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Bor S, Kalkan İH, Savarino E, Rao S, Tack J, Pasricha J, Cangemi D, Schol J, Karunaratne T, Ghisa M, Ahuja NK, Lacy B. Prokinetics-safety and efficacy: The European Society of Neurogastroenterology and Motility/The American Neurogastroenterology and Motility Society expert review. Neurogastroenterol Motil 2024; 36:e14774. [PMID: 38462678 DOI: 10.1111/nmo.14774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 02/02/2024] [Accepted: 02/13/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Prokinetics are a class of pharmacological drugs designed to improve gastrointestinal (GI) motility, either regionally or across the whole gut. Each drug has its merits and drawbacks, and based on current evidence as high-quality studies are limited, we have no clear recommendation on one class or other. However, there remains a large unmet need for both regionally selective and/or globally acting prokinetic drugs that work primarily intraluminally and are safe and without systemic side effects. PURPOSE Here, we describe the strengths and weaknesses of six classes of prokinetic drugs, including their pharmacokinetic properties, efficacy, safety and tolerability and potential indications.
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Affiliation(s)
- Serhat Bor
- Division of Gastroenterology, School of Medicine & Ege Reflux Study Group, Ege University, Izmir, Turkey
| | - İsmail H Kalkan
- Department of Gastroenterology, School of Medicine, TOBB University of Economics and Technology, Ankara, Turkey
| | - Edoardo Savarino
- Gastroenterology Unit, Azienda Ospedale Università di Padova (AOUP), Padua, Italy
| | - Satish Rao
- Division of Gastroenterology and Hepatology, Digestive Health Center, Augusta University, Augusta, Georgia, USA
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium
| | - Jay Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - David Cangemi
- Division of Gastroenterology & Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Jolien Schol
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
| | - Tennekon Karunaratne
- Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Matteo Ghisa
- Digestive Endoscopy Unit, Division of Gastroenterology, Padua University Hospital, Padua, Italy
| | - Nitin K Ahuja
- Division of Gastroenterology, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Brian Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Kitazawa T, Kaiya H. Motilin Comparative Study: Structure, Distribution, Receptors, and Gastrointestinal Motility. Front Endocrinol (Lausanne) 2021; 12:700884. [PMID: 34497583 PMCID: PMC8419268 DOI: 10.3389/fendo.2021.700884] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/16/2021] [Indexed: 12/26/2022] Open
Abstract
Motilin, produced in endocrine cells in the mucosa of the upper intestine, is an important regulator of gastrointestinal (GI) motility and mediates the phase III of interdigestive migrating motor complex (MMC) in the stomach of humans, dogs and house musk shrews through the specific motilin receptor (MLN-R). Motilin-induced MMC contributes to the maintenance of normal GI functions and transmits a hunger signal from the stomach to the brain. Motilin has been identified in various mammals, but the physiological roles of motilin in regulating GI motility in these mammals are well not understood due to inconsistencies between studies conducted on different species using a range of experimental conditions. Motilin orthologs have been identified in non-mammalian vertebrates, and the sequence of avian motilin is relatively close to that of mammals, but reptile, amphibian and fish motilins show distinctive different sequences. The MLN-R has also been identified in mammals and non-mammalian vertebrates, and can be divided into two main groups: mammal/bird/reptile/amphibian clade and fish clade. Almost 50 years have passed since discovery of motilin, here we reviewed the structure, distribution, receptor and the GI motility regulatory function of motilin in vertebrates from fish to mammals.
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Affiliation(s)
- Takio Kitazawa
- Comparative Animal Pharmacology, Department of Veterinary Science, Rakuno Gakuen University, Ebetsu, Japan
| | - Hiroyuki Kaiya
- Department of Biochemistry, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
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Xu Z, Xu C, Ge H, Li Y, Chu L, Zhang J, Cheng K. Modified dachengqi tang improves decreased gastrointestinal motility in postoperative esophageal cancer patients. J TRADIT CHIN MED 2015; 35:249-54. [PMID: 26237826 DOI: 10.1016/s0254-6272(15)30093-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate the clinical effects of modified dachengqi tang (DCQT) on promoting gastrointestinal motility in post-operative esophageal cancer patients. METHODS Sixty postoperative esophageal cancer patients were enrolled and randomly assigned to the modified treatment group or the control group (30 patients in each group). Patients in the treatment group were given DCQT made from decocted herbs and administered via nasojejunal tube at a dosage of 150 mL. Gastrointestinal motility was assessed by recording time for recovery of bowel sounds, flatus, defecation, and the total amount of gastric drainage during the first three postoperative days. Plasma motilin (MTL) and vasoactive intestinal peptide (VIP) were measured one hour before and three days after surgery. RESULTS Compared with the control group, the times to first bowel sound, flatus, and defecation were significantly shorter and there was less gastric drainage in the treatment group (P < 0.01, P < 0.01, P < 0.01, and P < 0.05, respectively). In the treatment group, postoperative plasma MTL was significantly higher (P < 0.01) and VIP was significantly lower than those in the control group (P < 0.05). There was no difference found in either MTL or VIP from before to after operation in the treatment group (P > 0.05). MTL was significantly lower and VIP was higher postoperatively in the control group, compared to before surgery (P < 0.01). CONCLUSION Modified DCQT effectively improved decreased gastrointestinal motility in postoperative esophageal cancer patients by increasing MTL and reducing VIP.
