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Dr KK Aggarwal

From the Desk of Editor in Chief
Padma Shri and Dr B C Roy National Awardee

Dr KK Aggarwal
President, Heart Care Foundation of India; Sr Consultant Physician, Cardiologist and Dean Medical Education Moolchand Medcity; Chairman Ethical Committee Delhi Medical Council; Chairman (Delhi Chapter) International Medical Sciences Academy; 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 of Publications & Hony. Visiting Professor (Clinical Research) DIPSAR

17 August, 2010, Tuesday

For regular emedinews updates follow at www.twitter.com/DrKKAggarwal

Do Medications Really Expire?

Are drug manufacturers being honest with us when they put an expiration date on their medications, or is the practice of dating just another drug industry scam, to get us to buy new medications when the old ones that purportedly have "expired" are still perfectly good?

  1. The expiry date, required by law in the United States, beginning in 1979, specifies only the date the manufacturer guarantees the full potency and safety of the drug –– it does not mean how long the drug is actually "good" or safe to use. Medical doctors uniformly say it is safe to take drugs past their expiration date –– no matter how "expired" the drugs purportedly are.
  2. Except in rare situations you won’t get hurt and you certainly won’t get killed by using a drug beyond its expiray date.
  3. An example of a rare exception was a case of renal tubular damage purportedly caused by expired tetracycline (G. W. Frimpter and colleagues in JAMA, 1963;184:111). This outcome (disputed by other scientists) was supposedly caused by a chemical transformation of the active ingredient.
  4. Studies show that expired drugs may lose some of their potency over time, from as little as 5% or less to 50% or more (though usually much less than the latter).
  5. Even 10 years after the "expiration date," most drugs have a good deal of their original potency.
  6. If it is a life or death situation, you must have 100% or so of its original strength but if life does not depend on an expired drug –– such as that for headache, hay fever, or menstrual cramps –– take it and see what happens.
  7. One of the largest studies ever conducted that supports the above points about "expired drug" labeling was done by the US military 15 years ago, according to a feature story in the Wall Street Journal (March 29, 2000), reported by Laurie P. Cohen. The military was sitting on a $1 billion stockpile of drugs and facing the daunting process of destroying and replacing its supply every 2 to 3 years, so it began a testing program to see if it could extend the life of its inventory. The testing, conducted by the US FDA ultimately covered more than 100 drugs, prescription and over–the–counter. The results showed that about 90% of them were safe and effective as far as 15 years past their original expiration date.
  8. In light of these results, a former director of the testing program, Francis Flaherty, said that expiration dates put on by manufacturers typically have no bearing on whether a drug is usable for longer. A drug maker is required to prove only that a drug is still good on whatever expiration date the company chooses to set. The expiration date doesn’t mean, or even suggest, that the drug will stop being effective after that, nor that it will become harmful.
  9. Manufacturers put expiration dates on for marketing, rather than scientific, reasons (Mr. Flaherty, a pharmacist at the FDA until his retirement in 1999). It’s not profitable for them to have products on a shelf for 10 years as they want turnover.
  10. ASs per Joel Davis, a former FDA expiration-date compliance chief, with a handful of exceptions –– notably nitroglycerin, insulin, and some liquid antibiotics –– most drugs are probably as durable as those the agency has tested for the military. Most drugs degrade very slowly. In all likelihood, you can take a product you have at home and keep it for many years, especially if it’s in the refrigerator.
  11. Consider aspirin. Bayer AG puts 2–year or 3–year dates on aspirin and says that it should be discarded after that. However, Chris Allen, a vice president at the Bayer unit that makes aspirin, said the dating is "pretty conservative"; when Bayer has tested 4–year–old aspirin, it remained 100% effective. So why doesn’t Bayer set a 4–year expiration date? Because the company often changes packaging, and it undertakes "continuous improvement programs," Mr. Allen said. Each change triggers a need for more expiration–date testing, and testing each time for a 4–year life would be impractical. Bayer has never tested aspirin beyond 4 years. But Jens Carstensen has. Dr. Carstensen, professor emeritus at the University of Wisconsin’s pharmacy school, who wrote what is considered the main text on drug stability, said, "I did a study of different aspirins, and after 5 years, Bayer was still excellent. Aspirin, if made correctly, is very stable.


