American College of Physicians: Internal Medicine — Doctors for Adults ®

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ACP InternistWeekly



In the News for the Week of May 1, 2012




Highlights

Screening mammography may benefit younger women with increased breast cancer risk

Screening mammography may have more benefit than harm in women 40 to 49 years of age who are at increased risk for breast cancer, according to two new studies published in today's Annals of Internal Medicine. More...

Neurology guidelines rate migraine prophylaxis options

Prescription, over-the-counter and complementary treatments for migraine prevention were evaluated in two new guideline updates from the American Academy of Neurology. More...


Test yourself

MKSAP Quiz: Screening urine culture grows E. coli

This week's quiz asks readers to evaluate a 65-year-old woman whose insurance policy screening reveals Escherichia coli. More...


Lung cancer

ALA recommends low-dose CT screening for current, former smokers with at least 30 pack-years, ages 55 to 74

Low-dose screening with computed tomography (CT) should be recommended for people who meet National Lung Screening Trial criteria: current or former smokers age 55 to 74 years with a smoking history of at least 30 pack-years and no history of lung cancer, according to a guidance statement released last week by the American Lung Association (ALA). More...


Heart failure

New performance measures released for in- and outpatient heart failure care

Updated heart failure performance measures, released last week by three major medical groups, include expanded use for beta-blockers in the inpatient setting. The new measures, which appear online at Circulation, include changes to inpatient and outpatient care. More...


Hyperthyroidism

Subclinical hyperthyroidism associated with CHD risk, afib risk, total mortality, study indicates

Subclinical hyperthyroidism is associated with increased risk for total mortality, coronary heart disease (CHD) mortality, and incident atrial fibrillation, according to a new study. More...


Medicare update

CMS sponsors CME on fraud and abuse

CMS is now offering a Web-based training session for physicians called "Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians." More...


From ACP Internist

The next issue of ACP Internist is online

The May issue of ACP Internist features stories on drug shortages, early recruitment for health careers, bed bugs, and more. More...


From the College

ACP and ACR issue consensus points for mammography screening

The American College of Physicians (ACP) and the American College of Radiology (ACR) recently released a joint set of talking points regarding how and when women should have screening mammograms. The points are the result of a meeting between the two organizations in May 2010 and follow-up discussions that took place through August 2011. More...

ACP joins the Choosing Wisely Campaign

ACP is one of nine leading physician specialty societies participating in the Choosing Wisely Campaign. More...

Governance committee seeks Regent, Treasurer candidates for 2013

The ACP Governance Committee oversees the process for nominating and electing Masters and Fellows of the College to the Board of Regents and is beginning the process of seeking Regents to join the Board in May 2013. The position of Treasurer will also open in 2013. More...

ACP Master to chair task force on Japanese nuclear disaster

Kiyoshi Kurokawa, MD, MACP, former Governor for the ACP Japan chapter, was recently designated to chair an independent task force to investigate the Fukushima nuclear disaster. More...


Cartoon caption contest

And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption. More...


Physician editor: Daisy Smith, MD, FACP



Highlights


.
Screening mammography may benefit younger women with increased breast cancer risk

Screening mammography may have more benefit than harm in women 40 to 49 years of age who are at increased risk for breast cancer, according to two new studies published in today's Annals of Internal Medicine.

annals.jpg

In a systematic review and meta-analysis, researchers evaluated data from 66 published articles and from the Breast Cancer Surveillance Consortium to determine what factors were associated with increased breast cancer risk in women 40 to 49 years of age. Extremely dense breasts and a first-degree relative with breast cancer were each associated with at least a 2-fold increase in risk. Previous breast biopsy, heterogeneously dense breasts and second-degree relatives with breast cancer were each associated with a 1.5- to 2-fold increased risk, while current oral contraceptive use, nulliparity, and age 30 or older at first childbirth were each associated with a 1.0- to 1.5-fold increased risk.

