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Lu W, Yon DK, Lee SW, Koyanagi A, Smith L, Shin JI, Rahmati M, Xiao W, Li Y. Safety of Early Surgery in Hip Fracture Patients Taking Clopidogrel and/or Aspirin: A Systematic Review and Meta-Analysis. J Arthroplasty 2024; 39:1374-1383.e3. [PMID: 37972664 DOI: 10.1016/j.arth.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND The aim of this study was to investigate the safety of early surgery in hip fracture patients who took clopidogrel and/or aspirin. METHODS A systematic search was conducted using databases, including PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science, for studies relating to early arthroplasty or internal fixation for femoral neck fractures, intertrochanteric fractures, and subtrochanteric fractures in patients taking clopidogrel and/or aspirin. A total of 20 observational studies involving 3,077 patients were included in this meta-analysis, and analyzed in groups of early surgery versus delayed surgery, and clopidogrel and/or aspirin versus nonantiplatelet agents. RESULTS Patients in the clopidogrel and/or aspirin group who underwent early surgery had significantly more intraoperative blood loss than those in the non-antiplatelet group (mean difference = 17.96, 95% confidence interval [CI] [4.37, 31.55], P = .01), and patients in the clopidogrel and/or aspirin group had a lower overall incidence of complications after early surgery than those in the delayed surgery group (odds ratio = 0.26, 95% CI [0.14, 0.29], P < .001) and a shorter length of hospital stay (odds ratio = 0.26, 95% CI [0.14, 0.29], P < .001). There was no significant difference in postoperative mortality and other related indicators. CONCLUSIONS Early surgery in hip fracture patients taking clopidogrel and/or aspirin appears to be safe based on the available evidence and needs to be clarified by higher quality studies. However, the increased risk of cardiovascular events associated with discontinuation of clopidogrel or clopidogrel combined with aspirin dual antiplatelet therapy requires attention in the perioperative period.
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Affiliation(s)
- Wenhao Lu
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Dong Keon Yon
- Center for Digital Health, Medical Science Research Institute, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, Republic of Korea; Department of Pediatrics, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Seung Won Lee
- Department of Precision Medicine, Sungkyunkwan University College of Medicine, Suwon, Republic of Korea
| | - Ai Koyanagi
- Research and Development Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
| | - Lee Smith
- Centre for Health, Performance, and Wellbeing, Anglia Ruskin University, Cambridge, UK
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Masoud Rahmati
- Department of Physical Education and Sport Sciences, Faculty of Literature and Human Sciences, Lorestan University, Khoramabad, Iran; Department of Physical Education and Sport Sciences, Faculty of Literature and Humanities, Vali-E-Asr University of Rafsanjan, Rafsanjan, Iran
| | - Wenfeng Xiao
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yusheng Li
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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Premji AM, Blegen MB, Corley AM, Ulloa J, Booth MS, Begashaw M, Larkin J, Shekelle P, Girgis MD, Maggard-Gibbons M. Dual antiplatelet management in the perioperative period: updated and expanded systematic review. Syst Rev 2023; 12:197. [PMID: 37838696 PMCID: PMC10576385 DOI: 10.1186/s13643-023-02360-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 09/25/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND Antiplatelet agents are central in the management of vascular disease. The use of dual antiplatelet therapy (DAPT) for the management of thromboembolic complications must be weighed against bleeding risk in the perioperative setting. This balance is critical in patients undergoing cardiac or non-cardiac surgery. The management of patients on DAPT for any indication (including stents) is not clear and there is limited evidence to guide decision-making. This review summarizes current evidence since 2015 regarding the occurrence of major adverse events associated with continuing, suspending, or varying DAPT in the perioperative period. METHODS A research librarian searched PubMed and Cochrane from November 30, 2015 to May 17, 2022, for relevant terms regarding adult patients on DAPT for any reason undergoing surgery, with a perioperative variation in DAPT strategy. Outcomes of interest included the occurrence of major adverse cardiac events, major adverse limb events, all-cause death, major bleeding, and reoperation. We considered withdrawal or discontinuation of DAPT as stopping either aspirin or a P2Y12 inhibitor or both agents; continuation of DAPT indicates that both drugs were given in the specified timeframe. RESULTS Eighteen observational studies met the inclusion criteria. No RCTs were identified, and no studies were judged to be at low risk of bias. Twelve studies reported on CABG. Withholding DAPT therapy for more than 2 days was associated with less blood loss and a slight trend favoring less transfusion and surgical re-exploration. Among five observational CABG studies, there were no statistically significant differences in patient death across DAPT management strategies. Few studies reported cardiac outcomes. The remaining studies, which were about procedures other than exclusively CABG, demonstrated mixed findings with respect to DAPT strategy, bleeding, and ischemic outcomes. CONCLUSION The evidence base on the benefits and risks of different perioperative DAPT strategies for patients with stents is extremely limited. The strongest signal, which was still judged as low certainty evidence, is that suspension of DAPT for greater than 2 days prior to CABG surgery is associated with less bleeding, transfusions, and re-explorations. Different DAPT strategies' association with other outcomes of interest, such as MACE, remains uncertain. SYSTEMATIC REVIEW REGISTRATION A preregistered protocol for this review can be found on the PROSPERO International Prospective Register of systematic reviews ( http://www.crd.york.ac.uk/PROSPERO/ ; registration number: CRD42022371032).