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He W, Zhang Y, Wang X, Guo L, Han L, Liu E, Wang T. Zhizhu Decoction Promotes Gastric Emptying and Protects the Gastric Mucosa. J Med Food 2013; 16:306-11. [DOI: 10.1089/jmf.2012.2438] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Wei He
- Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Ministry of Education, Tianjin, China
| | - Yi Zhang
- Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Ministry of Education, Tianjin, China
| | - Xinrui Wang
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Ministry of Education, Tianjin, China
| | - Lingling Guo
- Key Laboratory of Pharmacology of Traditional Chinese Medical Formulae, Tianjin University of Traditional Chinese Medicine, Ministry of Education, Tianjin, China
| | - Lifeng Han
- Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Ministry of Education, Tianjin, China
| | - Erwei Liu
- Key Laboratory of Pharmacology of Traditional Chinese Medical Formulae, Tianjin University of Traditional Chinese Medicine, Ministry of Education, Tianjin, China
| | - Tao Wang
- Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Ministry of Education, Tianjin, China
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Noorian AR, Taylor GM, Annerino DM, Greene JG. Neurochemical phenotypes of myenteric neurons in the rhesus monkey. J Comp Neurol 2012; 519:3387-401. [PMID: 21618236 DOI: 10.1002/cne.22679] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Understanding the neurochemical composition of the enteric nervous system (ENS) is critical for elucidating neurological function in the gastrointestinal (GI) tract in health and disease. Despite their status as the closest models of human neurological systems, relatively little is known about enteric neurochemistry in nonhuman primates. We describe neurochemical coding of the enteric nervous system, specifically the myenteric plexus, of the rhesus monkey (Macaca mulatta) by immunohistochemistry and directly compare it to human tissues. There are considerable differences in the myenteric plexus along different segments of the monkey GI tract. While acetylcholine neurons make up the majority of myenteric neurons in the stomach (70%), they are a minority in the rectum (47%). Conversely, only 22% of gastric myenteric neurons express nitric oxide synthase (NOS) compared to 52% in the rectum. Vasoactive intestinal peptide (VIP) is more prominent in the stomach (37%) versus the rest of the GI tract (≈10%), and catecholamine neurons are rare (≈1%). There is significant coexpression of NOS and VIP in myenteric neurons that is more prominent in the proximal GI tract. Taken as a whole, these data provide insight into the neurochemical anatomy underlying GI motility. While overall similarity to other mammalian species is clear, there are some notable differences between the ENS of rhesus monkeys, humans, and other species that will be important to take into account when evaluating models of human diseases in animals.
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Affiliation(s)
- Ali Reza Noorian
- Department of Neurology and the Center for Neurodegenerative Disease, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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Kandulski A, Venerito M, Malfertheiner P. Therapeutic strategies for the treatment of dyspepsia. Expert Opin Pharmacother 2011; 11:2517-25. [PMID: 20726822 DOI: 10.1517/14656566.2010.501794] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE OF THE FIELD Dyspeptic symptoms are highly prevalent in the population and represent a major burden for healthcare systems. The ROME III criteria address and define two separate entities of functional dyspepsia: epigastric pain syndrome and postprandial distress syndrome. The etiology of dyspeptic symptoms is heterogeneous, underlying mechanisms are poorly understood and symptomatic improvement after drug therapy is often incomplete. AREAS COVERED IN THIS REVIEW This review of the literature included Medline data being published in the field of functional dyspepsia and different therapies. WHAT THE READER WILL GAIN The reader will gain a current, unbiased understanding of the pathophysiological mechanisms underlying functional dyspepsia and of the therapeutic regimens based on randomized, controlled trials and on the meta-analyses that have been published on different therapeutic agents. TAKE HOME MESSAGE Before starting medical treatment, a careful physical examination should exclude 'alarm symptoms'. Laboratory data, ultrasound and endoscopy are recommended in patients older than 45 - 55 years (depending on the guidelines being used). In areas with a high prevalence of Helicobacter pylori, the initial strategy includes 'test and treat' for H. pylori in addition to empiric acid suppressive therapy. Many studies have focused on the role of gastrointestinal dysmotility and hypersensitivity for dyspepsia with inconclusive results. Further therapeutic medical strategies include prokinetics, herbal preparations and psycho-/neurotopic drugs as well as additional psycho- or hypnotherapy.