As per FDA, drugs expire on the date they’re projected to have lost 10 percent of their potency.

  1. Factors that will shorten the lifespan of a drug are: Moisture, increased temperature, manufacturing impurities, and, for some drugs, light.
  2. Drugs such as phenobarbital, dilantin, lidocaine, and theophylline lose potency fairly quickly and aren’t as effective once they've expired.
  3. Eye and Ear drops should be discarded 2 weeks after they are opened, regardless of expiry dates as they lose their potency very quickly.
  4. Never use a medication (expired or not) that has changed color or consistency.
  5. As tetracycline breaks down with age, it forms epitetracycline, which is known to cause problems.
  6. Store all your oil-based medications (especially Vitamin E and Omega 3s) in a cool, dark place. Preferably a fridge, as rancid Vitamin E oil (including foods containing Vit E such as wheat germ) are highly toxic. (Source: Medscape)

This edt is in response to M J S Narula: "I wish to seek clarifications regarding the expiry of medicine and related literature available as you are the authority on such subjects. Many time the physician samples are given free to the patients. If in case some sample medicine is inadvertently passed and it has been expired, then what is the standing of the doctor who has given it to the patient free. Searches on Internet says that expiry date is only to ensure that efficacy of medicine is 100%. But is there some literature available. Hope you must have understood the problem many a times faced by physicians)"

Dr KK Aggarwal
Editor in Chief
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Photo Feature

14th MTNL Perfect Health Mela was organised collaboratively by Heart Care Foundation of India, at Sanjay Lake park New Delhi from Oct 27-Nov 4, 2007. Distinguished Service awards were distributed for outstanding service to the society.

In the photo: Ms. Arti Mehra, Mayor Delhi . Also in the photo: Padmashri and B C Roy National Awardee Dr. K K Aggarwal, President HCFI

Dr K K Aggarwal



The following points had been inadvertently missed out in the Editorial of 14th August:The 3rd Padma Awardees Drs meet

33. Ayurveda is a 5000-year-old science and needs a proper research and development wing. One should remember that Allopathic drugs are the third most common cause of death in the US.
34. Ayurveda needs to be glamorized so that more and more scientists are attracted towards it.

The name of Dr Kameshwar Prasad was misspelt.

35. Need to put resources for cinical research training


News and Views ( Dr Brahm and Dr Monica Vasudev)

Cold weather may increase risk of heart attack

Cold weather increases the risk of having a heart attack, especially in the elderly patients and those with a history of heart disease. According to a study published in the British Medical Journal, each drop in temperature of one degree centigrade (1.8 degrees Fahrenheit) was associated with about 200 more heart attacks. One–degree reduction in average daily temperature was associated with a cumulative 2% gain in risk of heart attack for the following 28 days.

Comapred to other groups, patients aged 75 to 84 years and those with a history of coronary heart disease had a slightly higher risk of MI associated with a drop in temperature. Patients who were on aspirin were slightly less vulnerable.

Prevalence of type 2 diabetes associated with socioeconomic inequality in women

Based on the results of a study published online in the European Journal of Public Health, women from the lowest social class, defined according to the Registrar General’s Classification, had 4.54 times more chances of developing diabetes than women in the top social class in 2006.

Nearly one in three people with diabetes has evidence of diabetic retinopathy.

Nearly three in 10 Americans with diabetes over the age of 40 suffer from vision impairment caused by diabetic retinopathy, and about 4.4% have a form of the condition so severe it threatens their eyesight. The findings suggest that good control of blood sugar, blood pressure, and cholesterol can go a long way toward preventing or slowing diabetic eye disease. The study is published in the August 11 issue of the Journal of the American Medical Association.

Updated guidelines discourage general use of testosterone therapy in older men with low testosterone levels

Up to a quarter of men may have testosterone levels that fall below normal in middle age, and in some cases this transition causes a collection of symptoms that has come to be known as male menopause, which some doctors now treat with testosterone. But, Alvin Matsumoto, MD, who helped draft a set of updated guidelines for testosterone therapy that were released in June by the Endocrine Society, a professional organization focused on hormone research, discourages the general use of testosterone therapy in older men with low testosterone levels unless their levels are consistently low and are accompanied by significant physical and sexual symptoms.