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Affiliation(s)
- Alykhan M Premji
- Veterans Health Administration, Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA, 90073, USA.
| | - Mariah B Blegen
- Veterans Health Administration, Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA, 90073, USA
- National Clinician Scholars Program, University of California, Los Angeles, 1100 Glendon Ave., Suite 900, Los Angeles, CA, 90024, USA
| | - Alyssa M Corley
- Duke University School of Medicine, DUMC Box 104002, Durham, NC, 27710, USA
| | - Jesus Ulloa
- Veterans Health Administration, Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA, 90073, USA
- David Geffen School of Medicine at University of California, Los Angeles, 885 Tiverton Dr., Los Angeles, CA, 90095, USA
| | - Marika S Booth
- Southern California Evidence-Based Practice Center, RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA
| | - Meron Begashaw
- Veterans Health Administration, Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA, 90073, USA
| | - Jody Larkin
- Southern California Evidence-Based Practice Center, RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA
| | - Paul Shekelle
- Veterans Health Administration, Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA, 90073, USA
| | - Mark D Girgis
- Veterans Health Administration, Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA, 90073, USA
- David Geffen School of Medicine at University of California, Los Angeles, 885 Tiverton Dr., Los Angeles, CA, 90095, USA
| | - Melinda Maggard-Gibbons
- Veterans Health Administration, Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, CA, 90073, USA
- David Geffen School of Medicine at University of California, Los Angeles, 885 Tiverton Dr., Los Angeles, CA, 90095, USA
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Fisher A, Srikusalanukul W, Fisher L, Smith PN. Comparison of Prognostic Value of 10 Biochemical Indices at Admission for Prediction Postoperative Myocardial Injury and Hospital Mortality in Patients with Osteoporotic Hip Fracture. J Clin Med 2022; 11:jcm11226784. [PMID: 36431261 PMCID: PMC9696473 DOI: 10.3390/jcm11226784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/09/2022] [Accepted: 11/11/2022] [Indexed: 11/19/2022] Open
Abstract
Aim: To evaluate the prognostic impact at admission of 10 biochemical indices for prediction postoperative myocardial injury (PMI) and/or hospital death in hip fracture (HF) patients. Methods: In 1273 consecutive patients with HF (mean age 82.9 ± 8.7 years, 73.5% women), clinical and laboratory parameters were collected prospectively, and outcomes were recorded. Multiple logistic regression and receiver-operating characteristic analyses (the area under the curve, AUC) were preformed, the number needed to predict (NNP) outcome was calculated. Results: Age ≥ 80 years and IHD were the most prominent clinical factors associated with both PMI (with cardiac troponin I rise) and in-hospital death. PMI occurred in 555 (43.6%) patients and contributed to 80.3% (49/61) of all deaths (mortality rate 8.8% vs. 1.9% in non-PMI patients). The most accurate biochemical predictive markers were parathyroid hormone > 6.8 pmol/L, urea > 7.5 mmol/L, 25(OH)vitamin D < 25 nmol/L, albumin < 33 g/L, and ratios gamma-glutamyl transferase (GGT) to alanine aminotransferase > 2.5, urea/albumin ≥ 2.0 and GGT/albumin ≥ 7.0; the AUC for developing PMI ranged between 0.782 and 0.742 (NNP: 1.84−2.13), the AUC for fatal outcome ranged from 0.803 to 0.722, (NNP: 3.77−9.52). Conclusions: In HF patients, easily accessible biochemical indices at admission substantially improve prediction of hospital outcomes, especially in the aged >80 years with IHD.