The authors noted that they did not assess effects of multiple risk factors and that the included studies varied in measures, reference groups, and adjustment for cofounders. However, they concluded that their analysis identified two important potential risk factors for breast cancer in women age 40 to 49 years: very dense breasts and first-degree relatives with breast cancer. Clinicians and patients may want to consider this information when deciding on personalized screening, they said.

In the second study, researchers used four independent models to determine the threshold relative risk (RR) at which the harm/benefit ratio of screening mammography in women age 40 to 49 years equals that of biennial screening in women age 50 to 74 years. Mammography screening starting at age 40 was compared with mammography screening starting at age 50 using digital or film mammography. Annual and biennial screening intervals were also compared to determine which approach yielded the most benefits (life-years gained, breast cancer deaths averted) and least harms (false-positive results).

For women age 40 to 49 with a 2-fold increased risk for breast cancer, the harm/benefit ratio of biennial screening with digital mammography (defined as false-positive findings/life-years gained) was similar to that of biennial screening in average-risk women age 50 to 74 years (median threshold RR, 1.9 [range across models, 1.5 to 4.4]). The threshold RRs were higher for annual digital mammography (median, 4.3 [range, 3.3 to 10]), as well as for a harm/benefit ratio defined as false-positive findings/deaths averted rather than false-positive findings/life-years gained. Film mammography had a more favorable harm/benefit ratio than digital mammography because it has a lower false-positive rate, the authors noted.

The study considered false-positive results as the only potential harm from screening and did not take differences in preferences between older and younger women into account, among other limitations. However, the authors concluded that biennial screening starting at age 40 has more benefit than harm in women whose risk for breast cancer is twice as high as average.

In an editorial accompanying both studies, the chief medical and scientific officer and executive vice president of the American Cancer Society stressed the need for further education about risks and benefits of mammography since future guidelines for screening will likely be tailored to the individual.

"This will be challenging because many health care providers and members of the lay community do not understand screening and the concept of risk," he wrote. "Specific tools designed to educate them need to be developed and rigorously assessed. Ultimately, the preferences of individual women, recognizing the potential for harm and benefit, should be respected."


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Neurology guidelines rate migraine prophylaxis options

Prescription, over-the-counter and complementary treatments for migraine prevention were evaluated in two new guideline updates from the American Academy of Neurology (AAN).

The group's evidence-based update on pharmacologic treatment included 29 article reviews (out of 284 abstracts that were considered) and divides medications into Levels A, B, C and U. According to a Level A recommendation, medications that are established as effective and should be offered for migraine prevention are divalproex sodium, sodium valproate, topiramate, metoprolol, propranolol, timolol and, for menstrual migraines, frovatriptan. In a negative Level A recommendation, the update said lamotrigine should not be prescribed for migraine prophylaxis.

Level B drugs, which are probably effective and should be considered, include amitriptyline, venlafaxine, atenolol, nadolol, naratriptan and, for menstrual migraine, zolmitriptan. Level C options (possibly effective, may be considered) are lisinopril, candesartan, clonidine, guanfacine, carbamazepine, nebivolol and pindolol.

The other update, which covers nonsteroidal anti-inflammatories and other complementary treatments, included 15 article reviews. Petasites (or butterbur) is the only treatment that received a Level A recommendation. Level B options are fenoprofen, ibuprofen, ketoprofen, naproxen, naproxen sodium, MIG-99 (feverfew), magnesium, riboflavin and subcutaneous histamine. Level C treatments are cyproheptadine, Co-Q10, estrogen, mefenamic acid and flurbiprofen. In a negative Level B recommendation, the update said that montelukast was probably ineffective for migraine prevention.

Level U (evidence conflicting or inadequate) treatments (from both updates) include gabapentin, fluoxetine, fluvoxamine, protriptyline, acenocoumarol, warfarin, picotamide, bisoprolol, nicardipine, nifedipine, nimodipine, verapamil, acetazolamide, cyclandelate, aspirin, indomethacin, omega-3 and hyperbaric oxygen. Both sets of guidelines were published by Neurology on April 24.

