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Lou Q. Neutrophil-to-Lymphocyte Ratio: A Promising Predictor of Mortality in Patients With Acute Respiratory Distress Syndrome. A Retrospective Analysis of a Single Hospital Center. J Cardiothorac Vasc Anesth 2024; 38:1716-1726. [PMID: 38821730 DOI: 10.1053/j.jvca.2024.03.027] [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: 08/14/2023] [Revised: 02/29/2024] [Accepted: 03/20/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVES To examine how the neutrophil-to-lymphocyte ratio (NLR) affects both short-term and long-term mortality in individuals with acute respiratory distress syndrome (ARDS). DESIGN A retrospective study. SETTING Critical care unit. PARTICIPANTS A total of 785 patients with ARDS. INTERVENTIONS There were three groups in the NLR study. A Cox proportional hazards regression model was used to calculate the hazard ratio (HR) between the NLR and 30-day, 90-day, and 1-year mortality. MEASUREMENTS AND MAIN RESULTS The 785 patients included 329 women (41.9%) and 456 men (58.1%), with a mean age of 63.4 ± 16.7 years and a mean NLR of 14.2 ± 9.8. The study population was divided into 3 groups based on NLR value. In the unadjusted model, compared to group 1 (NLR <6.0), group 2 (NLR 6.0-11.3) and group 3 (NLR >11.3) had HR values of 1.12 (95% confidence interval [CI], 0.83-1.52) and 2.39 (95% CI, 1.87-3.04), respectively, for 30-day all-cause mortality. This association remained significant after adjusting for potential confounding variables (HR, 1.54; 95% CI, 1.18-2.02), with a statistically significant trend (p = 0.0004) in group 3 (NLR >11.3). A similar effect was seen on both 90-day and 1-year all-cause mortality. The R2 value in a 2-piecewise linear regression was 1.25 (95% CI, 1.06-1.48; p < 0.0001) on the left side of the inflection point (NLR 17.1). CONCLUSIONS In this retrospective single-center study, the NLR was a potential predictor of both short- and long-term mortality in patients with ARDS and may aid risk stratification.
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Affiliation(s)
- Qiyan Lou
- Department of Respiratory Medicine, Zhuji People's Hospital Affiliated to Shaoxing University of Arts and Sciences, Shaoxing, China.
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Haynes ME, Sullivan DP, Muller WA. Neutrophil Infiltration and Function in the Pathogenesis of Inflammatory Airspace Disease. THE AMERICAN JOURNAL OF PATHOLOGY 2024; 194:628-636. [PMID: 38309429 PMCID: PMC11074974 DOI: 10.1016/j.ajpath.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/07/2023] [Accepted: 12/21/2023] [Indexed: 02/05/2024]
Abstract
Neutrophils are an important cell type often considered the body's first responders to inflammatory insult or damage. They are recruited to the tissue of the lungs in patients with inflammatory airspace diseases and have unique and complex functions that range from helpful to harmful. The uniqueness of these functions is due to the heterogeneity of the inflammatory cascade and retention in the vasculature. Neutrophils are known to marginate, or remain stagnant, in the lungs even in nondisease conditions. This review discusses the ways in which the recruitment, presence, and function of neutrophils in the airspace of the lungs are unique from those of other tissues, and the complex effects of neutrophils on pathogenesis. Inflammatory mediators produced by neutrophils, such as neutrophil elastase, proresolving mediators, and neutrophil extracellular traps, dramatically affect the outcomes of patients with disease of the lungs.