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Affiliation(s)
- Alexander Fisher
- Departments of Geriatric Medicine, The Canberra Hospital, ACT Health, Canberra 2605, Australia
- Departments of Orthopaedic Surgery, The Canberra Hospital, ACT Health, Canberra 2605, Australia
- Medical School, Australian National University, Canberra 2605, Australia
- Correspondence:
| | - Wichat Srikusalanukul
- Departments of Geriatric Medicine, The Canberra Hospital, ACT Health, Canberra 2605, Australia
| | - Leon Fisher
- Department of Gastroenterology, Frankston Hospital, Peninsula Health, Melbourne 3199, Australia
| | - Paul N. Smith
- Departments of Orthopaedic Surgery, The Canberra Hospital, ACT Health, Canberra 2605, Australia
- Medical School, Australian National University, Canberra 2605, Australia
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The effect of granules characters on mechanical properties of press-coated tablets: A comparative study. Int J Pharm 2022; 624:121986. [PMID: 35820516 DOI: 10.1016/j.ijpharm.2022.121986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/02/2022] [Accepted: 07/02/2022] [Indexed: 11/20/2022]
Abstract
The aim of this study was to investigate the correlation between critical granules characters (including particle size, surface roughness, and apparent porosity) and mechanical properties of press-coated tablets. Granules of a model formulation were prepared through Roll Compaction Granulation (RCG), High Shear Granulation (HSG), and Fluidized Bed Granulation (FBG) to prepare granules with different surface roughness and apparent porosity. The surface roughness and porosity of granules had a significantly greater effect on mechanical properties than the particle size of granules. Whether for brittle or plastic materials, FBG granules with the roughest surface and the greatest apparent porosity exhibited the best compression properties. The elastic recovery test, the interlayer adhesion forces study, the break pattern test, and the X-ray microcomputed tomography investigation suggested that granules with great apparent porosity and rough surfaces could contribute to the production of stable press-coated structures. Moreover, for press-coated tablets prepared using granules, the proper granules in the coat layer could eliminate the side effect of the rigid core on the mechanical strength. The above understandings will be conducive to the selection of compatible and appropriate granules characters, which can enhance mechanical properties and extend the application of press-coated tablets.
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De Vincentis A, Behr AU, Bellelli G, Bravi M, Castaldo A, Galluzzo L, Iolascon G, Maggi S, Martini E, Momoli A, Onder G, Paoletta M, Pietrogrande L, Roselli M, Ruggeri M, Ruggiero C, Santacaterina F, Tritapepe L, Zurlo A, Antonelli Incalzi R. Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus. Aging Clin Exp Res 2021; 33:2405-2443. [PMID: 34287785 DOI: 10.1007/s40520-021-01898-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues. AIM To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF. METHODS A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence. RESULTS A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics). CONCLUSION These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.
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Tescione M, Vadalà E, Marano G, Battaglia E, Bruni A, Garofalo E, Longhini F, Rovida S, Polimeni N, Squillaci R, Lascala S, Franco G, Labate D, Caracciolo M, Macheda S. Platelet aggregometry for hip fracture surgery in patients treated with clopidogrel: a pilot study. J Clin Monit Comput 2021; 36:823-828. [PMID: 33956283 DOI: 10.1007/s10877-021-00714-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 04/23/2021] [Indexed: 11/25/2022]
Abstract
Surgery for hip fractures should be performed within 48 h from patient's admission. However, several factors including chronic antiplatelet therapy could delay operation. Among the totality of patients taking clopidogrel, up to 30% are resistant to the drug and have a normal platelets reactivity. We propose thromboelastography (TEG) with an ADP Platelet Mapping assay kit to assess platelet aggregation, a safe tool that could help to avoid surgery delay in those patients treated with antiplatelet therapy. A patient's blood sample was collected for aggregometry. If MA-ADP and platelets aggregation (%) were within normal values, the patient was fit for immediate surgery with neuraxial anesthesia and ultrasound-guided nerve block. If one of the two parameters or both were deranged, a mortality risk assessment was estimated. In the low risk category, the patients waited till normalization of the parameters, whereas in the high-risk group a general anesthesia and peripheral antalgic block was carried out. Nine patients were enrolled. Four of them showed normal aggregometry and surgery was performed within 24 h from admission. Two patients were classified as high mortality risk and surgery was carried out under general anesthesia. Three patients awaited operation till normalization of parameters. No peri or post-operative complications were reported. An aggregometry-guided protocol can safely expedite hip fracture surgery in patients taking clopidogrel. Nonetheless, in presence of a normal platelets function, clinician can opt for a neuraxial instead of general anesthesia reducing the incidence of postoperative delirium and cognitive dysfunction.Trial registration: prospectively registered at clinicaltrials.gov (NCT04642209; date of registration: 23rd November 2020).
