In the article by Greingor et al on carbon monoxide
poisoning in pregnancy, one word is
notably absent from the Discussion. I quote, with the word inserted,'CO intoxication is the most frequently reported (FATAL) poisoning in Western developed countries'. Most of us are aware that analgesic drugs are still the commonest intoxicating agent - are we not?
While I agree that the specialty in the UK should move to using the title
"Emergency Medicine" I would council that it may be difficult to gain
acceptance of the name amongst the wider community - both medical and non-
medical.
Here in Australia, the specialty has been officially named "Emergency
Medicine" since the Australasian College for Emergency Medicine was
incorporated in 1984. However, this mes...
While I agree that the specialty in the UK should move to using the title
"Emergency Medicine" I would council that it may be difficult to gain
acceptance of the name amongst the wider community - both medical and non-
medical.
Here in Australia, the specialty has been officially named "Emergency
Medicine" since the Australasian College for Emergency Medicine was
incorporated in 1984. However, this message has not permeated the wider
community. On a daily basis, I field letters and phone calls for "cas",
"casualty", A&E, to name but three of the most common names used. The
process of re-education begins as soon as the name change becomes official
– but obviously the effective timescale is an extended one.
Thus I would recommend that the name change be made as soon as possible –
and let the schooling process begin!
We thank Dr. T. Ho for his comment on our article reporting a young patient with tuberculous osteomyelitis [1]. We wrote the article from the perspective of emergency medicine. Although polymerase chain reaction (PCR) is a good adjunct to microbiological culture for diagnosing mycobacterium tuberculosis, it is not available to the majority of emergency physicians in Hong Kong. Nonetheless, we should discuss it b...
We thank Dr. T. Ho for his comment on our article reporting a young patient with tuberculous osteomyelitis [1]. We wrote the article from the perspective of emergency medicine. Although polymerase chain reaction (PCR) is a good adjunct to microbiological culture for diagnosing mycobacterium tuberculosis, it is not available to the majority of emergency physicians in Hong Kong. Nonetheless, we should discuss it briefly so that our article is more informative to readers.
Without argument, PCR provides an opportunity for early diagnosis and treatment. However, we should also note the limitation of the PCR especially when the PCR result is negative.
In 1998 Shah et al reported the accuracy of the AMPLICOR PCR test in diagnosing mycobacterium tuberculosis in tissue and body fluid specimens [2]. In this study, culture proof was adopted as the gold standard for diagnosing tuberculosis. Although 1032 patients were included in this study, only 34 specimens were positive for tuberculosis. Therefore, the sample size was too small and the 95% confidence interval of the sensitivity was too wide to suggest that PCR would not miss the diagnosis of mycobacterium tuberculosis. In this study, the PCR had a sensitivity of 76.4%, a specificity of 99.8% when results were compared with the gold standard. With the high specificity, PCR is a good "rule-in" test. However, PCR should not be used as a "rule-out" test because of the high false negative rate.
In 2000 Lim et al reported the accuracy of the AMPLICOR PCR test in diagnosing pulmonary tuberculosis in smear-negative respiratory tract specimens. Once again, the PCR test had a low sensitivity of 44% and a high specificity of 99% [3].
With evidence from both studies, a positive PCR test result facilitates early diagnosis, but a negative PCR test result cannot exclude mycobacterium tuberculosis. At the moment, microbiological culture remains the gold standard for diagnosing tuberculosis and a high index of suspicion for tuberculosis is the key to diagnosis.
References:
(1) Yuen MC, Tung WK. An uncommon cause of foot ulcer: tuberculous osteomyelitis. Emerg Med J 2001;18: 140-141
(2) Shah S, Miller A, Mastellone A, et al. Rapid diagnosis of tuberculosis in various biopsy and body fluid specimens by the AMPLICOR mycobacterium tuberculosis polymerase chain reaction test. Chest 1998;113: 1190-1194
(3) Lim TK, Gough A, Chin NK, et al. Relationship between estimated pretest probability and accuracy of automated mycobacterium tuberculosis assay in smear-negative pulmonary tuberculosis. Chest 2000;118: 641-647
Yuen and Tung describe a case of tuberculous osteomyelitis of the foot [1] and the potential difficulties in making the diagnosis. The authors were fortunate enough to have typical histological biopsy findings which subsequently cultured Mycobacterium tuberculosis (TB), providing diagnostic confirmation and estimations of sensitivities. However, in many instances, the diagnosis of tuberculosis is difficult to ve...