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Affiliation(s)
- Maureen E Haynes
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David P Sullivan
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - William A Muller
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Kim HI, Park J, Gallo D, Shankar S, Konecna B, Han Y, Banner-Goodspeed V, Capers KR, Ko SG, Otterbein LE, Itagaki K, Hauser CJ. DANGER Signals Activate G -Protein Receptor Kinases Suppressing Neutrophil Function and Predisposing to Infection After Tissue Trauma. Ann Surg 2023; 278:e1277-e1288. [PMID: 37154066 DOI: 10.1097/sla.0000000000005898] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Injured tissue predisposes the subject to local and systemic infection. We studied injury-induced immune dysfunction seeking novel means to reverse such predisposition. BACKGROUND Injury mobilizes primitive "DANGER signals" [danger-associated molecular patterns (DAMPs)] activating innate immunocyte (neutrophils, PMN) signaling and function. Mitochondrial formyl peptides activate G -protein coupled receptors (GPCR) like formyl peptide receptor-1. Mitochondrial DNA and heme activate toll-like receptors (TLR9 and TLR2/4). GPCR kinases (GRKs) can regulate GPCR activation. METHODS We studied human and mouse PMN signaling elicited by mitochondrial DAMPs (GPCR surface expression; protein phosphorylation, or acetylation; Ca 2+ flux) and antimicrobial functions [cytoskeletal reorganization, chemotaxis (CTX), phagocytosis, bacterial killing] in cellular systems and clinical injury samples. Predicted rescue therapies were assessed in cell systems and mouse injury-dependent pneumonia models. RESULTS Mitochondrial formyl peptides activate GRK2, internalizing GPCRs and suppressing CTX. Mitochondrial DNA suppresses CTX, phagocytosis, and killing through TLR9 through a novel noncanonical mechanism that lacks GPCR endocytosis. Heme also activates GRK2. GRK2 inhibitors like paroxetine restore functions. GRK2 activation through TLR9 prevented actin reorganization, implicating histone deacetylases (HDACs). Actin polymerization, CTX, bacterial phagocytosis, and killing were also rescued, therefore, by the HDAC inhibitor valproate. Trauma repository PMN showed GRK2 activation and cortactin deacetylation, which varied with severity and was most marked in patients developing infections. Either GRK2 or HDAC inhibition prevented loss of mouse lung bacterial clearance, but only the combination rescued clearance when given postinjury. CONCLUSIONS Tissue injury-derived DAMPs suppress antimicrobial immunity through canonical GRK2 activation and a novel TLR-activated GRK2-pathway impairing cytoskeletal organization. Simultaneous GRK2/HDAC inhibition rescues susceptibility to infection after tissue injury.
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Affiliation(s)
- Hyo In Kim
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jinbong Park
- College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - David Gallo
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sidharth Shankar
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Barbora Konecna
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Yohan Han
- College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Valerie Banner-Goodspeed
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Krystal R Capers
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Seong-Gyu Ko
- College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Leo E Otterbein
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kiyoshi Itagaki
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Carl J Hauser
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Becker N, Hammen A, Bläsius F, Weber CD, Hildebrand F, Horst K. Effect of Injury Patterns on the Development of Complications and Trauma-Induced Mortality in Patients Suffering Multiple Trauma. J Clin Med 2023; 12:5111. [PMID: 37568511 PMCID: PMC10420136 DOI: 10.3390/jcm12155111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/30/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Abstract
Patients that suffer from severe multiple trauma are highly vulnerable to the development of complications that influence their outcomes. Therefore, this study aimed to evaluate the risk factors that can facilitate an early recognition of adult patients at risk. The inclusion criteria were as follows: admission to a level 1 trauma center, injury severity score (ISS) ≥ 16 (severe injury was defined by an abbreviated injury score (AIS) ≥ 3) and ≥18 years of age. Injury- and patient-associated factors were correlated with the development of four complication clusters (surgery-related, infection, thromboembolic events and organ failure) and three mortality time points (immediate (6 h after admission), early (>6 h-72 h) and late (>72 h) mortality). Statistical analysis was performed using a Chi-square, Mann-Whitney U test, Cox hazard regression analysis and binominal logistic regression analysis. In total, 383 patients with a median ISS of 24 (interquartile range (IQR) 17-27) were included. The overall mortality rate (27.4%) peaked in the early mortality group. Lactate on admission significantly correlated with immediate and early mortality. Late mortality was significantly influenced by severe head injuries in patients with a moderate ISS (ISS 16-24). In patients with a high ISS (≥25), late mortality was influenced by a higher ISS, older age and higher rates of organ failure. Complications were observed in 47.5% of all patients, with infections being seen most often. The development of complications was significantly influenced by severe extremity injuries, the duration of mechanical ventilation and length of ICU stay. Infection remains the predominant posttraumatic complication. While immediate and early mortality is mainly influenced by the severity of the initial trauma, the rates of severe head injuries influence late mortality in moderate trauma severity, while organ failure remains a relevant factor in patients with a high injury severity.
