgery, chemo- osteopontin, soluble mesothelin-related protein, therapy, and radiation has been adapted. In 183 and others) are useful for discriminating between patients who were treated with taxol, carboplatin, asbestos-exposed individuals with malignant extrapleural pneumonectomy, and radiation the- mesothelioma as compared with other benign (eg, rapy, the overall median survival time was asbestosis, pleural plaques, etc) and malignant 17 months, and the 5-year survival rate was 14%. Although select patients may 300 genes of the 6,500 genes surveyed that could survive longer when managed with multimodality serve as useful markers of human mesothelioma. There is a latency period of at suggested62 that asbestos alone may cause airways least 20 to 40 years from the time of initial exposure obstruction in part attributable to the large airways to the development of respiratory symptoms. The inﬂammation resulting from ﬁber deposition along earliest symptom of asbestosis is insidiously pro- the respiratory bronchioles and alveolar duct gressive exertional dyspnea that often progresses bifurcations. A diagnosis of asbestosis is based on several Cough with sputum production is generally attrib- characteristic features and does not require histo- uted to exposure to cigarette smoke rather than pathologic evaluation for compensation pur- asbestos. For patients with an atypical presentation, the most Honeycombing and upper lobe involvement deﬁnitive evidence supporting the diagnosis of develop in the advanced stages of asbestosis. The early phase of asbestosis is charac- asbestosis, although nonspeciﬁc, include the fol- terized by peribronchiolar ﬁbrosis with normal lowing: (1) subpleural linear densities parallel to the distal alveoli. Given have challenged this conclusion, arguing that the long latency between exposure and disease as asbestos exposure, and not asbestosis, causes lung well as the direct relationship between asbestos cancer. This controversy is not likely to be Lung Cancer resolved soon because of the nonuniform deﬁnition of asbestosis used in the various studies (eg, clini- By the mid-1950s, epidemiologic data ﬁrmly cal vs histopathologic) and the uncertain biological supported a relationship between asbestosis and scenario whereby the molecular mechanisms lung cancer. In the mid-1980s, the Environmental underlying interstitial fibrosis are required to Protection Agency and the World Health Organi- develop a malignancy. Oksa et al70 showed that zation’s International Agency for Research declared lung cancer developed in 11 of 24 patients with asbestos a proven human carcinogen. From a 2001 progressive asbestosis (46%), whereas lung cancer review66 of 23 studies of the associations among developed in only 5 of 54 patients with stable asbestos, cigarette smoke, and lung cancer, it was asbestosis (9%). They postulated that the progres- concluded that asbestos causes lung cancer in sion of asbestosis, in addition to cigarette smoke nonsmokers despite the small numbers of such and asbestos exposure, is an independent predictor workers available for study. This distinc- tion, promotion, and progression) and, as such, is tion implies that the combined attributable lung not dependent on the presence of ﬁbrosis. The mechanisms underlying this synergistic gene at codon 12 in lung cancers without radio- effect are not fully known but are caused in part graphic determination of asbestosis, suggesting by impaired lung ﬁber clearance and enhanced that these two events are not necessarily linked. Until more deﬁnitive stud- Asbestos-induced lung cancers can occur in any ies have clarified this controversy, lung cancer lobe of the lung, and the distribution of the four attribution should be based on the merits of each major histopathologic lung cancer types is similar patient’s carcinogen exposure history combined to the distribution pattern among patients with with the appropriate clinical history and laboratory cigarette smoke-induced lung cancer. Considerable controversy surrounds the hypothesis that excess lung cancer risk in those Talc Pneumoconiosis persons with an occupational asbestos exposure is limited to workers with asbestosis. There is general Defnition/Occupations agreement that histologically and radiographically deﬁned asbestosis, in addition to other forms of Talc is a heterogeneous term that includes pulmonary ﬁbrosis, signiﬁcantly increase the risk hydrated magnesium silicates, and it is used com- of lung cancer. Weiss47 reviewed 34 cohort studies mercially to describe mixed materials that may and reported a direct correlation between the rate contain minimal amounts of talc. Less pure talc (approximately The nodular form of talcosis is similar, both 60%) that is contaminated with asbestos, carbon- clinically and radiographically, to silicosis in that ates, and silica is mined from other areas (eg, New patients are typically asymptomatic despite sub- York, Texas, and California) and is used extensively stantial chest radiographic abnormalities. Rock containing talc is crushed into a ﬁne ﬁbrosis results in cough and dyspnea, bibasilar powder, bagged, and shipped for numerous com- inspiratory crackles on examination, and chest mercial uses in the manufacturing of ceramics, radiographic abnormalities that are similar to those rubber products, chemicals, cosmetics, and phar- seen in silicosis and other forms of pulmonary maceuticals and as a ﬁller in