Yuen and Tung describe a case of tuberculous osteomyelitis of the foot [1] and the potential difficulties in making the diagnosis. The authors were fortunate enough to have typical histological biopsy findings which subsequently cultured Mycobacterium tuberculosis (TB), providing diagnostic confirmation and estimations of sensitivities. However, in many instances, the diagnosis of tuberculosis is difficult to verify. For instance, acid fast bacilli may not be identified on biopsy or may be non-tuberculous in origin. Additionally, subsequent culture confirmation can take several weeks or may fail completely, due to TB's fastidious nature.
Although the reliance on clinical suspicion is the basis for the diagnosis of many cases of TB, definitive confirmation is desirable in view of the long-term nature of therapy. It is also important to ensure that the organism is not resistant to the chemotherapeutic regime being employed, particularly with the increasing incidence of multi-drug resistant TB strains. A number of novel diagnostic techniques have been developed to facilitate this. The use of the polymerase chain reaction (PCR) to amplify specific TB DNA sequences allows a rapid confirmation of the diagnosis and an estimation of drug sensitivity [2]. These techniques have been successfully used on both clinical specimens and culture material [3]. Thus, acid fast bacilli can rapidly be identified as Mycobacterium tuberculosis and an estimation of rifampicin sensitivity can be obtained in a matter of days, free from the contraints of waiting up to several weeks for the standard culture to grow. These techniques should therefore be considered, particularly if the clinical findings are subtle or atypical.
References
(1) Yuen MC, Tung WK. An uncommon cause of foot ulcer: tuberculous osteomyelitis. Emerg Med J 2001; 18: 140-141.
(2) Telenti A, Imboden P, Marchesi F, et at. Detection of rifampicin-resistance mutations in Mycobacterium tuberculosis. Lancet 1993;341:647-650.
(3) Shah S, Miller A, Mastellone A, et al. Rapid diagnosis of tuberculosis in various biopsy and body fluid specimens by the AMPLICOR Mycobacterium tuberculosis polymerase chain reaction test. Chest 1998;113: 1190-1194.
We are delighted that our paper [1] has stimulated a response from overseas colleagues, who have shared with us some Australasian opinions.
Whilst we agree that adopting the term 'emergency medicine' would bring us into line with international standard terminology, the fact remains that 'accident and emergency' appeals to many, and debate will continue as long as practice between and within United Kingdom...
We are delighted that our paper [1] has stimulated a response from overseas colleagues, who have shared with us some Australasian opinions.
Whilst we agree that adopting the term 'emergency medicine' would bring us into line with international standard terminology, the fact remains that 'accident and emergency' appeals to many, and debate will continue as long as practice between and within United Kingdom departments varies so widely. For example, some accident and emergency consultants have greater experience in the management of patients with minor musculoskeletal injury - a major component of our workload - than in the resuscitation of critically ill medical patients. In addition a significant number of consultants draw private income from medicolegal reports, specialising in 'accidents', which at such a stage cannot be considered 'emergencies'. Such arguments have been put forward by our colleagues in support of retaining the word 'accident' in our title.
That terms such as 'Casualty' or 'Accident and Emergency' are derogatory is a matter of opinion. Of greater relevance is that disagreement continues not only over our name, but also regarding our specialty's key direction and consultants' future working patterns in a climate of increasing public demand, limited staffing and resources, and uncertainty over the future structure of emergency health care in the National Health Service. That is what makes emergency medicine such a fascinating specialty to be in, and the formation of a College of Emergency Medicine such a critical step in defining a unified direction for the specialty, whatever we in the United Kingdom finally agree to call it.
References
(1) Reid C, Chan L. Emergency Medicine Terminology in the United Kingdom - time to follow the trend? Emerg Med J 2001;18:79-80
The paper on Emergency Medicine terminology by Reid and Chan [1] has stimulated me to write this letter. As an Australian emergency physician who works in a Department of Emergency Medicine, I view the debate on the naming of our specialty in the United Kingdom with some bewilderment and concern. What should be clearcut has somehow been usurped.
In October 1991, the International Federation of Emergenc...