Also last week, a meta-analysis of botulinum toxin A for prophylaxis of migraine and tension headaches was published in the Journal of the American Medical Association. According to the analysis, the toxin did not reduce the number of episodic migraines or tension headaches per month but provided a small to modest benefit in chronic daily headaches and chronic migraines. The AAN update noted that a new guideline on botulinum toxin is currently in development and that the academy's 2008 guideline contained a Level B recommendation against using the toxin for treatment of episodic migraine.



Test yourself


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MKSAP Quiz: Screening urine culture grows E. coli

A 65-year-old woman is evaluated because a screening urine culture for an insurance policy grows greater than 105 colony-forming units/mL of Escherichia coli. She does not have fever, dysuria, urinary frequency, or other symptoms. Medical history is unremarkable. She has no allergies and takes no medications. Physical examination findings are normal.

mksap.jpg

Which of the following is the most appropriate treatment?

A) Amoxicillin
B) Ciprofloxacin
C) Trimethoprim-sulfamethoxazole
D) No treatment

Click here or scroll to the bottom of the page for the answer and critique.


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Lung cancer


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ALA recommends low-dose CT screening for current, former smokers with at least 30 pack-years, ages 55 to 74

Low-dose screening with computed tomography (CT) should be recommended for people who meet National Lung Screening Trial (NLST) criteria: current or former smokers age 55 to 74 years with a smoking history of at least 30 pack-years and no history of lung cancer, according to a guidance statement released last week by the American Lung Association (ALA).

People should not receive a chest X-ray for lung cancer screening, and low-dose CT screening is not recommended for everyone, according to an interim report published on the ALA's website. Although the U.S. Preventive Services Task Force has not recommended screening for lung cancer, results from the National Cancer Institute's NLST, published in the New England Journal of Medicine in August 2011, showed that screening high-risk individuals with CT scans reduced lung cancer deaths by 20.3% compared to chest X-rays, the ALA report noted. The number needed to treat was 320.

Based on the results of that trial, the committee made several specific recommendations, including the following:

  • Low-dose CT screening should be recommended for those who meet the NLST criteria.
  • Smoking cessation or never smoking is the best way to prevent smoking-related lung cancer.
  • Universal screening is not recommended because of the questions that remain about optimal methods and effectiveness in general populations, as in well as high-risk populations such as patients with chronic obstructive pulmonary disease.
  • Patient education is important, not only to encourage smoking cessation but also to teach patients about the risks of radiation exposure, about how to follow up on abnormal findings, and that a negative result does not rule out future lung cancer.
  • The ALA should develop a toolkit that outlines patient information in coordination with discussions with a pulmonologist or other physician.
  • Hospitals and screening centers should establish ethical policies for advertising and promoting lung cancer screening, especially because Medicare and private insurers don't cover the costs, as well as avoid using direct-to-consumer advertising or promotions that prey upon public fears about lung cancer.
  • Screening should be linked to "best practice" multidisciplinary teams that can provide follow-up evaluation of nodules.


Heart failure


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New performance measures released for in- and outpatient heart failure care

Updated heart failure performance measures, released last week by three major medical groups, include expanded use for beta-blockers in the inpatient setting. The new measures, which appear online at Circulation, include changes to inpatient and outpatient care.

Changes to inpatient measures include the following:

Left ventricular systolic function. The new measures added a qualitative description of left ventricular ejection fraction (LVEF) to allow easier implementation of treatment-based measures.

Beta-blocker therapy for left ventricular systolic dysfunction (LVSD). The new measures added this to the inpatient setting and specified bisoprolol, carvedilol and sustained-release metoprolol succinate to harmonize treatment across settings. Starting these therapies is recommended in stable patients before hospital discharge.

Angiotensin-converting enzyme inhibitors (ACEs) or angiotensin receptor blockers (ARBs) for LVSD. The measure set combines inpatient and outpatient measures, defines what is prescribed, and simplifies exclusions. This harmonizes treatment across settings, clarifies which drugs should be used, and allows for patient preferences and clinical judgment.