Legal Column

Forensic Column (Dr Sudhir Gupta, Associate Professor, Forensic Medicine & Toxicology, AIIMS)

WMA declaration of Malta on hunger strikers-Balancing dual loyalties

Physicians attending hunger strikers can experience a conflict between their loyalty to the employing authority (such as prison management) and their loyalty to patients. Physicians with dual loyalties are bound by the same ethical principles as other physicians, i.e. their primary obligation is to the individual patient. It must be kept in mind that clinical independence required to be observed. Physicians must remain objective in their assessments and not allow third parties, particularly the police, to influence their medical judgment. They must not allow themselves to be pressured to breach ethical principles, such as intervening medically for non–clinical reasons.


Experts’ Views

Interesting Tips in Hepatology & Gastroenterology

Dr. Neelam Mohan, Director Pediatric Gastroenterology, Hepatology and Liver Transplantation Medanta Medicity

Chronic pancreatitis is characterized by pancreatic inflammation and fibrosis the endpoint of which is destruction of pancreatic parenchyma with eventual loss of exocrine and endocrine function. It is a syndrome of destructive inflammatory condition that encompasses the many sequelae of long standing pancreatic injury. Thus acute pancreatitis is an event, whereas chronic pancreatitis is a process.

Question of the day

Is intra articular steroid injection safe in childhood arthritis?

Yes. Intra–articular steroid injections are safe in children and are the preferred mode of treatment in oligoarticular juvenile idiopathic arthritis. Intraarticular steroid injection in the knee joint has been proven to be effective in preventing leg length discrepancy which occurs early because of increased blood supply to the inflamed joint in the presence of an open epiphysis. The preferred drug is triamcinalone hexacetonide used in a dose of 0.5 mg/kg/large joint.


Sherry DD, Stein LD, Reed AM, et al. Prevention of leg length discrepancy in young children with pauciarticular juvenile rheumatoid arthritis by treatment with intraarticular steroids. Arthiritis Rheum 1999;42(11):2330–4.

Evidence–Based Medicine

Treatment of Hypertension Improves Executive Function
(Dr N P Singh (Nanu), Professor of Medicine, Maulana Azad Medical College and Associated Lok Nayak Hospital)

Parents reported improvements in executive function in children with hypertension after 1 year of antihypertensive treatment

Executive function is necessary for problem solving, planning, purposeful goal–directed behavior, vigilance, and working memory. Researchers recently reported that children (age range, 10–18 years) with untreated, newly diagnosed primary hypertension had poorer executive function than normotensive controls (J Pediatr 2009;154:207). Now, the same researchers examined the effect of 12 months of antihypertensive treatment in 22 (70%) of the hypertensive youth (age range, 13–16 years) enrolled in that study. At baseline and 12–month follow–up, patients underwent 24–hour blood pressure (BP) monitoring, and their parents completed the Behavior Rating Inventory of Executive Function (BRIEF) and the Child Behavior Checklist (CBCL). All assessments were compared with those in 25 matched normotensive controls. One hypertensive patient had improved BP with lifestyle modification alone. The remaining 21 patients received lisinopril, and 5 of these patients required another antihypertensive medication to achieve target casual BP <95th percentile. Mean 24–hour daytime systolic and diastolic BP in the hypertensive group improved significantly (from 138 to 127 mm Hg and 78 to 68 mm Hg, respectively). Parent ratings of executive function improved significantly in the hypertensive group but did not change in the normotensive group. Parent ratings of internalizing and externalizing behaviors on the CBCL did not change in either group.

Comment: This study is the first to demonstrate significant improvement in executive function after pharmacological treatment in children with primary hypertension. The authors hypothesize that early treatment of hypertension prevents sustained end–organ damage to the brain. Antihypertensive treatment might prove to be important for preservation of executive function. The study is limited by the small sample size and potential for bias because parents were not blinded. However, the unchanged ratings on the CBCL in both patients and controls suggest that parental bias was not a factor. This study provides pediatricians with more evidence to support the practice of monitoring BP routinely and treating hypertensive patients according to National Institutes of Health recommendations.