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Affiliation(s)
- Arne Kandulski
- Otto-von-Guericke University Magdeburg, Department of Gastroenterology, Hepatology and Infectious Diseases, Germany
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Woitalla D, Goetze O. Treatment approaches of gastrointestinal dysfunction in Parkinson's disease, therapeutical options and future perspectives. J Neurol Sci 2011; 310:152-8. [PMID: 21798561 DOI: 10.1016/j.jns.2011.06.050] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 06/15/2011] [Accepted: 06/27/2011] [Indexed: 12/14/2022]
Abstract
Gastrointestinal (GI) dysfunction is a common but underestimated feature in Parkinson's disease (PD). Out of the multimodal spectrum of treatment options, there currently are only a few pharmacological treatments available to improve gastrointestinal motility and symptoms. Because enteric nervous function is mainly regulated by transmitters different from those involved in the brain, dopamine replacement is not a treatment option in PD patients. This article focuses on the known regulative mechanism of GI function and presents known and upcoming treatment options for GI dysfunction in PD.
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Affiliation(s)
- D Woitalla
- Department of Neurology, St. Josef Hospital, Ruhr-University-Bochum, Germany.
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Abstract
Gastroparesis is a chronic motility disorder of the stomach that involves delayed emptying of solids and liquids, without evidence of mechanical obstruction. Although no cause can be determined for the majority of cases, the disease often develops as a complication of abdominal surgeries or because of other underlying disorders, such as diabetes mellitus or scleroderma. The pathophysiology behind delayed gastric emptying is still not well-understood, but encompasses abnormalities at 3 levels--autonomic nervous system, smooth muscle cells, and enteric neurons. Patients will often cite nausea, vomiting, postprandial fullness, and early satiety as their most bothersome symptoms on history and physical examination. Those that present with severe disease may already have developed complications, such as the formation of bezoars or masses of undigested food. In patients suspected of gastroparesis, diagnostic evaluation requires an initial upper endoscopy to rule out mechanical causes, followed by a gastric-emptying scintigraphy for diagnosis. Other diagnostic alternatives would be wireless capsule motility, antroduodenal manometry, and breath testing. Once gastroparesis is diagnosed, dietary modifications, such as the recommendation of more frequent and more liquid-based meals, are encouraged. Promotility medications like erythromycin and antiemetics like prochlorperazine are offered for symptomatic relief. These agents may be frequently changed, as the right combination of effective medications will vary with each individual. In patients who are refractory to pharmacologic treatment, more invasive options, such as intrapyloric botulinum toxin injections, placement of a jejunostomy tube, or implantation of a gastric stimulator, are considered. Future areas of research are based on current findings from clinical studies. New medications, such as hemin therapy, are emerging because of a better understanding of the pathophysiology behind gastroparesis, and present treatment options, such as gastric electric stimulation, are evolving to be more effective. Regenerative medicine and stem cell-based therapies also hold promise for gastroparesis in the near future.
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Abstract
Motilin, first discovered by Brown in 1966, is a 22-amino acid polypeptide hormone secreted by Mo cells in a regular and cyclic pattern during the interdigestive period. The main function of motilin is to increase the migrating myoelectric complex component of gastrointestinal motility and stimulate the production of pepsin. This article gives an overview of the physiological function of motilin and summarizes the latest advances in understanding the relationship between motilin levels and evaluation of gastrointestinal function.
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Lee TH, Son M, Kim SY. Effects of corydaline from Corydalis tuber on gastric motor function in an animal model. Biol Pharm Bull 2011; 33:958-62. [PMID: 20522959 DOI: 10.1248/bpb.33.958] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The aim of this study was to evaluate the prokinetic and gastric-relaxing effects of the isoquinoline alkaloid corydaline, which was extracted from Corydalis tubers (CT). Corydaline is a marker compound used for quality control of DA-9701, a prokinetic agent formulated from extracts of Pharbitidis semen and Corydalis tuber that is currently in clinical trials in Korea for the treatment of functional dyspepsia (FD). DA-9701 was previously reported to be a potential therapeutic agent for the treatment of abnormalities in gastrointestinal motor function in FD patients; however, the therapeutic effects of corydaline on FD have yet to be demonstrated in an in vivo study. In the current study, oral administration of corydaline not only significantly accelerated gastric emptying in normal rats but also improved delayed gastric emptying to near normal levels. Furthermore, corydaline induced significant gastric relaxation, shifting the pressure-volume curve towards higher volumes compared to controls. These results suggest that corydaline promotes gastric emptying and small intestinal transit and facilitates gastric accommodation.