Postdischarge appointment for heart failure patients. This is a new measure.

The report retired the measures on use of anticoagulants at discharge, discharge instructions and smoking cessation counseling because they have become a standard of care for broader populations.

Changes to outpatient measures include:

LVEF assessment. The description was modified because evaluation of LVEF in heart failure patients provides important information to direct appropriate treatment.

Symptom and activity assessment. Assessment of activity levels and assessment of clinical symptoms of volume overload were combined to provide a more comprehensive overview of patient status.

Symptom management. This new measure is intended as a quality metric.

Patient self-care education. This measure changed to a quality metric.

ACEs or ARBs for LVSD. Use of these classes of drugs remains suboptimal, especially in the outpatient setting.

Counseling about implantable cardioverter defibrillators (ICDs). This quality metric changed to a measure because ICDs have proved to be highly effective for preventing sudden death, but half of eligible patients don't undergo implantation.

Initial lab tests and weight measurement were retired because they have become a standard of care. Blood pressure measurement and assessment of volume overload were retired as measures because of poor evidence support. Warfarin for patients with atrial fibrillation was retired because it became part of a larger measure set for a broader population of patients.

The measures were released by the American College of Cardiology Foundation, the American Heart Association and the American Medical Association-Physician Consortium for Performance Improvement.



Hyperthyroidism


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Subclinical hyperthyroidism associated with CHD risk, afib risk, total mortality, study indicates

Subclinical hyperthyroidism is associated with increased risk for total mortality, coronary heart disease (CHD) mortality, and incident atrial fibrillation, according to a new study.

Researchers examined pooled individual data from 52,674 participants in 10 large, prospective cohorts to determine the association between endogenous subclinical hyperthyroidism and risks of total and CHD death, CHD events, and atrial fibrillation. Six cohorts had data available on CHD events in 22,437 participants, and five cohorts had data available on incident atrial fibrillation in 8,711 participants. The median age of participants was 59 years, and 58.5% were women. The authors defined euthyroidism as a thyrotropin level of 0.45 mIU/L to 4.49 mIU/L and endogenous subclinical hyperthyroidism as a thyrotropin level below 0.45 mIU/L with normal free thyroxine levels when participants taking thyroid-altering medications were excluded. The study results were published online April 23 by Archives of Internal Medicine.

A total of 2,188 (4.2%) of the 52,674 participants had endogenous subclinical hyperthyroidism. Overall, 8,527 participants died during follow-up, 1,896 from CHD. CHD events occurred in 3,653 of 22,437 participants and atrial fibrillation developed in 785 of 8,711 participants. Subclinical hyperthyroidism was found to be associated with increased total mortality, CHD mortality, CHD events and atrial fibrillation in analyses adjusted for age and sex. No differences in risk were seen by age, sex or preexisting cardiovascular disease, and risk remained similar after adjustment for cardiovascular risk factors. Participants with a thyrotropin level below 0.10 mIU/L had a higher risk for CHD death and atrial fibrillation than those with a thyrotropin level between 0.10 and 0.44 mIU/L.

The authors acknowledged that their study involved mainly white participants, that thyroid function was tested only at baseline, and that other conditions that could have affected mortality were not assessed, among other limitations. However, they concluded that an association exists between endogenous subclinical hyperthyroidism and risk for total mortality, CHD mortality and incident AF. Risks for CHD mortality and atrial fibrillation are highest with a thyrotropin level below 0.10 mIU/L, they noted.

An accompanying editorial also noted the study's limitations but said it provides important information about the importance of subclinical hyperthyroidism in clinical practice. "Until further data are available, the relationship between subclinical hyperthyroidism and increased mortality, CHD mortality and atrial fibrillation presently provides sufficient evidence to consider treatment of subclinical hyperthyroidism, especially in elderly patients with cardiac risks, hyperthyroid symptoms, or osteoporosis," the editorialist wrote.



Medicare update


.
CMS sponsors CME on fraud and abuse

CMS is now offering a Web-based training session for physicians called "Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians."

