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Finkelstein JL, Cuthbert A, Weeks J, Venkatramanan S, Larvie DY, De-Regil LM, Garcia-Casal MN. Daily oral iron supplementation during pregnancy. Cochrane Database Syst Rev 2024; 8:CD004736. [PMID: 39145520 PMCID: PMC11325660 DOI: 10.1002/14651858.cd004736.pub6] [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] [Indexed: 08/16/2024]
Abstract
BACKGROUND Iron and folic acid supplementation have been recommended in pregnancy for anaemia prevention, and may improve other maternal, pregnancy, and infant outcomes. OBJECTIVES To examine the effects of daily oral iron supplementation during pregnancy, either alone or in combination with folic acid or with other vitamins and minerals, as an intervention in antenatal care. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Trials Registry on 18 January 2024 (including CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO's International Clinical Trials Registry Platform, conference proceedings), and searched reference lists of retrieved studies. SELECTION CRITERIA Randomised or quasi-randomised trials that evaluated the effects of oral supplementation with daily iron, iron + folic acid, or iron + other vitamins and minerals during pregnancy were included. DATA COLLECTION AND ANALYSIS Review authors independently assessed trial eligibility, ascertained trustworthiness based on pre-defined criteria, assessed risk of bias, extracted data, and conducted checks for accuracy. We used the GRADE approach to assess the certainty of the evidence for primary outcomes. We anticipated high heterogeneity amongst trials; we pooled trial results using a random-effects model (average treatment effect). MAIN RESULTS We included 57 trials involving 48,971 women. A total of 40 trials compared the effects of daily oral supplements with iron to placebo or no iron; eight trials evaluated the effects of iron + folic acid compared to placebo or no iron + folic acid. Iron supplementation compared to placebo or no iron Maternal outcomes: Iron supplementation during pregnancy may reduce maternal anaemia (4.0% versus 7.4%; risk ratio (RR) 0.30, 95% confidence interval (CI) 0.20 to 0.47; 14 trials, 13,543 women; low-certainty evidence) and iron deficiency at term (44.0% versus 66.0%; RR 0.51, 95% CI 0.38 to 0.68; 8 trials, 2873 women; low-certainty evidence), and probably reduces maternal iron-deficiency anaemia at term (5.0% versus 18.4%; RR 0.41, 95% CI 0.26 to 0.63; 7 trials, 2704 women; moderate-certainty evidence), compared to placebo or no iron supplementation. There is probably little to no difference in maternal death (2 versus 4 events, RR 0.57, 95% CI 0.12 to 2.69; 3 trials, 14,060 women; moderate-certainty evidence). The evidence is very uncertain for adverse effects (21.6% versus 18.0%; RR 1.29, 95% CI 0.83 to 2.02; 12 trials, 2423 women; very low-certainty evidence) and severe anaemia (Hb < 70 g/L) in the second/third trimester (< 1% versus 3.6%; RR 0.22, 95% CI 0.01 to 3.20; 8 trials, 1398 women; very low-certainty evidence). No trials reported clinical malaria or infection during pregnancy. Infant outcomes: Women taking iron supplements are probably less likely to have infants with low birthweight (5.2% versus 6.1%; RR 0.84, 95% CI 0.72 to 0.99; 12 trials, 18,290 infants; moderate-certainty evidence), compared to placebo or no iron supplementation. However, the evidence is very uncertain for infant birthweight (MD 24.9 g, 95% CI -125.81 to 175.60; 16 trials, 18,554 infants; very low-certainty evidence). There is probably little to no difference in preterm birth (7.6% versus 8.2%; RR 0.93, 95% CI 0.84 to 1.02; 11 trials, 18,827 infants; moderate-certainty evidence) and there may be little to no difference in neonatal death (1.4% versus 1.5%, RR 0.98, 95% CI 0.77 to 1.24; 4 trials, 17,243 infants; low-certainty evidence) or congenital anomalies, including neural tube defects (41 versus 48 events; RR 0.88, 95% CI 0.58 to 1.33; 4 trials, 14,377 infants; low-certainty evidence). Iron + folic supplementation compared to placebo or no iron + folic acid Maternal outcomes: Daily oral supplementation with iron + folic acid probably reduces maternal anaemia at term (12.1% versus 25.5%; RR 0.44, 95% CI 0.30 to 0.64; 4 trials, 1962 women; moderate-certainty evidence), and may reduce maternal iron deficiency at term (3.6% versus 15%; RR 