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Affiliation(s)
- Tae Ho Lee
- Research Center, Dong-A Pharm. Co., Ltd., Gyeonggi-do 446-905, Republic of Korea
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De Smet B, Mitselos A, Depoortere I. Motilin and ghrelin as prokinetic drug targets. Pharmacol Ther 2009; 123:207-23. [DOI: 10.1016/j.pharmthera.2009.04.004] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Accepted: 04/09/2009] [Indexed: 12/13/2022]
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Motilides: a long and winding road: lessons from mitemcinal (GM-611) on diabetic gastroparesis. ACTA ACUST UNITED AC 2009; 155:18-23. [PMID: 19345243 DOI: 10.1016/j.regpep.2009.03.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Accepted: 03/25/2009] [Indexed: 12/17/2022]
Abstract
Mitemcinal (GM-611) is a macrolide motilin receptor agonist with acid-resistance and without antibiotic activity. Since ABT-229 (a first generation of motilin receptor agonist) had failed to demonstrate symptomatic relief in functional dyspepsia and diabetic gastroparesis, there is a controversy for which of prokinetics or relaxants is clinically beneficial. Currently, oral mitemcinal has been focused on diabetic gastroparesis under clinical development. It showed to accelerate gastric-emptying in diabetic animals and in patients with gastroparesis. The latest double-blind, placebo-controlled study demonstrated to be effective at improving diabetes-related gastroparesis symptoms. A sub-group analysis, which included patients with BMI < 35 kg/m2 and hemoglobin A1c < 10%, there were significantly more symptomatic relieves in the 10 mg mitemcinal group than in the placebo group. The frequency of adverse events did not differ between groups. Mitemcinal shows promise in the subset of patients who should be confirmed in future studies.
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Heptulla RA, Rodriguez LM, Mason KJ, Haymond MW. Gastric emptying and postprandial glucose excursions in adolescents with type 1 diabetes. Pediatr Diabetes 2008; 9:561-6. [PMID: 18761650 DOI: 10.1111/j.1399-5448.2008.00430.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Because amylin is co-secreted with insulin from beta cells, patients with type 1 diabetes (T1DM) are deficient in both insulin and amylin. Amylin delays gastric emptying and suppresses glucagon in the postprandial period. Hence, we hypothesized that children with complication-naive T1DM have accelerated gastric emptying in response to a mixed meal because of amylin deficiency. Amylin, glucagon, insulin, glucose, and gastric emptying were measured in seven T1DM and in eight control subjects without diabetes. Subjects with T1DM had markedly elevated glucose concentrations when compared with controls (p < 0.0001). Amylin concentrations as predicted were lower in T1DM compared with those in controls (p < 0.0001). Insulin did not peak in the immediate postprandial period in T1DM when compared with controls (p < 0.0001). Glucagon concentrations did not significantly differ between groups. Interestingly, gastric velocity was delayed in patients with T1DM compared with controls (p < 0.01). In conclusion, subjects with T1DM do have amylin deficiency but this is not associated with accelerated gastric emptying as we had hypothesized but rather with delayed gastric emptying. Factors other than amylin play a role in control of gastric motility in T1DM. Subcutaneous insulin delivery fails to reach adequate concentrations in the postprandial period to curtail peak glucose concentration in T1DM.
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Affiliation(s)
- Rubina A Heptulla
- Department of Pediatrics, Division of Diabetes and Endocrinology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX 77030, USA.
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Therapeutic effects of ghrelin and growth hormone releasing peptide 6 on gastroparesis in streptozotocin-induced diabetic guinea pigs in vivo and in vitro. Chin Med J (Engl) 2008. [DOI: 10.1097/00029330-200807010-00007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Onoma M, Ozaki KI, Yogo K, Monnai M, Muramatsu H, Kamei K, Kawabe Y, Hayashi S, Shiga T, Matsuo S, Suzuki M, Itoh Z, Ōmura S, Takanashi H. MITEMCINAL (GM-611), AN ORALLY ACTIVE MOTILIN RECEPTOR AGONIST, IMPROVES DELAYED GASTRIC EMPTYING IN A CANINE MODEL OF DIABETIC GASTROPARESIS. Clin Exp Pharmacol Physiol 2008; 35:788-96. [DOI: 10.1111/j.1440-1681.2008.04924.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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