The 30-minute session can qualify physicians for 0.5 hour of accredited CME credits. This, and other, CMS sponsored Web-based training sessions are available on the CMS website.



From ACP Internist


.
The next issue of ACP Internist is online

Drugs come up short for doctors, patients. Drug shortages, especially among injectables and cancer medications, have left physicians and patients alike wondering where their next doses will come from. Even simple antibiotics have become scarce commodities.

acpi-20120501-internist.jpg

Programs start early to promote health careers. Rural facilities are recruiting their next generation of doctors early—from high school. They're offering paid, entry-level jobs to immerse the youngest scholars in a health care environment with the hope they'll pursue careers in the field.

Bed bug infestations can bring itchy, stressed patients. A surge in bed bug infestations leads internists to look for warning signs: not just rashes, but recent travel, confirmation by an exterminator, and bullous reactions.

Another story on diagnosing mystery ailments and a MKSAP Quiz question on an oral mucosal lesion are online.



From the College


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ACP and ACR issue consensus points for mammography screening

The American College of Physicians (ACP) and the American College of Radiology (ACR) recently released a joint set of talking points regarding how and when women should have screening mammograms. The points are the result of a meeting between the two organizations in May 2010 and follow-up discussions that took place through August 2011.

Historically, the screening guidelines for each organization have differed. Yet, when controversy arose after the U.S. Preventive Services Task Force (USPSTF) guidelines were released in November 2009, the groups decided to collaborate to find common ground and provide guidance for physicians and other medical personnel to help clarify the pros and cons of screening mammography to their patients.

For example, the ACP and the ACR have differing mammography screening guidelines for women ages 40 to 49. The ACP guideline recommended a shared decision-making approach for this group, stating that annual mammograms should be based on the benefits and harms of screening, the individual woman's preferences, and her breast cancer risk profile. The rationale behind the ACP recommendation is that the benefits of mammography do not clearly outweigh the potential harms for all women ages 40 to 49, and, because of the potential risks, women should be fully informed rather than routinely screened.

Conversely, the ACR recommends that asymptomatic women begin annual screening at age 40. The ACR rationale for this approach is that the overall benefits of mammography outweigh potential harms in women in this age group, and almost all women would be willing to accept the risks of screening for the mortality benefit.

Although each group maintains separate recommendations, a consensus was reached on important talking points that can be used by physicians, technologists, and others to educate themselves and others about the benefits and risks surrounding mammography screening. The talking points are available online.


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ACP joins the Choosing Wisely Campaign

ACP is one of nine leading physician specialty societies participating in the Choosing Wisely Campaign. The initiative, led by the ABIM Foundation, is designed to help physicians, patients and other health care stakeholders think and talk about overuse of health care resources in the United States. ACP developed a list of "Five Things Physicians and Patients Should Question" as part of the initiative.

More information, including the lists of evidence-based recommendations for physicians and patients, is available online.


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Governance committee seeks Regent, Treasurer candidates for 2013

The ACP Governance Committee oversees the process for nominating and electing Masters and Fellows of the College to the Board of Regents and is beginning the process of seeking Regents to join the Board in May 2013. The position of Treasurer will also open in 2013.

The Governance Committee strives to represent the diversity within internal medicine on ACP's Board of Regents. Important general qualifications include commitment to ACP, dependability, leadership qualities, and the ability to represent the College in numerous and diverse arenas. Regent nominees must be Fellows or Masters of the College.

Candidates for Treasurer do not need to be current members of the Board of Regents, but will become a member of the Board upon election to Treasurer. The Treasurer will be a member of the Executive Committee of the Board of Regents and Chair of the Financial Policy and Audit Committee. Treasurer candidates should be experienced and/or comfortable with investments, pensions, insurance and financial management issues; have proven leadership ability in order to guide the Financial Policy and Audit Committee toward effective decision making; be willing to devote the time necessary to become familiar with the College's financial policies and practices; have the ability to work with College management; and possess the ability to make financial matters and recommendations understandable to persons with little or no financial background.