paint, paper, soaps, fibrosis. There is no proven treatment for talc pneumoconiosis; therefore, the prevention of fur- Talc pneumoconiosis, also known as talcosis, ther exposure is the key to management. Beryllium Lung Disease Because talc is frequently contaminated with other mineral dusts, other lung diseases occur in talc- Defnition/Occupations exposed workers. Although widely used by con- sumers, talc rarely causes disease except in adults Beryllium is a rare light metal that is extracted exposed to massive amounts of baby powder. Also, from beryl ore that is mined in the United States, talcosis can develop in drug abusers who inject or Brazil, and China, and is reﬁned in the United inhale crushed tablets containing talc. These properties make it ideally The toxic manifestations of talc depend on the suited for use in heat shields, rotor blades, radio- purity of the material to which the workers are graph tubes, and parts for microwave equipment exposed. Since then, an esti- Multinucleated giant cells can occur, but focal and mated 800,000 workers have had past or current diffuse ﬁbrosis occurs in the later stages. Beryl- cough, chest pain, weight loss, fatigue, and lium also incites an antigen-specific immune arthralgias and who have an abnormal chest response that can cause a noncaseating granulo- radiograph finding, with a reticular-nodular matous inﬂammatory reaction that is histopatho- inﬁltrate seen predominately in the upper lung logically similar to that seen in patients with lobes (although all lobes can be involved). Persistent low-level beryllium expo- chest radiographic pattern is similar to that found sure results in chronic berylliosis, which is mani- with sarcoidosis, including mediastinal and bilat- fested by chronic interstitial ﬁbrosis, often with eral hilar adenopathy. A beryllium lymphocyte bullous changes, as well as systemic involvement transformation test should be performed to in the skin, liver, spleen, lymph nodes, myocar- document sensitization. T lym- 50% of beryllium-sensitized workers have evi- phocytes from the lung and blood of patients with dence of chronic beryllium disease at the time of an initial presentation, a 2005 longitudinal study74 berylliosis proliferate when exposed in vitro to beryllium salts, which act as an antigen or hapten. Although because of improved industrial hygiene methods, the clinical course of chronic berylliosis is variable, but when it does occur, beryllium acts as a direct most patients have a slow, inexorable decline that irritant. The diagnosis should be suspected when can result in cor pulmonale in nearly one-third of there is high-level beryllium exposure in association patients. Treatment options are sparse but of prime with acute pneumonitis, conjunctivitis, periorbital importance is the elimination of further beryllium edema, nasopharyngitis, and tracheobronchitis. Although there are no controlled studies cough, sputum production, chest pain, tachycardia, demonstrating their efﬁcacy, most reports have crackles, and hypoxemia.
Such devices can provide a life-saving solution to a severe airway problem generic sumycin 250 mg virus 7g7, especially when endotracheal intubation skills are not available sumycin 500mg generic virus removal mac. Endotracheal intubation Endotracheal intubation is potentially harmful in unskilled hands and undetected oesophageal intubation may be fatal for the patient purchase sumycin 500mg overnight delivery antibiotic resistance microbiology. The procedure should be drug assisted (see Chapter 9) unless the patient is in cardiac arrest or deeply unconscious with an absent gag reﬂex cheap sumycin 500 mg fast delivery antibiotics for sinusitis. The age-appropriate size and type of laryngo- scope blade and endotracheal tube are listed in Box 6. GlideRite®) are preferred as they are less traumatic and less liable to catch on the laryngeal cartilages on insertion. Laryngoscopes are notoriously unreliable and a secondary handle and blade should be available in case of failure of the primary device. Most of the 2–4 years 2 Miller (Age/4) + 4 modern devices have an oesophageal drainage channel through Uncuffed which a nasogastric tube can be inserted and the stomach con- 4–9 years 2 Miller/Mackintosh (Age/2) + 12 9–16 years 3 Mackintosh (Age/4) + 3. Airway Assessment and Management 25 It is imperative to optimize intubation conditions in order to Every system should have a written, and well rehearsed, ‘failed increase the rate of ﬁrst pass success (Box 6. Where conditions intubation plan’ for use in the event of failure of the 30-second are suboptimal (e. Direct visualization of the tube passing through the cords is be employed should the initial laryngoscopic view be suboptimal. Auscultation is then performed ﬁrst These form the basis of the ‘30-second drills’ – 30 seconds being in the epigastric area, then in both axillae. Cricoid pressure should be oesophagus it will bubble violently in this area in synchrony with releasedasthereislimitedevidencetosayitisbeneﬁcialbuthasbeen your bag–valve–tube ventilation. If that happens, the patient must shown to impair laryngoscopic view if performed poorly. Therefore always auscultate the epigastric area used to elevate the epiglottis and improve the view at laryngoscopy ﬁrst. Measurement of the end-tidal carbon dioxide using waveform in difﬁcult intubations (e. A number of options are available for securing the correctly placed endotracheal