Published in Journal Watch Pediatrics and Adolescent Medicine August 4, 2010.


Public Forum (Press Release for use by the newspapers)

High BP in Pregnancy Increases Risk for Future Atherosclerosis

Women who have hypertension during pregnancy are at increased risk of developing atherosclerosis when they are older said Padma Shri and Dr B C Roy National Awardee Dr K K Aggarwal, President Heart Care Foundation of India, BSNL Dil ka Darbar & MTNL Perfect Health Mela.

Quoting a study from the Netherlands, and a report published in Hypertension, Dr Aggarwal said that hypertension in pregnancy acts as a kind of "nature’s cardiovascular stress test" showing proneness to future disease.

Gestational Hypertension Leads to 57% Increased Risk of Calcification

Gestational hypertension normally resolves following the birth, and blood pressure returns to normal. But women with elevated blood pressure during pregnancy are at higher risk of hypertension, diabetes, and cardiovascular disease later in life.

491 healthy postmenopausal women selected from participants enrolled in the PROSPECT (Predictors of Response to Cardiac Resynchronization Therapy) study from 1993–1997 were evaluated.

Women with a history of gestational hypertension had an almost 60% increased risk of having coronary calcification several decades later compared with women who had normal blood pressure during pregnancy.

The relationship held for women who had mild elevations in blood pressure during pregnancy as well as for those who developed preeclampsia — a more serious complication of pregnancy characterized by very high blood pressure, edema, and risk of organ damage.

Hypertension during pregnancy should be an alert for women.

Until now it has been assumed that high blood pressure subsides after pregnancy, and there was no structured follow-up of the women who experienced it.

Hypertensive disorders are common in pregnancy, affecting 2% to 35% of all pregnancies, and rank among the leading causes of maternal and perinatal morbidity and mortality worldwide. Preeclampsia or gestational hypertension associated with proteinuria is particularly linked with an increased risk for adverse pregnancy outcomes for both the mother and the fetus.


Conference Calendar

Endosurg 2010 – Horizons of Minimal Access Surgery

Date: August 20 – 22, 2010
Venue: Smt. Kashibai Navale Medical College & General Hospitals, Pune, Maharashtra.


An Inspirational Story

Sharing lives

We were meant to share our lives with each other, because life can be painful. We face too many fragile moments standing alone, often unable to contain our sadness, the feeling of staying lost forever. Sharing our sorrow helps us feel protected. We feel hopeful.

We were meant to share our lives with each other because life can be full of joy. It can overflow with each new success, rediscovering an old friendship, winning against all odds, carrying life within us. Sharing the abundance of our joy brings us the pleasure of feeling cherished. We have chosen happiness.

We were meant to share our lives with each other because life can catch us unaware. It can suddenly surprise us with unwanted adventures and the dare–devil risk of starting new jobs, falling out of love, questioning our faith. Sharing this crisis gives our loved ones a chance to hold steady a safety net even if we choose not to jump. They stand by, a proud witness to our courage.

We were meant to share our lives with each other, because we need each other. For our lives to sustain its purpose and continue to hold its profound significance, we need to be connected, appreciated and understood. We need to share and we need to belong.


IJCP Special

Dr Good Dr Bad

Situation: A female with past history of DVT needed an OC prescription.
Dr Bad: Start OC patch (transdermal).
Dr Good: You cannot be on OCs.
Lesson: There is a possibility of an increased risk of venous thromboembolism in oral contraceptive patch users.

Make Sure

Situation: A child with sore throat and the large lymph nodes develops fever.
Reaction: Oh my God! Why were antibiotics not given in time?
Lesson: Make Sure, that all children with sore throat and enlarged lymph nodes are given antibiotics as such sore throats are Streptococcal unless proved otherwise.

Quote of the Day

Successful people always have 2 things on their lips - Silence and Smile. Smile to solve the problem, and Silence to avoid the problem.

(Contributed by Dr Chandresh Jardosh)

Asthma Alert

All asthmatics do not wheeze and all that wheeze is not asthma.

Chronic cough may be the only symptom of asthma.


International Medical Science Academy Update (IMSA)

Blood pressure control in children with chronic kidney disease

Intensified blood pressure control with a targeted goal of a 24–hour mean arterial pressure (MAP) below the 50th percentile, compared with conventional blood pressure control, results in slower progression of chronic kidney disease in children.