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Affiliation(s)
- Marco Tescione
- Anesthesia and Intensive Care Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy.
| | - Eugenio Vadalà
- Anesthesia and Intensive Care Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
| | - Graziella Marano
- Anesthesia and Intensive Care Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
| | - Enzo Battaglia
- Anesthesia and Intensive Care Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
| | - Andrea Bruni
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Eugenio Garofalo
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Serena Rovida
- Department of Emergency Medicine, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Nicola Polimeni
- Anesthesia and Intensive Care Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
| | - Rosalba Squillaci
- Anesthesia and Intensive Care Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
| | - Stefano Lascala
- Anesthesia and Intensive Care Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
| | - Gaetana Franco
- Anesthesia and Intensive Care Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
| | - Demetrio Labate
- Anesthesia and Intensive Care Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
| | - Massimo Caracciolo
- Anesthesia and Intensive Care Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
| | - Sebastiano Macheda
- Anesthesia and Intensive Care Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
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Tarrant SM, Catanach MJ, Sarrami M, Clapham M, Attia J, Balogh ZJ. Direct Oral Anticoagulants and Timing of Hip Fracture Surgery. J Clin Med 2020; 9:jcm9072200. [PMID: 32664649 PMCID: PMC7408859 DOI: 10.3390/jcm9072200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/01/2020] [Accepted: 07/07/2020] [Indexed: 11/16/2022] Open
Abstract
Timely surgical intervention in hip fracture has been linked to improved outcomes. Direct Oral Anticoagulants (DOACs) are an emerging class of anticoagulants without evidence-based guidelines on surgical timing. This study aims to investigate how DOACs affect surgical timing and hence perioperative outcomes. A retrospective database/registry review was conducted for geriatric hip fracture patients aged 65 and over between 2011 and 2018. Primary outcome was 30-day mortality. Secondary outcomes included serious adverse events (SAE), transfusion and postoperative day (POD) 1 haemoglobin (Hb) levels. From a cohort of 3264 patients, 112 admitted subjects were taking DOACs; the annual proportion on DOACs increased over time. Mean time to surgery from last dose (Ts) was 2.2 (±1.0 SD) days. The primary outcome, 30-day mortality, occurred in 16 (14%) patients with secondary outcomes of SAEs in 25 (22%) patients and transfusion in 30 (27%) patients. Ts (days) did not significantly affect 30-day mortality (odds ratio (OR): 1.37, 95% confidence interval (CI): 0.80–2.33; p = 0.248), SAE (hazard ratio (HR): 1.03, 95% CI: 0.70–1.52; p = 0.885), transfusion (OR: 0.72 95% CI: 0.45 to 1.16; p = 0.177) or POD 1 Hb (OR: 1.99, 95% CI: −0.59 to 4.57; p = 0.129). Timing of surgery does not influence common surgical outcomes such as 30-day mortality, SAE, transfusion, and POD1 Hb in patients taking DOACs on admission.
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Affiliation(s)
- Seth M. Tarrant
- John Hunter Hospital, Lookout Rd, New Lambton Heights, NSW 2305, Australia; (S.M.T.); (M.J.C.)
- University of Newcastle, Callaghan, NSW 2308, Australia; (M.S.); (J.A.)
| | - Michael J. Catanach
- John Hunter Hospital, Lookout Rd, New Lambton Heights, NSW 2305, Australia; (S.M.T.); (M.J.C.)
| | - Mahsa Sarrami
- University of Newcastle, Callaghan, NSW 2308, Australia; (M.S.); (J.A.)
| | - Matthew Clapham
- Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia;
| | - John Attia
- University of Newcastle, Callaghan, NSW 2308, Australia; (M.S.); (J.A.)
- Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia;
| | - Zsolt J. Balogh
- John Hunter Hospital, Lookout Rd, New Lambton Heights, NSW 2305, Australia; (S.M.T.); (M.J.C.)
- University of Newcastle, Callaghan, NSW 2308, Australia; (M.S.); (J.A.)
- Correspondence:
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