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To the contrary 120 mg sildigra with mastercard erectile dysfunction reviews, evidence is particularly relevant when ordering imaging examina- tions for diagnostic purposes order sildigra now erectile dysfunction injections. First, proper treatment depends on an accurate xiv xiv Preface diagnosis, and therefore it is essential that the proper test be ordered. Second, imaging tests may trigger a “cascade” of follow-up testing if the initial results are equivocal. T us, it is critical that clinicians are parsimonious in selecting imaging examinations to avoid unnecessary tests and interventions. Finally, as you will learn in the section dedicated to radiation exposure, many imaging tests result in substantial exposure to ionizing radiation, which can be harmful. Using an evidence-based approach with imaging is important not only for ob- taining the proper diagnosis but also to avoid inadvertent harm. In this volume, we have atempted to identify key studies from the radiology literature and to present them in an accessible format. A small handful of the studies we selected come directly from the original edition of 50 Studies Every Doctor Should Know but most are new to this edition. We begin each study sum- mary by identifying the clinical question being addressed; we then summarize the main fndings and methodological strengths and weaknesses. We conclude each summary by highlighting the central message and the implications for clinical practice. We also provide a clinical case at the end of each chapter, which gives you an opportunity to apply the fndings in a real-life situation. Although the study summaries in this volume focus on the feld of radiology, we have writen the book for a general medical audience. Afer all, it is non- radiologists who order most imaging examinations, and thus clinicians in all felds must be familiar with the evidence behind what they are ordering. Based on feed- back from the original edition of 50 Studies Every Doctor Should Know, we used a rigorous selection process in which we surveyed experts in the feld of internal medicine, and we used their input to develop our list. Even despite our eforts to use a systematic process to select studies, we suspect that some will disagree with our selections. Still, we believe the studies we describe cover a wide array of topics in medical imaging. As always, we are happy to receive feedback and suggestions for future editions of this book. Finally, we hope that you will fnish this book not only with a strong under- standing of the key studies in the feld of radiology but also with a framework xv Preface xv for reviewing clinical studies and applying the results to practice. We hope this will enable physicians and patients alike to make more thoughtful and in- formed decisions when ordering medical imaging examinations. Michael Hochman, the series editor, for the opportu- nity to write this book and for allowing me to borrow several chapters from his original book in this series, 50 Studies Every Doctor Should Know. Joseph Fotos for serving as a chapter text editor and for providing almost all of the excellent imaging examples found throughout the book. Andrea Knobloch and Rebecca Suzan at Oxford University Press have been extremely supportive, and simpli- fed the logistics for this work. I also thank the several anonymous expert re- viewers commissioned by Oxford who helped select the list of included studies. I’ve been fortunate to have many mentors help guide me to successfully get to where I am today as a physician-scientist. Howard Forman, Terry Desser, Carol Mangione, Norman Beauchamp, Connie Lehman, Jerry Jarvik, Janie Lee, Joann Elmore, and Scot Ramsey for their generosity and sage advice. I credit having the time and encouragement to write this book to my wife and best friend, Monique Mogensen, and my amaz- ing family, including John, Jay, Betina, Elena, Carson, and Elsa Lee. Finally, I would like to thank the authors of the studies included in this book that I have listed hereafer. T ese authors graciously took the time to review the scientifc summaries for accuracy. Importantly, the views expressed in this book do not represent those of the authors acknowledged next, nor is the overall accuracy of information a refection of their reviews; any mistakes remain my own. He completed his radiology residency at Stanford University and a health policy fellowship as a Robert Wood Johnson Foundation Clinical Scholar. He joined the University of Washington School of Medicine as an assistant professor in 2012, and was promoted to associate professor in 2015. Lee is the lead editor and author of fve textbooks spanning the basic sciences, evidence-based medicine, and medical imaging, distributed both