The paper on Emergency Medicine terminology by Reid and Chan [1] has stimulated me to write this letter. As an Australian emergency physician who works in a Department of Emergency Medicine, I view the debate on the naming of our specialty in the United Kingdom with some bewilderment and concern. What should be clearcut has somehow been usurped.
In October 1991, the International Federation of Emergency Medicine defined the appropriate terminology as 'Emergency Medicine'. The United Kingdom was a founding member and agreed to this definition!
Following this, the Australasian College for Emergency Medicine (ACEM) produced a position paper on standard terminology. This paper states that older terms such as 'casualty' and 'accident and emergency' should be actively discouraged. [2]
At the same time, the then president of ACEM wrote a paper titled: 'Why "Emergency Department" - not "Casualty" or "Accident and Emergency" which was published in Emergency Medicine. [3] I recommend this paper to all readers. In summary , older terms such as "Casualty" or "A&E" are derogatory as the underlying thrust is that the standard of care in the emergency department is "not up to scratch." "Casualty" implies "casual treatment by casual doctors for casual patients." The term "Accident & Emergency" is an absurd tautology.
Words are powerful implements because they shape our thoughts. [3] When someone uses the term "Emergency Department" (or "ED"), they are connoting a facility that provides a decent standard of care for every member of the community, from minor ailments through to life threatening conditions.
It is time for the standard terminology to be adopted and used in the United Kingdom To not use standard terminology is an anathema to our speciality. If the speciality cannot agree on this, then we will be the casualty and this will be no accident!
References
(1) Reid C, Chan L. Emergency Medicine terminology in the United Kingdom -time to follow the trend? Emerg Med J 2001; 18:79-80
(2) http://www .acem.org.au/open/documents/standard.htm
(3) Epstein J. Why Emergency Department" ~ not "Casualty" or " Accident and Emergency". Emergency Medicine 1991 ;3 :70- 73
Brown and Warwick [1] have published an interesting descriptive study of
'blue calls' made to a single inner city hospital over a 3 month period in
1998. They state that their aim was to determine whether the current
system results in inappropriate deployment of hospital staff. However,
the results in the published paper do not show whether any of the patients
who arrived with a pre-hospital warning ha...
Brown and Warwick [1] have published an interesting descriptive study of
'blue calls' made to a single inner city hospital over a 3 month period in
1998. They state that their aim was to determine whether the current
system results in inappropriate deployment of hospital staff. However,
the results in the published paper do not show whether any of the patients
who arrived with a pre-hospital warning had staff inappropriately deployed
to their care. In addition, the authors state that the preparation of
specific drugs or equipment might be useful with warning calls, but no
exploration of whether this was done or not is contained within the paper.
The comparison group chosen (''clinically critical'') was based on
subsequent outcome, (though from Figure 1 at least on patient was
discharged and thus fails to meet the criteria for inclusion), and thus is
poorly matched with the study group recruited in the pre-hospital phase.
It would thus be expected that these patients form a significantly
different population from the study group population and comparisons
between the two should be made cautiously. With the difficulties in
studying this population a case-control study, matching non cardiac arrest
blue calls with controls based on pre-hospital physiological criteria may
have proved more useful. This would then enable an analysis of subsequent
outcome, as well as departmental process, in patients for whom blue calls
were or weren't made. The evaluation of significant confounding variables
(e.g. pre-hospital transport time, on scene time, patient age,etc) could
be made in a regression model.
In any study where separate individuals assess 'appropriateness' of
an intervention or adequacy of an assessment it is useful to know not just
the final (93% in this case) agreed level, but the degree of discrepancy
between the two observers. A measurement of agreement such as Cohen's
kappa would have been useful to determine the inter-observer variability
between an emergency physician and a paramedic in deciding appropriateness
of 'blue calls'.
King's College Hospital may one of the few emergency departments in
the UK where 'blue calls' made by civilian controllers in the ambulance
control centre are given to non-medically trained reception staff rather
than nursing or medical personnel. The authors conclude that no critical
changes were made in this further relay of the message, yet in the results
section they illustrate nine cases of the receptionist making errors in
recording the messages.
The most important message that can be drawn from this paper is that
prior to the introduction of the London Ambulance Service (LAS) 'acute
coronary syndrome' protocol, based on the national service framework for
coronary heart disease [2], some patients with myocardial infarction
arrived at King's College Hospital without a prior warning from the
control room. It may be that the subsequent outcome of these patients
differed during the study period from those that were 'blue-lighted' in.