tube. As the name suggests access to the airway is gained through Obese patients should be positioned so that the ear canal and sternum are in the same horizontal plane the cricothyroid membrane (Figure 6. The patient should be placed supine and if there is no risk of cervicalspineinjurytheneckextended. With the free hand the needle is inserted at a 45-degree Adjust patient position caudal angle through the skin over the cricothyroid membrane. Change operator The syringe should be used to aspirate as the needle is inserted, Suction stopping when there is free aspiration of air after the cricothyroid Use longer blade membrane is punctured. At this point the needle tip is in the airway Use McCoy Blade and the cannula may be advanced over the needle into the airway. The oxygen tubing should be connected to an oxygen supply set at a ﬂow rate (in litres) equal to the patient’s age (maximum 15 L/min). Thyroid cartilage Cricothyroid membrane Cricoid cartilage Cricothyroidotomy site Figure 6. The incision should be dilated and an appro- priately sized endotracheal tube (internal diameter 6 mm in adults) To patient or tracheostomy tube inserted. Once in position the cuff should be inﬂated and the position veriﬁed by auscultation and end-tidal 5ml Syringe carbon dioxide measurement during ventilation. A bougie can then be 12G Adult 14G child threaded into the incision to maintain patency and an uncut 18G infant To oxygen endotracheal tube railroaded into the airway. Tips from the ﬁeld • In heavily soiled airways, suction tubing can be cut off and used Occlusion of the open three-way tap port for 1 second should lead directly to suction the airway in place of the narrower diameter to visible chest movement. If it does not, the ﬂow rate may be Yankauer increased by increments of a litre until it does. This ratio of • Always lubricate a bougie prior to use • During paediatric intubation an anterior larynx should be 1 second on to 4 seconds off should be continued while transporting anticipated – look in and up the patient rapidly to deﬁnitive care. In a complete obstruction the • Maintain laryngoscopy until the tube position is conﬁrmed and the gas ﬂow should be reduced to 1–2 L/min to provide oxygenation cuff inﬂated without ventilation in order to prevent barotrauma. It requires only minimal equipment: a scalpel • Consider performing a cricothyroidotomy under ketamine (e. A horizontal stab incision is made with the scalpel through the skin and underlying Further reading membrane into the airway (Figure 6. Air or blood (or both, bubbling) may pass through Acta Anaesthesiol Scand 2008;52:897–907. A meta-analysis of prehospital airway control techniques part I: orotracheal and nasotracheal intubation success rates. Prehospital and resuscitative airway care: should the gold standard be reassessed? By the end of this chapter you should be able to: Hypercarbic (type 2) respiratory failure is characterized by • Recognize the signs of impending respiratory failure failure of ventilation. Hypoventilation prevents sufﬁcient oxygen • Understand the importance of a thorough respiratory reaching the alveoli to replace that taken up by the blood, caus- assessment ing hypoxaemia. At the same time carbon dioxide accumulates • Identify life-threatening chest injuries leading to progressive hypercarbia. Causative mechanisms include • Initiate the management of patients with life-threatening depression of respiratory drive (e. Introduction It is vital to recognize the early signs of respiratory fail- ure in order to prevent further deterioration and respiratory A patent airway does not ensure adequate ventilation and oxygena- arrest. A number of life-threatening trau- matic and medical disease processes may interfere with one or more Box 7. Mismatch between ventilation and perfusion within the lungs is In such environments a greater reliance is placed on signs that the commonest mechanism by which this occurs (e. A thorough embolism, pneumonia, pulmonary oedema, pulmonary contu- assessment of breathing is essential. Peripheral cyanosis is common at the extremes of age but does not always indicate hypoxaemia. Reassess regularly as changes in respiratory rate are often the ﬁrst indicator of deteriorating respiratory and circulatory function. The inability to speak in full sentences or count to 10 in one breath are indirect indicators that tachypnoea is present. Preschool children 20–30 Older children 15–25 Adults 12–20 Listen Conscious patients should be asked about any pain on inspiration and difﬁculty breathing. Note any wheeze or prolonged expiratory Inadultsuseofaccessorymusclesandintercostalrecessionindicates time suggestive of lower airway obstruction. Auscultate the chest increased effort of breathing, usually as result of lower airway with a stethoscope. A slight unilateral wheeze in children due to increased chest wall compliance and may be may be the only indicator of an evolving pneumothorax in a subcostal, intercostal and even sternal in young infants. Monitor Signs of injury A pulse oximeter should be attached and the oxygen saturation Are there visible signs of injury? Note crepitus from fractured ribs or subcutaneous emphy- Non-invasive capnography (Figure 7. In low light the be extremely useful in monitoring a conscious patient’s venti- hands may be placed on the chest to assess for the presence of chest latory status.
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