nationally and internationally. Lee has authored more than 50 peer-reviewed journal articles, and currently serves on the editorial boards of the American Journal of Roentgenology and the Journal of the American College of Radiology. He is considered a national thought leader in imaging-related policy and health services research. Year Study Began: 1997 Year Study Published: 2000 Study Location: Single large inner-city level 1 trauma center. How Many Patients: 520 patients for frst phase; 909 patients for second phase Study Overview: T is was a two-phase study. T e frst phase was to record clinical fndings in consecutive patients presenting with minor head trauma, including demographic data, symptoms, and physical exam fndings. Follow- Up: Patients were followed until discharge from the emergency department or hospital. Endpoints: Sensitivity, specifcity, and negative predictive value of the deter- mined criteria. Patients were not fol- lowed after discharge, so data are unavailable on delayed complications of minor head injuries. T e patient was the driver of the vehicle, and he experienced a brief loss of consciousness afer his head hit the steering wheel just before the air bag deployed. His Glasgow Coma Scale score is 15 of 15 and he does not have any neurologic defcits on examination. On physical exam, he exhibits neck stifness, as well as abrasions and burns involving his neck and forehead, likely from impact and airbag deploy- ment. T e New Orleans Criteria apply to all patients >3 years of age with normal Glasgow Coma Scale scores (15 out of 15) and neurologic exam- inations at presentation. T is patient does show evidence of physical trauma above the level of the clavicles, 1 of the 7 criteria associated with an acute traumatic intracranial lesion. Prediction of intracranial injury in children aged fve years and older with loss of consciousness afer minor head injury due to nontrivial mechanisms. Who Was Studied: Children <18 years presenting to emergency departments within 24 hours of blunt traumatic head injuries. Who Was Excluded: Children with “trivial” injuries such as ground-level falls without signs or symptoms of head injuries aside from scalp lacerations or abrasions, as well as children with penetrating trauma, brain tumors, and “pre- existing neurological disorders. In the derivation phase, binary recursive partitioning was used to derive a set of criteria with the goal of max- imizing the negative predictive value and sensitivity of prediction rules. In the validation phase, performances of the rules were evaluated in similar, respec- tive age cohorts. Derivation of Prediction Rules: emergency department physicians inter- viewed and examined a sample of children with head trauma (the derivation sample) to collect information about each child’s history and physical exam- ination fndings.

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Which of the following represents the patient history that most likely explains the adverse event? The angiotensin converting enzyme also breaks down bradykinins cheap sildigra 50mg fast delivery erectile dysfunction protocol jason, potent vasodilators trusted sildigra 25mg erectile dysfunction drugs at walgreens, to prevent hypotension. Normally, the angiotensin converting enzyme rapidly degrades bradykinin to minimize vasodilation. Other classes of antihypertensive drugs have not been associated with anaphylactoid responses (Answers A, C, and D). John’s wort is not known to interfere with bradykinin metabolism, it is important to consider alternative therapies when investigating adverse reactions (Answer E). For an average 70-kg adult, the estimated total body water is estimated to be ∼40 L. Therefore, periprocedural monitoring of the patient’s therapeutic range is recommended (Answer B). A 35-year-old female in previously good health presents to the emergency room complaining of extreme fatigue. She also reports that she is currently having unusually prolonged and heavy menstruation for the past 5 days. Her pertinent laboratory values are as follows: Patient value White cell count 13 × 109/L Hemoglobin 6. Platelet transfusions are relatively contraindicated, based on anecdotal reports and theoretical risk of thrombotic complications (Answers A and B). While some providers may be hesitant to insert a central line, it can be performed safely in most patients with thrombocytopenia without platelet transfusions. A 20-year-old woman is admitted to the hospital for work-up of ocular pain and reduced vision in her right eye. She states that she has experienced occasional bladder incontinence in the previous week. These lesions are associated with vision loss, paresthesia, paraplegia, radiculopathy, and ocular pain. Plasma exchange is indicated for all of the autoimmune neurologic