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  From the Desk of Editor–in–Chief
Dr KK Aggarwal

Padma Shri and Dr B C Roy National Awardee
Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant Physician, Cardiologist & Dean Medical Education Moolchand Medcity; Chairman Ethical Committee Delhi Medical Council; Chairman (Delhi Chapter) International Medical Sciences Academy; National Vice President Elect Elect, Indian Medical Association; Hony Director IMA AKN Sinha Institute (08–09); Hony Finance Secretary National IMA (07–08); Chairman IMA Academy of Medical Specialties (06–07); President Delhi Medical Association (05–06), President IMA New Delhi Branch (94–95, 02–04); Editor in Chief IJCP Group & Hony. Visiting Professor (Clinical Research) DIPSAR

For updates follow at www.twitter.com/DrKKAggarwal     www.facebook.com/Dr KKAggarwal

    Health Videos …
Nobility of medical profession Video 1 to 9 Health and Religion Video 1–7
DD Take Care Holistically Video 1–7 Chat with Dr KK On life Style Disorders
Health Update Video 1–15 Science and Spirituality
Obesity–Towards all Pathy Consensus ALLOVEDA: A Dialogue with Dr KK Aggarwal
  Editorial …

16th September 2012, Sunday

Doctors at Risk of Higher Burnout

According to a study in the journal Archives of Internal Medicine, doctors are at a higher risk of burnout than the general population of employed people in the US.

The study found that 38 percent of doctors reported burnout symptoms, compared to 28 percent of the non–doctors. Frontline doctors such as ED or family practice doctors were the most susceptible to burnout, while dermatologists and preventive care specialists reported the lowest rates of burnout.

There was no increased rate of depression or suicide among doctors compared with the general population, a sign that the burnout is specific to the work environment.

University of Rochester Medical Center researchers found in 2009 that mindfulness meditation decreased burnout symptoms and improved feelings of well-being in doctors who underwent weekly sessions of the practice.

Compared with the general population, healthcare professionals worked a median 10 hours more a week (50 versus 40 hours), and 37.9% of physicians reported working 60 or more hours, versus 10.6% of the general population.

For More editorials…

Dr KK Aggarwal
Group Editor in Chief

    Constipation Update

How is constipation treated?

Stool softeners, suppositories (glycerin or bisacodyl), and enemas, although widely used, have limited clinical efficacy. Glycerin or bisacodyl suppositories can be used in institutionalized older adults with dyssynergic defecation to help with rectal evacuation.

For More editorials…

 
Dr K K Aggarwal
  eMedinewS Audio PostCard

Stay Tuned with Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal on

Lifestyle change can reduce aging

Audio PostCard
    Photo Feature (from the HCFI Photo Gallery)

A non–stop Interaction between Patients and Cardiologists

A press conference was organized by Heart Care Foundation of India to announce the forthcoming 4th Dil Ka Darbar. The event would be held at Talkatora Stadium on Sunday, 23rd September, 2012 in association with World Fellowship of Religions.

 
Dr K K Aggarwal
    National News

Health agencies join hands to check diabetes in state

Several health–related agencies supported by the state health department will jointly work on "a first–of–its–kind" project to "discover and manage diabetes" among rural, tribal and slum populations. The "Conquer Diabetes" project is a joint initiative of Swasthya Diabetes Care, All India Institute of Diabetes and Research (AIIDR), Ahmedabad, Indian Institute of Public Health, Gandhinagar (IIPHG), and BMS foundation, a foreign not–for–profit organisation. Health Minister Jaynarayan Vyas will launch it on Sunday.

"The focus of the work will be improving diagnosis and care to poor patients by capacity building of doctors and paramedical workers from various Government health centers and creating awareness about the silent killer named Diabetes," said Dr Mayur Patel, chairman of the Swasthya Diabetes Care, All India Institute of Diabetes & Research and the project’s chief mentor. He said the slums of Ahmedabad city, rural parts of Mehsana district and the tribal blocks of Kavath and Nasvadi in Vadodara district would be covered. "For the rural areas, training is to be imparted to the medical officers, both working at PHCs and CHCs. They have to diagnose and manage uncomplicated diabetes and also screen them for complications. Diagnosed patients are to be referred to district hospital or private or NGO hospitals in the area or a nearby medical college hospital. In the tribal areas, the proposal is to pilot, train and mentor through information technology. "After training of urban medical officers, mentoring support will be provided either via telephone or regular meetings with them at training centres," Dr Patel added. Associate professor Deepak Saxena from IIPHG’s epidemics division said although large scale studies for the disease do not exist, isolated studies have shown that up to 16%–20% of slum populations in Ahmedabad suffer from the disease, while rural areas experience a 20% prevalence. (Source: Indian Express, Sep 15 2012)