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Affiliation(s)
- Nils Becker
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH University Hospital Aachen, 52074 Aachen, Germany; (N.B.)
| | - Antonia Hammen
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH University Hospital Aachen, 52074 Aachen, Germany; (N.B.)
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH University Hospital Aachen, 52074 Aachen, Germany
| | - Felix Bläsius
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH University Hospital Aachen, 52074 Aachen, Germany; (N.B.)
| | - Christian David Weber
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH University Hospital Aachen, 52074 Aachen, Germany; (N.B.)
| | - Frank Hildebrand
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH University Hospital Aachen, 52074 Aachen, Germany; (N.B.)
| | - Klemens Horst
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH University Hospital Aachen, 52074 Aachen, Germany; (N.B.)
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Hoofnagle MH, Hess A, Nalugo M, Ghosh S, Hughes SW, Fuchs A, Welsh JD, Kahn ML, Bochicchio GV, Randolph GJ, Leonard JM, Turnbull IR. Defects in vein valve PROX1/FOXC2 antithrombotic pathway in endothelial cells drive the hypercoagulable state induced by trauma and critical illness. J Trauma Acute Care Surg 2023; 95:197-204. [PMID: 37072887 PMCID: PMC10524206 DOI: 10.1097/ta.0000000000003945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
OBJECTIVES Deep venous thrombosis (DVT) causes significant morbidity and mortality after trauma. Recently, we have shown that blood flow patterns at vein valves induce oscillatory stress genes, which maintain an anticoagulant endothelial phenotype that inhibits spontaneous clotting at vein valves and sinuses, is lost in the presence of DVT in human pathological samples, and is dependent on expression of the transcription factor FOXC2. We describe an assay, modifying our mouse multiple injury system, which shows evidence of clinically relevant microthrombosis and hypercoagulability applicable to the study of spontaneous DVT in trauma without requiring direct vascular injury or ligation. Finally, we investigated whether these model findings are relevant to a human model of critical illness by examining gene expression changes by quantitative polymerase chain reaction and immunofluorescence in veins collected from critically ill. METHODS C57/Bl6 mice were subjected to a modified mouse multiple injury model with liver crush injury, crush and pseudofracture of a single lower extremity, and 15% total blood volume hemorrhage. Serum was assayed for d-dimer at 2, 6, 24, and 48 hours after injury by enzyme-linked immunosorbent assay. For the thrombin clotting assay, veins of the leg were exposed, 100 μL of 1 mM rhodamine (6 g) was injected retro-orbitally, and 450 μg/mL thrombin was then applied to the surface of the vein with examination of real-time clot formation via in vivo immunofluorescence microscopy. Images were then examined for percentage area of clot coverage of visible mouse saphenous and common femoral vein. Vein valve specific knockout of FOXC2 was induced with tamoxifen treatment in PROX1 Ert2Cre FOXC2 fl/fl mice as previously described. Animals were then subjected to a modified mouse multiple injury model with liver crush injury, crush and pseudofracture of a single lower extremity, and 15% total blood volume hemorrhage. Twenty-four hours after injury, we examined the valve phenotype in naive versus multiple injury animals, with and without loss of the FOXC2 gene from the vein valve (FOXC2 del ) via the thrombin assay. Images were then examined for proximity of clot formation to the valve present at the junction of the mouse saphenous, tibial, and superficial femoral vein and presence of spontaneous microthrombi present in the veins before exposure to thrombin. Human vein samples were obtained from excess tissue preserved after harvest for elective cardiac surgery and from organ donors after organ procurement. Sections were submitted for paraffin embedding and