conditions listed in the other choices (Answers B, C, D, and E). Yes, because Shiga toxin producing Escherichia coli is not the only bacteria that causes this condition C. Yes, because this patient is experiencing uncontrolled activation of alternative complement system D. A heart allograft is now available and the transplant is scheduled in the next four h. The antibody binds to the complexes and the heavy chain engages the Fc receptor on the platelet surface, leading to platelet activation, release of prothrombotic microparticles, which can lead to clot formation. However, the most serious and sometimes deadly consequence is the formation of venous or arterial thromboses that can lead to death or limb amputations due to tissue ischemia. A 54-year-old male patient with Waldenstrom macroglobulinemia presents with headache, confusion, blurred vision, dyspnea, and epistaxis. TherApeuTic AnD Donor Apheresis 343 hyperviscosity due to the excess immunoglobulins. Answer: C—Elevated levels of monoclonal IgM immunoglobulins are the cause of hyperviscosity in Waldenstrom’s macroglobulinemia. Because of the effciency of IgM removal, typically only 1–3 procedures are needed for signifcant relief from hyperviscosity symptoms. The patient has a mature fstula in her left arm that has been used for years without diffculty. The patient has one peripheral vein in her right arm that is suitable for access pressures required during the apheresis procedures. Program the apheresis instrument to perform a discontinuous procedure using a single access site Concept: Most therapeutic apheresis procedures are performed using a continuous fow that requires separate access and return sites. Continuous procedures are faster than discontinuous (or intermittent) procedures because the separation chamber is not emptied until the end of the process. Discontinuous procedures may be performed with a single access site that also serves as the return site. Answer: E—Because this patient has good peripheral access in her right arm, discontinuous/ single needle procedures can be performed until the fstula is functional or an alternative access is established. If at all possible, procedures should not be delayed to minimize risk of allograft loss (Answers A and B). Some apheresis instruments have dual programming that allows for continuous (double-needle) or discontinuous (single-needle) procedures. Although a central line is another option for this patient, a long-term tunneled line, not a temporary catheter (Answer C) should be placed to minimize infectious complications in this immunocompromised patient. Access and return needles should not be placed in the same vein to prevent recirculation and damage to the vasculature (Answer D). A 21-year-old female from Connecticut seeks evaluation in the emergency room for recurrent fevers, chills, night sweats, fatigue, and altered mental status. TherApeuTic AnD Donor Apheresis 2 weeks ago, who diagnosed her with the common cold. Incidentally, a peripheral smear was performed on the patient’s blood and the laboratory technologist observed intracellular parasites. The pathology resident on- call identifes the parasites as being consistent with Babesia and estimates that the parasite load is approximately 15%. Most patients receive antibiotics, such as azithromycin, as a frst line treatment. However, in cases that do not respond to antibiotics, or cases with high parasite loads (>10%) or with signifcant comorbidities, such as signifcant hemolysis, disseminated intravascular coagulation, pulmonary, renal, or hepatic compromise, red blood cell exchange of 1–2 blood volumes is indicated. Her kidney biopsy shows histologic changes consistent with antibody mediated rejection and positive complement staining (C4d positivity). Even closely matched donor and recipient pairs may have histocompatibility mismatches that could lead to rejection of the transplanted organ. While immunosuppression can be successful in preventing development of donor specifc antibodies, antibody production can be the result of medical noncompliance or other immunologic triggers, such as infection. TherApeuTic AnD Donor Apheresis 345 patient’s original plasma due to recirculation throughout the procedure. In other words, 63% of the intravascular protein (including pathogenic antibodies) can be removed with a one-volume plasma exchange. The relationship between plasma removal and plasma volumes processed is not linear because of recirculation during the procedure. After an exchange, approximately 30%–40% of a pathogenic antibody can remain in the patient’s plasma or be distributed in the tissues of the extravascular space. After the exchange, the antibody may slightly increase due to continued production by the patient or due to tissue redistribution.