For comments and archives

4th Dil Ka Darbar

September 23, 2012, 9:00 AM–6:00 PM , Tal Katora Indoor Stadium, Connaught Place, New Delhi

A non stop question answer–session between all top cardiologists of the NCR region and the public.

My Profession My Concern

Quality standards for any clinical establishment

Introduction

Hospital Compare, a quality tool provided by Medicare, currently provides performance data on 31 process measures in 5 clinical areas. These measures are adapted from JCI under "core measure set". (Heart attack, Heart failure, Pneumonia, Surgical care and Children’s asthma care)

Quality Measures related to pneumonia are as follows:

  • Initial antibiotic timing — The percentage of pneumonia inpatients who receive antibiotics within six hours after arrival at the hospital. National average performance is 95 percent.
  • Pneumococcal vaccination — The percentage of pneumonia inpatients age 65 and older who were screened for pneumococcal vaccine status and who were administered the vaccine prior to discharge, if indicated. US National average performance is 93 percent.
  • Influenza vaccination — The percentage of pneumonia inpatients age 50 years and older, hospitalized between October and the end of February who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated. US National average performance is 91 percent.
  • Blood culture prior to initial antibiotic received in hospital — The percentage of pneumonia patients whose initial emergency room blood culture specimen was collected prior to first hospital dose of antibiotics. US National average performance is 96 percent.
  • Appropriate initial antibiotic selection — The percentage of immunocompetent patients with pneumonia who receive an initial antibiotic regimen within the first 24 hours that is consistent with current guidelines. US National average performance is 92 percent.
  • Smoking cessation advice/counseling — The percentage of pneumonia patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay. US National average performance is 97 percent.

For comments and archives

    Valvular Heart Disease Update

When to intervene in patients with chronic mitral regurgitation?

Symptomatic severe chronic MR

  • EF ≥30, LVESD ≤55 mm
  • Primary, NYHA III–IV, severe LVD (EF < 30, LVESD > 55 mm)

Asymptomatic severe chronic severe MR

  • EF 30–60, LVESD ≥40 mm
  • Watchful waiting: EF 55–60, LVESD 40–45 mm
  • EF > 60, New onset AF or PAP >50 at rest or >60 with exercise
  • Severe MR, EF >60, LVESD <40 mm [Moderate LAE >50, mild PAH or PAP 30–50

Watchful waiting

  • Echo every 6 to 12 months or any time symptoms occur.
  • Do not meet the criteria for mitral valve surgery
  • Borderline EF 55–60, LVESD 40 to 45 mm on a single study.
  • Moderate MR may have hemodynamically severe disease.
  • Mild symptoms (NYHA II), and moderate MR, EF >60, LVESD <40, no PAH

Formula: 30–40–50–60

30 ( EF >30); 40 (LVESD > 40–45), 50 (LA or PAP >50), 60 (PAP > 60 on ex, EF> 60 with AF)

(Experts: Dr Bhabha Nanda Das and Dr Ganesh K Mani, Dr. Yugal Mishra, Dr Deepak Khurana, Dr K S Dagar, Dr Rajesh Kaushish, Dr K S Rathor, Dr Sandeep Singh and Dr KK Aggarwal)

For comments and archives

    International News

(Contributed by Dr Monica and Brahm Vasudev)

FDA approves second oral drug for MS

The US Food and Drug Administration (FDA) has approved a second oral agent for the treatment of multiple sclerosis (MS), teriflunomide (Aubagio, Genzyme/Sanofi). (Source: Medscape)