then assayed by immunofluorescence for PROX1, FOXC2, thrombomodulin, endothelial protein C receptor, and von Willebrand's factor. All animal studies were reviewed and approved by the Institutional Animal Care and Use Committee, and all human studies reviewed and approved by the institutional review board. RESULTS After mouse multiple injuries, enzyme-linked immunosorbent assay for d-dimer showed evidence of products of fibrin breakdown consistent with formation of clot related to injury, fibrinolysis, and/or microthrombosis. The thrombin clotting assay demonstrated higher percentage area of vein covered with clot when exposed to thrombin in the multiple injury animals compared with uninjured (45% vs. 27% p = 0.0002) consistent with a phenotype of hypercoagulable state after trauma in our model system. Unmanipulated FoxC2 knockout mice manifest increased clotting at the vein valve as compared with unmanipulated wild type animals. After multiple injuries, wild type mice manifest increase clotting at the vein after thrombin exposure ( p = 0.0033), and equivalent to that of valvular knockout of FoxC2 (FoxC2del), recapitulating the phenotype seen in FoxC2 knockout animals. The combination of multiple injuries and FoxC2 knockout resulted in spontaneous microthrombi in 50% of the animals, a phenotype not observed with either multiple injuries or FoxC2 deficiency alone (χ 2 , p = 0.017). Finally, human vein samples demonstrated the protective vein valve phenotype of increased FOXC2 and PROX1 and showed decreased expression in the critically ill organ donor population by immunofluorescence imaging in organ donor samples. CONCLUSION We have established a novel model of posttrauma hypercoagulation that does not require direct restriction of venous flow or direct injury to the vessel endothelium to assay for hypercoagulability and can generate spontaneous microthrombosis when combined with valve-specific FOXC2 knockout. We find that multiple injuries induce a procoagulant phenotype that recapitulates the valvular hypercoagulability seen in FOXC2 knockout and, in critically ill human specimens, find evidence for loss of oscillatory shear stress-induced gene expression of FOXC2 and PROX1 in the valvular endothelium consistent with potential loss of DVT-protective valvular phenotype.
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Affiliation(s)
- Mark H Hoofnagle
- From the Section of Acute and Critical Care Surgery, Department of Surgery (M.H.H., A.H., S.G., S.-W.H., A.F., G.V.B., J.M.L., I.R.T.), Section of Vascular Surgery, Department of Surgery (M.N.), and Department of Pathology (G.J.R.), School of Medicine, Washington University in Saint Louis, St. Louis, Missouri; Osciflex LLC (J.D.W.); and Department of Medicine (M.L.K.), Cardiovascular Institute, University of Pennsylvania, Philadelphia, Pennsylvania
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Heydari S, Khoshmohabat H, Akerdi AT, Ahmadpour F, Paydar S. Evaluating the effect of montelukast tablets on respiratory complications in patients following blunt chest wall trauma: A double-blind, randomized clinical trial. Chin J Traumatol 2022; 26:116-120. [PMID: 36357273 PMCID: PMC9558713 DOI: 10.1016/j.cjtee.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 08/30/2022] [Accepted: 09/26/2022] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Patients with multiple traumas are at high risk of developing respiratory complications, including pneumonia and acute respiratory distress syndrome. Many pulmonary complications are associated with systemic inflammation and pulmonary neutrophilic infiltration. Leukotriene-receptor antagonists are anti-inflammatory and anti-oxidant drugs subsiding airway inflammation. The present study investigates the effectiveness of montelukast in reducing pulmonary complications among trauma patients. METHODS This randomized, double-blind, placebo-control trial was conducted in patients with multiple blunt traumas and evidence of lung contusion detected via CT scan. We excluded patients if they met at least one of the following