All candidates for Regent or Treasurer must submit a letter of nomination (not from the candidate) and two letters of support (from two individuals other than the nominator) by Aug. 1, 2012.

Letters of nomination should include the following sections:

  • Brief description of the nominee's current activities
  • Special attributes the candidate would bring to the Board of Regents in terms of the desired characteristics outlined above
  • Previous and current service in College-related activities
  • Service in organizations other than the College (medical and non-medical)
  • Identification of two individuals who will write letters of support for the candidate

Letters of support do not need to have specific content or format but will be most useful if they focus on the candidate's qualifications and how they would contribute to the Board of Regents and College.

Please send your confidential nominations, no later than Aug. 1, 2012 to:

Governance Committee

ATTN: Mrs. Florence Moore

American College of Physicians

190 N. Independence Mall West

Philadelphia, PA 19106-1572

Fax: 215-351-2829

e-mail

Only candidates who submit a letter of nomination and two letters of support by Aug. 1, 2012 will be advanced to the Governance Committee for review.

If you have any questions, please contact Florence Moore toll free at (800) 523-1546, ext 2814, or direct at (215) 351-2814.


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ACP Master to chair task force on Japanese nuclear disaster

Kiyoshi Kurokawa, MD, MACP, former Governor for the ACP Japan chapter, was recently designated to chair an independent task force to investigate the Fukushima nuclear disaster. The 10-member task force is commissioned by the National Parliament of Japan, and most committee meetings can be viewed online with English translation.



Cartoon caption contest


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And the winner is …

ACP InternistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

acpi-20120501-cartoon.jpg

"Just as I suspected: ST-rex segment elevation."

This issue's winning cartoon caption was submitted by Kevin Koo, ACP Student Member, from Yale University. Readers cast 233 ballots online to choose the winning entry. Thanks to all who voted! The winning entry captured 54.5% of the votes.

The runners-up were:

"I know what you mean. There aren't very many of us solo practitioners around either."

"I'm not sure why you feel a sense of impending doom."


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MKSAP Answer and Critique



The correct answer is D) No treatment. This item is available to MKSAP 15 subscribers as item 15 in the Infectious Diseases section. More information about MKSAP 15 is available online.

This patient requires no treatment with antibiotics even if a urinalysis indicates pyuria. Asymptomatic bacteriuria does not cause symptoms of a urinary tract infection but is detected when the results of a urine culture grow greater than 105 colony-forming units/mL. This condition is not uncommon, especially among adult women and the elderly, and rarely requires treatment. Screening for asymptomatic bacteriuria is generally recommended before transurethral resection of the prostate, urinary tract instrumentation involving biopsy, or other tissue trauma resulting in mucosal bleeding. Screening is not recommended for simple catheter placement or cystoscopy without biopsy or in most asymptomatic ambulatory patients. Pregnant women are screened for asymptomatic bacteriuria, which is associated with low birth weight and prematurity.

Asymptomatic bacteriuria is only treated in the following circumstances: in pregnant women, in patients who recently had an indwelling catheter removed, before an invasive urologic procedure, in neutropenic patients, or in patients with a urinary tract obstruction. Chronic prophylactic antibiotic therapy is beneficial in pregnant women with recurrent asymptomatic bacteriuria; if untreated, 20% to 40% of patients will progress to symptomatic urinary tract infection, including pyelonephritis.

Key Point

  • Although asymptomatic bacteriuria in adult patients usually does not require treatment, pregnant women should be treated to decrease the risk of pyelonephritis.

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Test yourself

A 42-year-old woman is evaluated for an 8-month history of crampy abdominal pain and three loose bowel movements per day. The pain is relieved by a bowel movement. There are no nocturnal bowel movements, and there is no blood or dark tarry material in the stool. She has not had fever, night sweats, or weight loss. She has a history of Hashimoto disease and is treated with levothyroxine. Following a physical exam, rectal exam, and lab tests, what is the most appropriate next step in management?

Find the answer

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