For comments and archives

New insulin Degludec–Aspart combo may offer advantages

Type 1 diabetics who took a new combined formulation of insulins degludec and aspart (IDegAsp) at their main meal, with insulin aspart (IAsp) at other meals, had better nocturnal glycemic control than patients on basal–bolus therapy with insulin detemir (IDet) and IAsp. (Source: Medscape)

For comments and archives

Novel device reduces re–excision after lumpectomy

A new investigational device may reduce the need for further surgery following lumpectomy in patients with early breast cancer, without removing more volume. This can translate into less surgical risk for the patient, as well as improve the odds of preserving cosmetic appearance. The results of a large randomized trial using the experimental device, MarginProbe (Dune Medical Devices, Inc), showed that among patients with ductal carcinoma in situ (DCIS), there was a significant decrease in the need for re-excision: 13% with the device vs 37% in controls (P = .004). In a further cohort that included patients with both DCIS and invasive carcinoma, the decrease in re-excision candidates was also significant (17% vs 33%; P < .001). (Source: Medscape)

For comments and archives

Gene variant linked to schizophrenia symptom severity

A new study strengthens the case for the rs1344706 variant in the gene ZNF804A having a role in schizophrenia. This research builds on previous studies by showing a correlation between this specific risk allele and cortical white matter volume and symptom severity in individuals with schizophrenia. The study is published in the September issue of the Archives of General Psychiatry. (Source: Medscape)

For comments and archives

    Twitter of the Day

@DrKKAggarwal: The Right Action http://blog.kkaggarwal.com/2012/09/the–right–action/

@DeepakChopra: The perceptual is never the actual.

    Spiritual Update

(Dr KK Aggarwal, Group Editor in Chief, IJCP Group of Publications and eMedinews)

Neti-Neti (Not This Not This)

(The Main Principle of Knowing the Truth)

The main figure in the Upanishads is the sage Yajnavalkya known as one of the greatest philosophers. He taught the great doctrine of neti–neti, the view that truth can be found only through the negation of all thoughts about it.

For comments and archives

    4th Asia Pacific Vascular Intervention Course (APVIC)
  • 4th Asia Pacific Vascular Intervention Course–Excerpts from a Panel discussion Read More
  • The 4th Asia Pacific Vascular Interventional Course begins Read More
  • Excerpts of a talk and interview with Dr. Jacques Busquet by Padma Shri & Dr. B.C. Roy National Awardee, Dr. KK Aggarwal, President Heart Care Foundation of India and Editor–in–Chief Cardiology eMedinewS Read More
  • 4th Asia Pacific Vascular Intervention Course – Dr KK Aggarwal with Faculty Read More
  • Press Conference on 4th Asia Pacific Vascular Intervention Course – Dr KK Aggarwal with Faculty Read More
  • 4th Asia pacific vascular intervention course Read More
  • 4th Asia pacific vascular intervention course paper clippings Read More
    Infertility Update (Dr Kaberi Banerjee, IVF expert, New Delhi)

What are the indications for using a gestational surrogate?

The initial indication for use of a gestational carrier is a woman who has normally functioning ovaries but who lacks a uterus. Women with congenital absence of the uterus (müllerian agenesis), or prior hysterectomy due to benign or malignant conditions are obvious candidates. Women with congenital müllerian anomalies such as a T–shaped or hypoplastic uterus with a history of infertility or repetitive pregnancy loss are also candidates, as are women with untreatable intrauterine synechiae. Gestational surrogacy is also an appropriate treatment for women with medical contraindication to pregnancy.

For comments and archives

    Tat Tvam Asi………and the Life Continues……

(Dr N K Bhatia, Medical Director, Mission Jan Jagriti Blood Bank)

In which situations do patients need blood transfusion?

A: There are many situations which doctors face daily when patient may need blood to save his life. We can give some plasma substitutes for the time–being. But till we give blood everything becomes temporary measure.

  • A patient may need blood after a major accident when there is blood loss.
  • No major surgery is performed without blood as there is bound to be blood loss. On an average, for every open heart surgery about 6 units of blood is required. In Obs and Gyne, the patient may need large amount of blood to be transfused in order to save not only her life but also of the child that she carries in situations like, APH (bleeding before birth), or PPH (bleeding after birth).
  • For patients with blood diseases like severe anemias especially aplastic anemia, leukemia, hemophilia, thalassemia etc. Blood transfusion is the only hope for these patients; repeated transfusions are required.
  • In many cases like poisoning, drug reactions and conditions of shock, burns and many other situations, blood transfusion is the only way to save the precious human life.