conditions: <16 years old, history of cardiopulmonary diseases or positive history of montelukast-induced hypersensitivity reactions. Patients were allocated to the treatment (10 mg of montelukast) or placebo group using permuted block randomization method. The primary measured outcome was the volume of pulmonary contusion at the end of the trial. The secondary outcomes were intensive care unit and hospital length of stay, ventilation days, multi-organ failure, and the in-hospital mortality rate. RESULTS In total, 65 eligible patients (treatment = 31, placebo = 34) were included for the final analysis. The treatment group had more pulmonary contusion volume (mean (SD), mm3) at the right (68726.97 (93656.54) vs. 59730.27 (76551)) and the left side (67501.71 (91514) vs. 46502.21 (80604.21)), higher initial C-reactive peptide level (12.16 (10.58) vs. 10.85 (17.9)) compared to the placebo group, but the differences were not statistically significant (p > 0.05). At the end of the study, the mean (SD) of pulmonary contusion volume (mm3) (right side = 116748.74 (361705.12), left side = 64522.03 (117266.2)) of the treatment group were comparable to that of the placebo group (right side = 40051.26 (64081.56), left side = 25929.12 (47417.13), p = 0.228 and 0.082, respectively). Moreover, both groups have statistically similar hospital (mean (SD), days) (10.87 (9.83) vs. 13.05 (10.12)) and intensive care unit length of stays (mean (SD), days) (7.16 (8.15) vs. 7.82 (7.48)). Of note, the frequency of the in-hospital complications (treatment vs. control group) including acute respiratory distress syndrome (12.9% vs. 8.8%, p = 0.71), pneumonia (19.4% vs. 17.6%, p = 0.85), multi-organ failure (12.9% vs. 17.6%, p = 0.58) and the mortality rate (22.6% vs. 14.7%, p = 0.41) were comparable between the groups. CONCLUSION Administrating montelukast has no preventive or therapeutic effects on lung contusion or its complications.
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Affiliation(s)
- Soleyman Heydari
- Department of Surgery, Baqiyatallah University of Medical Sciences, Tehran, Iran; Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Hadi Khoshmohabat
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Ali Taheri Akerdi
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Fathollah Ahmadpour
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Shahram Paydar
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Signal Pathways and Markers Involved in Acute Lung Injury Induced by Acute Pancreatitis. DISEASE MARKERS 2021; 2021:9947047. [PMID: 34497676 PMCID: PMC8419500 DOI: 10.1155/2021/9947047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/10/2021] [Accepted: 08/18/2021] [Indexed: 12/23/2022]
Abstract
Acute pancreatitis (AP) is a common acute abdominal disease with a mortality rate of about 30%. Acute lung injury (ALI) is a common systemic complication of acute pancreatitis, with progressive hypoxemia and respiratory distress as the main manifestations, which can develop into acute respiratory distress syndrome or even multiple organ dysfunction syndrome (MODS) in severe cases, endangering human health. In the model of AP, pathophysiological process of the lung can be summarized as oxidative stress injury, inflammatory factor infiltration, and alveolar cell apoptosis. However, the intrinsic mechanisms underlying AP and how it leads to ALI are not fully understood. In this paper, we summarize recent articles related to AP leading to ALI, including the signal transduction pathways and biomarkers of AP-ALI. There are factors or pathway aggravating ALI, the JAK2-STAT3 signaling pathway, NLRP3/NF-κB pathway, mitogen-activated protein kinase, PKC pathway, neutrophil protease (NP)-LAMC2-neutrophil pathway, and the P2X7 pathway, and there are important transcription factors in the NRF2 signal transduction pathway which could give researchers better understanding of the underlying mechanisms controlling AP and ALI and lay the foundation for finally curing ALI induced by AP.
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