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In most cases order generic sildigra from india impotence at 40, the femoral neck is anterior to the transcondylar femoral axis (called anteversion) purchase sildigra with a mastercard erectile dysfunction treatment australia. Tibial torsion is measured clinically by malleolar position, which is the angle between the knee axis and the medial and lateral malleoli. Tibial varum is compensated in the foot with subtalar joint pronation, and tibial valgum is compensated by supination. Tibial varum and valgum must be evaluated in conjunction with knee angles (genu varum and valgum). A genu varum of 5° plus a tibial varum of 5° mean that the subtalar joint must pronate10° to allow the calcaneus to assume a vertical position. Talus Talar Neck Angle Long axis of the talar body and the long axis of the talar neck. This value increases with age, and brings the supinated embryonic foot into its pronated adult position. Longest 2-3-5-4-1 shortest Metatarsal Distal Protrusion Metatarsal distal protrusion is how far distally each metatarsal extends in relation to the other metatarsals, regardless of the actual length of the bone. Increases in calcaneal fracture Fowler–Philip Angle Normal 44° to 69° Pathology >75° 214 Useful in evaluating retrocalcaneal bone pathology. Total Angle of Ruch Calcaneal inclination angle + Fowler–Philips angle = total angle of Ruch Greater than 90° may be observed in a Haglund deformity. Like Fowler-Philip Angle used for retrocalcaneal bony pathology but takes the calcaneal inclination angle into account. If the posterior tubercle extends above the 2nd parallel line, it is indicative of Haglund deformity. Decreased pes planus 216 Increased in pes cavus Angle of Hibbs Long axis of 1st metatarsal and long axis of the calcaneus on a lateral view Less than 150° is a cavus foot. Normal 135° to 140° Kites Angle Long axis of talus and long axis of calcaneus Normal range is 20° to 40°. Increased in pronation; decreased in supination 217 Calcaneocuboid Angle The calcaneocuboid angle is the angle created by the lateral border of the calcaneus and lateral border of the cuboid on a weight-bearing lateral radiograph. Acts to reinforce the heel portion of the upper and help provide stability to calcaneus. Lace stays Part of the upper on the dorsum of the shoe; often reinforced with leather and contains holes for shoe laces 6. Located between the insole and outsole, the shank runs from the heel center to the ball of the shoe and acts to give 220 support to the longitudinal arch and prevent collapse of the shoe. Toe box (toe cap) The most anterior portion of the upper that covers the toes and acts to protect the toes and help maintain the shape of the upper in the toe 12. Tongue Piece of material continuous with the vamp and covers the dorsum of the foot under the lace stays 13. Upper The section of the shoe that covers the dorsum of the foot and attaches to the sole of the shoe. The upper includes the vamp, quarter, lace stays, tongue, throat, heel counter, and toe box. Vamp The anterior portion of the upper covering the forefoot and toes Last A last is a 3-D model of the shape and cubical content of a shoe that the shoe is built around. Children typically walk with a shoulder drop, but by age 13 to 14 years, compensatory scoliosis may develop. During stance, the foot of the longer leg is usually pronated and the shorter leg is supinated. Open kinetic chain pronation can be described as abduction, eversion, and dorsiflexion of the foot. Closed kinetic chain pronation can be described as talar plantarflexion and adduction in the ankle joint, and calcaneal eversion. The flexors fire earlier and longer than normal in an attempt to stabilize the forefoot. The flexors overpower the interosseous muscles and cause digital hammering or clawing. There is also a possible associated adductovarus of the fourth and fifth toes because the quadratus plantae loses its mechanical advantage. Flexor Substitution Occurs with weak triceps surae; the deep posterior leg and lateral leg muscles try to compensate for lack of plantarflexion. Extensor Substitution Extensor muscles normally contract to dorsiflex the ankle to allow the foot to clear the ground during swing phase. Causes include anything that will give the extensors a mechanical advantage over the lumbricals. Windlass Mechanism As the hallux is dorsiflexed, the plantar fascia is pulled under the head of the metatarsal. This brings the calcaneus toward the head of the 1st metatarsal, thereby creating an elevated medial longitudinal arch. Lateral Flare 224 Used for lateral instability and frequent inversion sprains Can be put on the orthotic or a shoe Thomas Heel An anteromedial extension made to the heel to provide additional support to the longitudinal arch and limit late midstance pronation A reverse Thomas heel is an anterolateral extension made to the heel to support a weak lateral longitudinal arch, rarely indicated. The heel lock is applied by placing the adhesive tape on the lateral side of the foot just proximal to the 5th metatarsal head and extending around the posterior aspect of the foot to just distal to the 1st metatarsal head. The plantar rest strap is applied by placing the first strip on the lateral aspect of the foot just below the malleoli, across the plantar surface, and up the medial foot to the navicular. Dyskinetic Gait A constant movement abnormality with a high degree of variability from patient to patient and gait cycle to gait cycle. It is characterized by motion involving considerable effort, often with deliberated almost concentrated steps. Ataxic Gait Characterized by a marked instability during single limb stance with an alternating wide/narrow base during double support. Waddling Gait A laboring gait exhibiting difficulty with balance proximal pelvic instability, leading to a lumbar lordosis. Seen with muscular dystrophies, spinal muscular atrophy, and congenital dislocated hip. Vaulting Gait Gait changes include a high step rate, increased lateral trunk movement, scissoring, and instability from step to step, suggesting a loss of balance. Equinus Gait Gait exhibiting a swing phase ankle plantarflexion with no heel contact. Trendelenburg Gait Stance phase of each step leads to a contralateral tilt of the pelvis with a deviation of the spine to the affected side. Increasing the kilovolts produces a more penetrating x-ray, with increased latitude, a shorter exposure time, and less x-ray tube heat. Milliamperage (mA) controls the quantity or amount of x-ray emitted from the x-ray tube and is the most important component controlling radiographic density. Grid: Composed of alternating strips of lead and aluminum spacers to control, by absorbing, scatter radiation Collimation: A method of limiting the area of an x-ray beam, which by law cannot exceed the film size. Photoelectric effect: Occurs at lower kVp when an x-ray photon collides with a lower shell electron.