1. Wuhl E, Trivelli A, Picca S, et al. Strict blood–pressure control and progression of renal failure in children. N Engl J Med 2009;361:1639.


Drug Update

List of Approved drugs from 01.01.2010 TO 30.4.2010

Drug Name


DCI Approval Date

Sodium chloride 6.80gm + Potassium chloride 0.30 gm + Calcium chloride dihydrate 0.37gm + Magnesium chloride hexahydrate 0.20gm + Sodium acetate trihydrate 3.27gm + L–malic acid 0.67gm in 1000ml solution for infusion

Replacement of extracellular fluid losses in case of isotonic dehydration, especially if acidosis is being imminent or present



Medi Finance

Q. Is it mandatory to file the return of income?

Ans. Yes, every individual or Hindu Undivided Family (HUF) whose income is in excess of the amount not chargeable to tax is required to file the return.


Lab Test (Dr Arpan Gandhi and Dr Navin Dang)


To help evaluate the body's water and electrolyte balance; to investigate hyponatremia and increased or decreased urine production; to detect the ingestion of toxins such as methanol; to monitor the effectiveness of treatment for conditions affecting osmolality; to help determine the cause of chronic diarrhea.


Lateral thinking

Read this………………

……..YOU S ME

The answer for yesterday’s puzzle "first aid"

Correct answers received from: Dr Jayashree B Keshav, In Charge – Scientific Publications, The Himalaya Drug Company, Dr Ashok Wasan, Dr Anurag Jain, Dr. Shashi Saini, Dr Girish Cally,

Send your answer to ijcp12@gmail.com


Humor Section (Dr Jagjit Singh)


Nurse: Doctor, there is an invisible man in your waiting room.
Doctor: Tell him I can't see him now. Next.

Patient: Doctor, should I file my nails?

Doctor: No, throw them away like everybody else.


Billy breaks a window in his neighbor’s car and his Dad gives him a whipping with his belt.

1957 – Billy is more careful next time, grows up normal, goes to college, and becomes a successful businessman.

2009 – Billy’s dad is arrested for child abuse. Billy removed to foster care and joins a gang. State psychologist tells Billy’s sister that she remembers being abused herself and their dad goes to prison.

(Contributed by Dr Chandresh Jardosh)

Funny One Liner

Jhatka enters kitchen, opens sugar container, looks inside and closes it. He does this again and again. Why? Because his Doctor told him to check sugar level regularly.

  Readers Responses
  1. Dear Editor, Thanks to Dr. Varesh Nagrath for recognising the virtues of Ayurveda: There are three distinctly different Government–recognised streams of medicine, i.e., Allopathy, Ayurveda and Homeopathy, governed by their own independent Councils. No stream of medicine seems to be competent enough to pass derogatory remarks against a stream other than their own, and the matter may well be decided by the Government and the judiciary taking into consideration merits and demerits of all systems of medicine in the overall interest of our massing millions. Coming back to Dr. Nagrath’s interest, there seems to be no harm in having special coverage of condensed ayurveda in M.B.,B.S. curriculum: Dr. Narendra Kumar, kumars@vsnl.com

  2. Dear Dr K K Aggarwal: At the outset I admire the Hungarian task taken by you for the medical community by publishing daily e–medinews paper which gives a wealth of information which is not possible otherwise. Since you are one of the most respected and knowledgeable person in medical fraternity so I thought to bring to your kind notice about Baba Ram Dev’s message regarding the CURE of incurable diseases like all types of Diabetes mellitus (It is pertinent to note that he stops even insulin on the very first day), cure for all types of Hypertension, all types of bronchial Asthma, all thyroid disorders and many more including Brain tumors, end stage renal disease etc. Being a non medical person how he can pass this message to general public. If it is so then why we don’t give him 100 documented patients of above disease and see whether he can cure all those in a manner which he is treating. To the utter surprise the entire medical fraternity is mum about it and not a single doctor from any platform ever DARED to speak. I thought it proper to bring to your notice and do the needful by highlighting all unbecoming statements of a non–medical person for making absolute and tall claims of incurable diseases. This I have written in short otherwise it can be expressed in several hundreds of pages. I hope you understand the gravity of the situation: Dr Gaurav Garg