However, the study design does not allow us to determine whether this
warning call and rapid transport was beneficial or detrimental to their
subsequent outcome. The impact of the change in LAS protocols should be
assessed with a more rigorous analysis of impact on not only adherence to
the 60 minute standard (in the case of patients with myocardial
infarction), but also on overall patient outcome.
Dr Peter Leman
Consultant in Emergency Medicine
St Thomas' Hospital
London SE1 7EH
References
(1) Brown R, Warwick J Blue calls—time for a change? Emerg Med J
2001; 18: 289-292
(2) Department of Health. National Service Framework for Coronary
Heart Disease. , London: March 2000
I thank Drs McIlwee and Jenkins both for their interest in this topic
and for their detailed LAT recipe. The sharing of such information and
experience is the key to enhancing UK knowledge of this technique's
effectiveness. I note that their practical experience with LAT was first
gained in North America.
I agree that there are several non-cocaine containing agents which
have been reported wit...
I thank Drs McIlwee and Jenkins both for their interest in this topic
and for their detailed LAT recipe. The sharing of such information and
experience is the key to enhancing UK knowledge of this technique's
effectiveness. I note that their practical experience with LAT was first
gained in North America.
I agree that there are several non-cocaine containing agents which
have been reported with similar effectiveness to TAC. There is little
doubt that LAT or LET (adrenaline vs. epinephrine) have similar
anaesthetic profiles to 1% lignocaine infiltration [1] or TAC [2-5].
Bupivanor [6] and Tetraphen [7] are also promising agents. However, wounds
treated with Tetralidophen had significantly greater pain scores than
those with TAC [7] or 1% lignocaine [8]. EMLA has also been shown to be
effective in extremity wounds in children [9] but it is not licensed for
this indication and also requires a prolonged application time. These
factors may have prevented its more widespread use. Ametop is similarly
unlicensed. If its application was associated with significant pain, this
may have contributed to the low satisfaction rate reported in the survey.
The subject of the questionnaire was wound management in children and the
questions were clearly worded. Confusion with venepuncture was unlikely to
occur.
Anyone who has had to restrain a struggling child during lignocaine
infiltration would agree that painless anaesthesia is better. Furthermore,
a child who has not been hurt may be calm, allowing more intricate
suturing under local anesthesia and so reduce the need for a general
anaesthetic.
Drs McIlwee and Jenkins feel that the LAT formula used in their
A&E department is safe and effective. If they were to publish their
results, along with the details of their application method and sterility
precautions, more UK A&E departments may be encouraged to adopt
topical anaesthesia for suturing lacerations in children.
We note with interest the letter by Bush and his final sentence " If
an agent without cocaine was shown to have similar efficacy to TAC
(Tetracaine, Adrenaline, and Cocaine), it may allow more widespread use of
topical anaesthesia (TA) in the UK." [1]
There are several agents which are at least as efficacious as TAC.
The following agents do not contain cocaine: LAT (Lidocaine, Adrenaline
and Tetracaine) [2,3], E...
We note with interest the letter by Bush and his final sentence " If
an agent without cocaine was shown to have similar efficacy to TAC
(Tetracaine, Adrenaline, and Cocaine), it may allow more widespread use of
topical anaesthesia (TA) in the UK." [1]
There are several agents which are at least as efficacious as TAC.
The following agents do not contain cocaine: LAT (Lidocaine, Adrenaline
and Tetracaine) [2,3], EMLA [4], Bupivanor [5], Tetraphen and
Tetralidophen [6,7].
We would like to share the formulation for a topical anaesthetic
which has been shown to be safe and effective. One of us (MGJ) has used
this regularly while working as Paediatric Emergency Medicine Fellow in
British Columbia's Children's Hospital Emergency Department.
We advise that the local hospital pharmacy services take
responsibility for quality assurance. Sourcing some of the ingredients may
prove difficult.
Procedure:
Dissolve lidocaine and tetracaine in 10ml bacteriostatic saline.
Transfer solution into a graduated cylinder.
Draw up epinephrine in 30ml syringe and add to the graduated cylinder Q.S.
to 50ml with bacteriostatic normal saline.