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Alternatively the Trak wheel may be rotated to select to that described above in that high-pressure driving gas is a parameter generic 120 mg sildigra free shipping impotence from diabetes. When pushed inwards (clicking) it highlights passed through an electronically controlled proportional 242 Automatic ventilators Chapter | 9 | fow valve to externally manipulate a bellows arrangement alarm will activate and the ventilator will automatically that contains patient gas order 100 mg sildigra overnight delivery erectile dysfunction pumps buy. Different manufacturers often add subtle changes by a programmable microprocessor to deliver a wide selec- to various modes and also use slightly differing nomen- tion of respiratory modes. As with most anaesthetic venti- clature for similar modes to that of their competitors. This mode also has a subsequent breaths which are gradually stepped up with back-up for unexpected apnoea. If the patient does not take the aim of achieving the set tidal volume within seven a breath within the pre-set apnoea delay time, the apnoea breaths. Hence all breaths after the frst are delivered using A F J E G K B C D A H L P N B Figure 9. B, working principles: (A) drive gas input flter; (B) Gas Inlet Valve – solenoid, opens when ventilator is on, closes under fault conditions such as system overpressure; (C) drive gas pressure regulator (output at 170 kPa); (D) fow control (proportional) valve; (E) mechanical overpressure safety valve (110 cm H2O); (F) bellows; (G) drive gas check valve (3. Working principles: (1) electric motor; (2) rod with screw thread; (3) piston; (4) cylinder; (5) rolling rubber seal; (6) incremental encoder; (7) sensor; (8) light barrier; (9) ventilator bellows. Like the sub-atmospheric pressure created by the downstroke ventilator described above, it has a rotary control (bottom of the ventilator sucks in gas from both the reservoir right) to alter selected variables. Again the reservoir bag will be are two banks of keys to select the alarms, menu set-up, seen to move. The home key restores information from the expiratory fow transducer is the screen to the default after any submenu called up passed to the microprocessor, which in turn causes is no longer required and the standby key stops the the movement of the piston backstroke in the ventilator and keeps any ventilatory parameters selected ventilator to match the expiratory fow. The ventilator has an compensation, along with the low compliance of the electric motor (1) with a hollow spindle. The inside of the bellows and breathing system, allows accurate delivery of spindle has a screw thread. When the electric ventilators may be used in the pressure support made motor spins, the spindle rotates and the action of the two that compensates for any small leak caused by an uncuffed threads, which are interlocked, causes the rod to move endotracheal tube. This movement is referred to as either The ventilator design can, therefore, be classifed as a a recirculating ball screw or a worm drive. One end of the high-powered, high-effciency, time-cycled ‘bag squeezer’ rod is connected to a piston (3) that moves backwards and ventilator. The head of the piston is ftted with a rolling neoprene seal Intermittent blowers (5) so that on the downstroke it is capable of producing These ventilators are driven by a pressurized source of a sub-atmospheric pressure to the bellows that sits above gasses or air, at a pressure of 250–400 kPa (37. The position of the piston rod at any one time is sensed The driving gas pathway is very small with a low internal by a high-resolution incremental encoder (6) and allows compliance making this type of device very effcient. The encoder consists of major component is an electronically timed and activated a metal disc that has 1024 perforations around the edge. Sophisticated ventila- perforations and then calculates the linear movement of tors such as those used in intensive care and anaesthetic the piston rod. At the bottom of the cylinder there is a workstations make use of a proportional fow valve (see light barrier to detect the lower stop position of the piston. Automatic resuscitators and more basic anaes- Interesting features thetic ventilators use the pneumatic oscillator principle (see below) as this is cheaper, does not require the same • Inspiration (Fig. During the inspiratory phase sophistication of operation and is powered by the driving the ventilator delivers the intended amount of gas requiring no electrical supply. It does this by diverting the Pneumatic oscillator A typical example is seen in Fig. The diagram is a very simplifed version and does valve (5) into the reservoir bag and not the patient. The main one passes to a of the absorber (which is isolated) and, therefore, cylinder that contains a shuttle (2), which travels between minimizes the compression volume of the inspiratory the ends of the cylinder. F, high- pressure driving gas input (300–600 kPa); G, pneumatic on/ off switch; H, pressure regulator; J, oscillator; K, variable 2 2 pneumatic inspiratory timer; L, variable pneumatic expiratory 5 timer; R, inspiratory fow restricter. The deliv- through a hole in the shuttle into the gas pathway (3) to ered tidal volume is a function of the inspiratory timer (K), the patient. The other two pathways supply two pneumatic which is calibrated in seconds, and fow restrictor (R), timers (6) (inspiratory) and (7) (expiratory), each of which is calibrated in l s−1. The respiratory rate is deter- which has a needle valve that regulates fow to the timer mined by the cycle time: inspiratory time (adjusted at K) mechanism at the relevant end of the cylinder. It blocks off the fow of driving gas through the Intermittent blowers are used in four different ways cylinder terminating the inspiratory fow. It opens a vent (4) to open on the inspiratory side of the cylinder that allows the pressure in the Basic resuscitators inspiratory timer to be released. It vent (5) so that a pressure can build up to reverse has no separate on/off switch and no fow restrictor and a the direction of the shuttle and terminate the fxed expiratory timer. Since the fow rate is constant, when the inspiratory time is lengthened, the tidal volume Working principles of pneumatically is increased, the cycling rate is reduced and the I/E ratio is controlled intermittent blowers prolonged, and vice versa. A generic line diagram of a typical pneumatically powered An example of this type is the Pneupac adult/child and controlled ‘intermittent blower’ is shown in Fig. D A, resuscitator/ventilator; B, patient valve; C, overpressure relief E valve; D, patient pathway; E, expiratory pathway. K J F H A B Expiratory To patient port Inspiratory port P S From ‘control Figure 9. Working principle of a basic resuscitator: module’ F, driving gas; H, pressure regulator; J, oscillator; K, tidal volume and rate control. The overpressure relief valve with its red cap is seen connected to the patient valve. Working principles of the Pneupac patient valve (inspiratory phase): C Inspiratory phase P, piston; S, spring. Side view showing the patient valve for connection to a facemask / endotracheal tube. The working principles of the patient valve are explained that no air is entrained and the delivered content is 100% in Fig. The output of the ventilator is connected to the wide-bore hose of breathing system, Sophisticated resuscitators the other end of which is attached to a light-weight This basic model has been superseded by the Pneupac low-resistance Laerdal pattern non-rebreathing valve. These devices can also be used in toxic environ- system via a pilot line (W) and triggers the demand valve ments (for example hazardous area response teams: (N). The variable fows are demand valve operates in conjunction with the oscillator also available when pushing the manual control button. Thus, if the patient demands a high fow for a Also most basic resuscitators now allow direct connection short duration or low fow from a longer duration (i. The cumulative effect of Alternatively, a length of wide bore tubing may be placed successive spontaneous breaths by the patient causes the between the patient valve and resuscitator (see Fig. This is taken as tidal volume of about passed via a variable fow restrictor (R) on to two coupled 450 ml at 12 to 16 breaths per minute. Lower rates will into a Venturi that entrains a fxed amount of ambient air only give partial inhibition, but providing the demand from S (this port has a non-return valve) and the total fow fow is above 15 l min−1 the ventilator will still interact is fed into the patient breathing system.

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