  3. Greetings: I start with congratulating Dr KK Aggrawal for floating this magazine a very tough and important task indeed. It's time that doctors chalked out a hierarchy for themselves. Docs need to have a medical administration (as separate exams) and medical representative (for governmental policy making). Then it should have uniform representation from all over India and the worthy ones must be selected. I have my comments to national Knowledge commission and at few other platforms and I wish to reiterate the need for establishment of hardcore, fundamental, autonomous, nonpolitical, talent replenished–research system in our country. In medical (and IITs) as far as science is concerned have the best of brains but most of them are left to perish with market and public arena where they are gulping up and down with market filth and other issues alien to a medical pro. the govt must sustain all the "govt college" (I categorize) docs especially all MBBSs. We need proper research infrastructure affiliated with all govt medical colleges (and pvt ones who have performed well) to confront specific challenges this nation faces in all fields including health. The infrastructure, national budget and moral support must rise for medical, health and related science research that includes Ayurvedic research but must incorporate those with proven promise from the Ayurveda side. Govt looks already biased with traditional medicine but it should not be preoccupied (for support anyhow) and the new technology and modern medicine expertise must be utilized. Every worker who has worked and proved themselves must be helped without any bureaucratic interference like Dr G P Dubey etc for recovering our ancient intellectual treasure. The education and research command should be with the doctors and a fresh aspiring brilliant crop of our wonderful children must be nurtured to bring the real worth and asset for our country. It needs great team and organization infrastructure to invent and excel. Let not only ask for AIIMS everywhere ask for research Institutes with no hoopla but with substance. The medical fraternity known for its divarications, academic differences, physical and mental apathies, social ignorance must now rise to, I request to form the biggest organization together, lets support and be a part of, at least be a member of IMA. We cannot sit aloof and dream that our interests will be safeguarded by religiously mugging the Harrison’s pages, only. I hope I'm through. Let’s give it a start, and for a start Dr KK is a great lighthouse: Dr Shailesh Gupta. Asst Prof, Department of Physiology, Clinical neurophysiology & Sleep studies, Institute of Medical Sciences, Banaras Hindu University, sanj001@gmail.com,
  4. Dear Dr. Aggarwal: The emedinews is transforming lot of medinews as well the professional issues. Recent one such issue is the supreme court division bench ruling that there is no need for getting expert opinion in consumer cases but it is needed only  in  criminal negligence cases . This verdict is a contradictory to previous supreme court rulings - expert opinion is needed to avoid unnecessary penalization of doctors both in consumer and other cases against doctors. We have to appeal before the full bench against this verdict otherwise there will be mushrooming of litigation cases against doctors. Hope I M A will take up this important professional problem. Dr. Alex Franklin

Forthcoming Events

eMedinewS Events: Register at emedinews@gmail.com

5th September: 3 PM to 5 PM – A dialogue with His Holiness Dalai Lama at C 599 Defence Colony Acharya Sushil Ashram in association with Acharya Sushil Muni Ahimsa Peace Award Trust

26 th September: Sunday- BSNL Dil ka Darbar A day-long interaction with top cardiologists of the city. 8 AM - 5 PM at MAMC Auditorium, Delhi Gate.

17th MTNL Perfect Health Mela 2010 Events: Venue: NDMC Ground Laxmi Bai Nagar, New Delhi

24th October, Sunday: Perfect Health Darbar, Interaction with top Medical experts of the city from 8 AM to 5 PM
30th October, Saturday: eMedinewS Update from 8 AM to 5 PM
29th October, Friday: Divya Jyoti Inter Nursing College/ School Competitions/ Culture Hungama
30th October, Saturday: Medico Masti Inter Medical College Cultural festival from 4 PM to
10 PM
31st October, 2010, Sunday: Perfect Health Darbar, An interaction with top Cardiologists

eMedinews Revisiting 2010

The 2nd eMedinewS – revisiting 2010 conference will be held at Maulana Azad Medical College, New Delhi on January 2, 2011. The event will have a day–long CME, Doctor of the Year awards, Cultural Hungama and Live Webcast. Suggestions are invited.

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