To put it in a nutshell, "There is no SUBSTITUTE FOR BLOOD and a patient who needs blood to save his life can only be saved if blood is transfused to him".

For comments and archives

    An Inspirational Story

The Power of Self–Confidence

(Authored by: Shriram Venkatachalapathy)

Dealing with the mind is creative. Dealing with people is a challenge. Dealing with the inanimate is monotony. The mind is sharper than a knife. Use it to fight the challenge. Use it to sculpt the stone. Everyone is creative. You just need to find the right key to unlock it. Follow along the short story below to understand the

The Power of Self–Confidence

Stumbling over stones, a man was trying to find his way through a dark cave with a light of hope from a lantern. Finally, he could trace a ray of sunlight entering the cave, which made him glitter with happiness.
But, as he drew closer, he was bewildered to see a gigantic rock standing before him like a mammoth. Courage was the only strength he possessed to devastate the barricade.
He pushed the rock with all his might, but it stood firmly denying to move. He tried again but it repudiated him from leaving the place. He felt as though being swallowed by a Blue Whale that was waiting to fulfill its enormous appetite.
He sat at the foot of the massive rock in the mouth of the gargantuan cave looking back at his endeavor and said, "I will get out of here."
This WILL added to his POWER and gave him more energy in pushing the colossal piece.
The rock moved a little which motivated him to work harder. It enervated him but he was not put off. He seemed an ant before a giant, not in terms of size or potency, but his attitude.
Slowly the rock made way for him paying tribute to all his efforts. He walked along the bright and evergreen path before him, with pride.
My Point: You can find a lot of inspirations by looking around. Listen to inspiring music and read motivating books. Life is to learn. Look back and learn from mistakes. There may be many causes for a problem. Identify the right one before finding a way to solve it.

Heal the fear within by injecting the spirit of confidence.

(Copyright with Shriram Venkatachalapathy, v_shriram@live.com)

For comments and archives

    Cardiology eMedinewS

Blood pressure meds may help protect against Alzheimer’s Read More

AF controlled by renal denervation Read More

    Pediatric eMedinewS

Chronic illness means more hospital medical errors for kids Read More

Mom’s diabetes, income may lead to child’s ADHD Read More

    IJCP Special

Dr Good Dr Bad

Situation: An asymptomatic patient came with erectile dysfunction.
Dr Bad: You can start Viagra.
Dr Good: Rule out CAD first.
Lesson: Patients with erectile dysfunction without an obvious cause (e.g., pelvic trauma), and who have no symptoms of coronary or other vascular disease, should be screened for cardiovascular disease prior to initiating therapy for their sexual dysfunction, as there are potential cardiac risks associated with sexual activity in patients with heart disease.

For comments and archives

Make Sure

Situation: A patient on dialysis and on oral antacid developed aluminum toxicity.
Reaction: You should have put him on magaldrate preparations.
Lesson: Magaldrate preparations do not cause aluminum toxicity in patients undergoing dialysis.

For comments and archives

    Quote of the Day (Dr GM Singh)

Morality is simply the attitude we adopt toward people whom we personally dislike. Oscar Wilde

   Ophthalmology Update

(Dr S K Verma, Consultant Ophthalmologist, New Delhi)

Hearing impaired may see sound through glasses

Scientists from the Korea Advanced Institute of Science and Technology have developed glasses that allow a hearing impaired person to see when a loud sound is made and give an indication of where from it came. An array of seven microphones, mounted on frame of glasses, pinpoints the location of such sounds and relays that directional information to the wearer through a set of LEDs embedded inside the frame. The prototype requires the user to carry a laptop in a backpack to process the signal. The lead researcher Yang Hann Kim has stressed that the device is a first iteration that will be miniaturised over the next few year. (Courtesy – TOI )

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    Legal Question of the Day (Dr M C Gupta)

Q. What is the legal position as regards the following?

a. The police brings an arrested person to an AYUSH doctor in government service for the purpose of preparing an MLC report? Can he prepare such a report?

b. Can a male prepare MLC report in respect of a female?