Weigh 1.5g of methylcellulose powder and place in mortar.
Slowly add small amounts of LAT solution to the methylcellulose, mixing
well before adding more liquid.
Package in 50g ointment jars, which should be labelled.
This will produce 50ml of LAT, with an expiry time of 150 days.
Sample label: " LAT Topical Gel Lidocaine 4% Adrenaline 1:2000
Tetracaine 0.5% EXP 5months. Keep refrigerated. Protect from light."
We were surprised to note the use of Ametop® by 26% of respondents in
open wound repair in children.
Ametop® is unlicensed for use in such a way. This preparation has a
5% sodium chloride base: this will cause marked pain when applied to an
open wound [8]. We wonder if the respondents, when answering the
questionnaire mistook the question as relating to venepuncture.
The ideal topical anaesthetic should be safe, effective, have rapid
onset with rasonable duration of action, while not causing discomfort.
(1) Bush S. Topical anaesthesia use in the management of children's
lacerations, a postal survey. J Accid Emerg Med 2000;17:310-311.
(2) Ernest A A, Marvez E, Nick T G, et al. Lidocaine adrenaline and
tetracaine gel versus tetracaine adrenaline and cocaine gel for topical
anaesthesia in linear scalp and facial lacerations in children aged 5 to
17 years. Paediatrics 1995;95:255-258.
(3) Schilling C G, Bank D E, Borchert B A, et al. Tetracaine, epinephrine
(adrenaline) and cocaine (TAC) versus lidocaine, epinephrine and
tetracaine (LET) for anaesthesia of lacerations in children. Ann Emerg Med
1995;25:203-208.
(4) Zempsky W T, Karasic R B. EMLA versus TAC for topical anaesthesia of
extremity wounds in children. Ann Emerg Med 1997;30:163-166.
(5) Smith G A, Straubaugh S D, Harbech-Weber C, et al. Comparison of
topical anaesthetics without cocaine to tetracaine-adrenaline-cocaine and
lidocaine infiltration during repair of lacerations:bupivicaine-
norepinephrine is an effective new topical anaesthetic agent. Paediatrics
1996;97:301-307.
(6) Smith G A, Strausbaugh S D, Harbech-Weber C et al. New non-cocaine
containing topical anaesthetics compared with tetracaine-adrenaline-
cocaine during repair of lacerations. Paediatrics 1997;100:825-830.
(7) Smith GA, Strausbaugh SD, Harbech-Weber C et al. Prilocaine-
phenylephrine and bupivacaine-phenylephrine topical anaesthetics compared
with tetracaine-adrenaline-cocaine during repair of lacerations. Am J
Emerg Med 1998;16:121-124.
(8) Professor Wolfson, The Queen's University of Belfast, Inventor of
Ametop ®, personal correspondence.
I was interested to read Dr de Andrade Nishioka’s letter. He wonders
which interventions we should focus on to decrease the mortality from
meningococcal disease. In a review of deaths from meningococcal disease,
the most frequent and lengthy delays were parents not recognising that
their child was seriously ill and doctors failing to make the diagnosis
[1]. We therefore need to improve both of these.
Early...
I was interested to read Dr de Andrade Nishioka’s letter. He wonders
which interventions we should focus on to decrease the mortality from
meningococcal disease. In a review of deaths from meningococcal disease,
the most frequent and lengthy delays were parents not recognising that
their child was seriously ill and doctors failing to make the diagnosis
[1]. We therefore need to improve both of these.
Early antibiotic treatment decreases the risk of dying from meningococcal
disease [2]. Strategies to improve this are thus worthwhile. However in a
single centre these cannot be expected to show a decrease in mortality.
Dr de Andrade Nishioka’s suggests "first manifestation to first
examination time" might be a useful prognostic indicator. However children
with severe meningococcal disease become unwell rapidly and present to
hospital sooner. In a previously reported cohort of children with
meningococcal disease [3], median "first manifestation to first
examination time" was significantly shorter in those who died compared to
survivors (12 Vs 17 hours; P=0.012). The usefulness of this time is thus
confounded by disease severity. However early recognition of meningococcal
disease by parents can lead to better outcomes [4].
I agree that parents require accurate and appropriate information about
meningococcal disease, but improvements are also required in the early
recognition and treatment of children with this potentially life-
threatening disease [5].