Ans. The answers to these questions are clear from section 53, CrPC, reproduced below:

"53. Examination of accused by medical practitioner at the request of police officer.

  • When a person is arrested on a charge of committing an offence of such a nature and alleged to have been committed under such circumstances that there are reasonable grounds for believing that an examination of his person will afford evidence its to the commission of an offence, it shall be lawful for a registered medical practitioner, acting, at the request of a police officer not below the rank of sub–inspector, and for- any person acting in good faith in his aid and –under his direction, to make such all examination of the person arrested as is reasonable necessary in order to ascertain the facts which may afford such evidence, and to use such force as is reasonably necessary for that purpose.
  • Whenever the pet-son of a female is to be examined under this section, the examination shall be made only by, or under the supervision of, a female registered medical practitioner.

    Explanation. In this section and in section 54, "registered medical practitioner means a medical practitioner who possesses any recognized medical qualification as defined in clause (l) of section 2 of the Indian Medical Council Act, 1956 (102 of 1956), and whose name has been entered in a State Medical Register."
    Lab Update (Dr Navin Dang and Dr Arpan Gandhi)

Total iron binding capacity (TIBC)

  • Increased: Acute and chronic blood loss, iron deficiency anemia, hepatitis and oral contraceptives.
  • Decreased: Anemia of infection and chronic diseases, cirrhosis, nephrosis and hemochromatosis
    Mind Teaser

Read this…………………

A major goal for the client during the first 48 hours after a severe bum is to prevent hypovolemic shock. The best indicator of adequate fluid balance during this period is

A. Elevated hematocrit levels.
B. Urine output of 30 to 50 ml/hour
C. Change in level of consciousness.
D. Estimate of fluid loss through the burn eschar

Yesterday’s Mind Teaser: Ms. Sy undergoes surgery and the abdominal aortic aneurysm is resected and replaced with a graft. When she arrives in the RR she is still in shock. The nurse's priority should be

A. Placing her in a Trendelenburg position
B. Putting several warm blankets on her
C. Monitoring her hourly urine output
D. Assessing her VS especially her RR

Answer for Yesterday’s Mind Teaser: D. Assessing her VS especially her RR

Correct answers received from: Dr KV Sarma, Dr Prabha Sanghi, Dr (Maj. Gen.) Anil Bairaria, Chandra Pal Singh, Dr Parimal Shah, Dr K Raju, Dr Arvind, Pankaj Agarwal, Dr Thakor Hitendrsinh G, Dr Chandresh Jardosh, Dr Jainendra Upadhyay, Kanta Jain.

Answer for 14th September Mind Teaser: C. Hypovolemia, wide fluctuations in serum sodium and potassium levels.
Correct answers received from: Dr Ajay Gandhi, Dr Avtar Krishan, Dr Kusum Singhal, Dr PC Das.

Send your answer to ijcp12@gmail.com

   Fitness Update (Rajat Bhatnagar, MonaVie, www.mymonavie.com/sonraj)

Can fitness protect against some negative effects of obesity?

It is well documented that obesity often leads to a host of other chronic conditions such as diabetes, hypertension and heart disease. New research is suggesting that some obese people may be able to avoid these conditions.

The Aerobics Center Longitudinal Study followed over 42,000 participants from 1979 to 2003 and measured their fitness levels, body fat composition, and other markers of metabolic health including cholesterol and triglycerides, blood glucose and blood pressure. According to the findings, about 30% of participants were obese, and of those about half were in "good metabolic health" – meaning their cholesterol, blood sugar, and blood pressure were within normal limits. The results also showed that obese people with good metabolic health were at no higher risk of chronic disease then healthy, normal weight people. According to lead study author Dr. Francisco Ortega, "Exercise benefits everyone, regardless of fitness and fatness level. So exercise should be encouraged by doctors to all the patients."