References.
(1) Slack J. Deaths from meningococcal infection in England and Wales
in 1978. J Roy Col Phys London 1982;16:40-44.
(2) Cartwright K, Strang J, Gossain S, Begg N. Early treatment of
meningococcal disease. BMJ 1992;305:774
(3) Riordan FAI, Thomson APJ, Sills JA, Hart CA. Who spots the spots?
The diagnosis and treatment of early meningococcal disease in children.
BMJ 1996;313:1255-1256
(4) Riordan FAI, Thomson APJ. Early presentation of meningococcal disease
after media publicity. Arch Dis Child 1993;69:711
(5) Nadel S, Britto J, Booy R, Maconochie I, Habibi P, Levin M.
Avoidable deficiencies in the delivery of health care to children with
meningococcal disease. J Accid Emerg Med 1998;15:298-303
In the article by Greingor et al on carbon monoxide poisoning in pregnancy, one word is notably absent from the Discussion. I quote, with the word inserted,'CO intoxication is the most frequently reported (FATAL) poisoning in Western developed countries'. Most of us are aware that analgesic drugs are still the commonest intoxicating agent - are we not?
Julian Kennedy
While I agree that the specialty in the UK should move to using the title "Emergency Medicine" I would council that it may be difficult to gain acceptance of the name amongst the wider community - both medical and non- medical.
Here in Australia, the specialty has been officially named "Emergency Medicine" since the Australasian College for Emergency Medicine was incorporated in 1984. However, this mes...
We thank Dr. T. Ho for his comment on our article reporting a young patient with tuberculous osteomyelitis [1]. We wrote the article from the perspective of emergency medicine. Although polymerase chain reaction (PCR) is a good adjunct to microbiological culture for diagnosing mycobacterium tuberculosis, it is not available to the majority of emergency physicians in Hong Kong. Nonetheless, we should discuss it b...
Yuen and Tung describe a case of tuberculous osteomyelitis of the foot [1] and the potential difficulties in making the diagnosis. The authors were fortunate enough to have typical histological biopsy findings which subsequently cultured Mycobacterium tuberculosis (TB), providing diagnostic confirmation and estimations of sensitivities. However, in many instances, the diagnosis of tuberculosis is difficult to ve...
We are delighted that our paper [1] has stimulated a response from overseas colleagues, who have shared with us some Australasian opinions.
Whilst we agree that adopting the term 'emergency medicine' would bring us into line with international standard terminology, the fact remains that 'accident and emergency' appeals to many, and debate will continue as long as practice between and within United Kingdom...
The paper on Emergency Medicine terminology by Reid and Chan [1] has stimulated me to write this letter. As an Australian emergency physician who works in a Department of Emergency Medicine, I view the debate on the naming of our specialty in the United Kingdom with some bewilderment and concern. What should be clearcut has somehow been usurped.
In October 1991, the International Federation of Emergenc...
Dear Editor
Brown and Warwick [1] have published an interesting descriptive study of 'blue calls' made to a single inner city hospital over a 3 month period in 1998. They state that their aim was to determine whether the current system results in inappropriate deployment of hospital staff. However, the results in the published paper do not show whether any of the patients who arrived with a pre-hospital warning ha...
Editor,
I thank Drs McIlwee and Jenkins both for their interest in this topic and for their detailed LAT recipe. The sharing of such information and experience is the key to enhancing UK knowledge of this technique's effectiveness. I note that their practical experience with LAT was first gained in North America.
I agree that there are several non-cocaine containing agents which have been reported wit...
We note with interest the letter by Bush and his final sentence " If an agent without cocaine was shown to have similar efficacy to TAC (Tetracaine, Adrenaline, and Cocaine), it may allow more widespread use of topical anaesthesia (TA) in the UK." [1]
There are several agents which are at least as efficacious as TAC. The following agents do not contain cocaine: LAT (Lidocaine, Adrenaline and Tetracaine) [2,3], E...
I was interested to read Dr de Andrade Nishioka’s letter. He wonders which interventions we should focus on to decrease the mortality from meningococcal disease. In a review of deaths from meningococcal disease, the most frequent and lengthy delays were parents not recognising that their child was seriously ill and doctors failing to make the diagnosis [1]. We therefore need to improve both of these. Early...
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