   Laugh a While (Dr GM Singh)

The border

Juan comes up to the Mexican border on his bicycle. He’s got two large bags over his shoulders. The guard stops him and says, "What’s in the bags?" "Sand," answers Juan.
The guard says,"We’ll just see about that. Get off the bike." The guard takes the bags and rips them apart; he empties them out and finds nothing in them but sand. He detains Juan overnight and has the sand analyzed, only to discover that there is nothing in the bags. The guard releases Juan,puts the sand into new bags, hefts them onto the man's shoulders, and lets him cross the border.

A week later, the same thing happens. The guard asks, "What have you got?" "Sand," says Juan. The guard does his thorough examination and discovers that the bags contain nothing but sand. He gives the sand back to Juan, who crosses the border on his bicycle. This sequence of events is repeated every week for three years. Finally, Juan doesn’t show up one day and the guard meets him in a cantina in Mexico. "Hey, Buddy," says the guard, "I know you are smuggling something. It’s driving me crazy. It’s all I think about. I can’t sleep. Just between you and me, what are you smuggling?"

Juan sips his beer and says, "Bicycles."

    Medicolegal Update

(Dr Sudhir Gupta, Additional Prof, Forensic Medicine & Toxicology, AIIMS)

Postmortem in case of medical negligence

In India, for the Autopsy surgeons, the strict test to be applied should be: ‘would death could have occurred, if the operation had not taken place?’

  • Information is needed before beginning the medicolegal autopsy. The patient’s notes are essential along with some other relevant information. Equally important is the attendance of clinicians at the autopsy, more indeed, in deaths associated with anesthesia.
  • Discussion among autopsy surgeon and the anesthetist may arrive at an amicable conclusion of opinion to offer the investigating authority.
  • The hospital lab may be requested to retain any antemortem blood or fluid samples sent to them so that they remain available for analytical checks, such as blood grouping in transfusion mishaps, or creatine phosphokinase activity in malignant hyperthermia
  • If death is due to a disease or disability, other than that for which the operation was performed, a distinction has to be drawn between those conditions that were known before the operation was performed
  • A distinction has to be drawn between those conditions that were known before the operations and those which were unexpected. Naturally, operative and anesthetic techniques may have to be modified to take account of the known adverse conditions
  • Death may occur due to failure of a surgical technique. This may be inadvertent, from a true ‘accident’ sometimes caused by unusually difficult operative circumstances, to anatomical abnormalities or even failure of equipment.
  • When it is one result of error of incompetence, then a legal action for negligence may ensue and the autopsy surgeon must be even more meticulous than usual in producing a detailed and impartial report.
  • When a failure of equipment may be responsible, then expert examination and advice is required. Anesthetic machines, gas supply, compatibility of connections and all the sophisticated hardware of Operation Theater must be subjected to the most rigorous inspection if a malfunction is suspected. This becomes important part of the autopsy surgeon concern, because he is responsible for the eventual decision about the cause of death.
  • The risk of death from all causes cardiac arrest was the most common single mode of death, being seen on average once or twice a year in most busy operating suites even under the most careful surgical and anesthetic regimens. Most cardiac arrest occurs at either the start or finish of the surgical procedure.

For comments and archives

    Public Forum

Public Forum (Press Release for use by the newspapers)

Long term use of painkillers can cause kidney cancer

A study published in the journal Archives of Internal Medicine has shown that people who regularly take painkiller drugs like ibuprofen or naproxen are 51 percent more likely to develop kidney cancer. There is no increased risk from taking aspirin or paracetamol, said Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal President Heart Care Foundation of India and Dil Ka Darbar to be held on 23rd September at Talkatora Stadium and MTNL Perfect Health Mela.

The mechanism through which painkillers could cause kidney disease is the inhibition of prostaglandin synthesis with resulting papillary and tubular injury, and ultimately damage to DNA.

The study analyzed data from 77,525 women in the Nurses’ Health Study and from 49,403 men in the Health Professionals Follow–up Study. The risk was related to the duration of use of the painkillers. There was a decrease in the risk by 19% if the painkiller was used for less than four years. There was a 36 per cent increase in risk of kidney cancer for people who used them regularly for 4 to 10 years. The risk increased almost three times for those who used these drugs regularly for 10 years or more.

The good news is that kidney cancer is uncommon so the risk is small for average users. Two other important causes of kidney cancer are obesity and smoking. So people on painkillers should not smoke and should also keep their weight under control to prevent kidney cancer.

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