0.24, 95% CI 0.06 to 0.99; 1 trial, 131 women; low-certainty evidence), compared to placebo or no iron + folic acid. The evidence is very uncertain about the effects of iron + folic acid on maternal iron-deficiency anaemia (10.8% versus 25%; RR 0.43, 95% CI 0.17 to 1.09; 1 trial, 131 women; very low-certainty evidence), or maternal deaths (no events; 1 trial; very low-certainty evidence). The evidence is uncertain for adverse effects (21.0% versus 0.0%; RR 44.32, 95% CI 2.77 to 709.09; 1 trial, 456 women; low-certainty evidence), and the evidence is very uncertain for severe anaemia in the second or third trimester (< 1% versus 5.6%; RR 0.12, 95% CI 0.02 to 0.63; 4 trials, 506 women; very low-certainty evidence), compared to placebo or no iron + folic acid. Infant outcomes: There may be little to no difference in infant low birthweight (33.4% versus 40.2%; RR 1.07, 95% CI 0.31 to 3.74; 2 trials, 1311 infants; low-certainty evidence), comparing iron + folic acid supplementation to placebo or no iron + folic acid. Infants born to women who received iron + folic acid during pregnancy probably had higher birthweight (MD 57.73 g, 95% CI 7.66 to 107.79; 2 trials, 1365 infants; moderate-certainty evidence), compared to placebo or no iron + folic acid. There may be little to no difference in other infant outcomes, including preterm birth (19.4% versus 19.2%; RR 1.55, 95% CI 0.40 to 6.00; 3 trials, 1497 infants; low-certainty evidence), neonatal death (3.4% versus 4.2%; RR 0.81, 95% CI 0.51 to 1.30; 1 trial, 1793 infants; low-certainty evidence), or congenital anomalies (1.7% versus 2.4; RR 0.70, 95% CI 0.35 to 1.40; 1 trial, 1652 infants; low-certainty evidence), comparing iron + folic acid supplementation to placebo or no iron + folic acid. A total of 19 trials were conducted in malaria-endemic countries, or in settings with some malaria risk. No studies reported maternal clinical malaria; one study reported data on placental malaria. AUTHORS' CONCLUSIONS Daily oral iron supplementation during pregnancy may reduce maternal anaemia and iron deficiency at term. For other maternal and infant outcomes, there was little to no difference between groups or the evidence was uncertain. Future research is needed to examine the effects of iron supplementation on other maternal and infant health outcomes, including infant iron status, growth, and development.
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Affiliation(s)
| | - Anna Cuthbert
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Jo Weeks
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | | | - Doreen Y Larvie
- Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Luz Maria De-Regil
- Multisectoral Action in Food Systems Unit, World Health Organization, Geneva, Switzerland
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Fan X, Wang L, Jiao R, Song W, Liu Y, Yu T. Correlation between high serum ferritin levels and adverse pregnancy outcomes in women with gestational diabetes mellitus. Heliyon 2023; 9:e14285. [PMID: 36942253 PMCID: PMC10023919 DOI: 10.1016/j.heliyon.2023.e14285] [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: 11/06/2022] [Revised: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 03/11/2023] Open
Abstract
Aims To explore the association between higher serum ferritin (SF) levels in mid-pregnancy and adverse pregnancy outcomes in gestational diabetes mellitus (GDM) pregnancies, then develop a predictive cut-off value that might effectively predict the risk of adverse pregnancy outcomes in future clinical. Methods The study involved 201 pregnant women with GDM. 201 gestational age and parity matched normoglycemic pregnant women were taken as control group. The differences in clinical data were compared by the Mann-Whitney U test and Chi-square tests. Multivariate logistic regression was used to determine the relationship between SF and GDM-relate adverse pregnancy outcomes. The predicted value of SF level was determined through receiver operating characteristic (ROC) curve analysis. Results SF level was significantly higher in women with GDM [16.10 (27.30-9.50) (ng/mL) vs. 12.04 (18.11-7.06) (ng/mL), (p < 0.001)]. Meanwhile, higher levels of SF were also discovered in GDM women with preeclampsia and neonatal hypoglycemia and respiratory distress (all p < 0.05). In the adjusted model, a positive association was shown between SF and preeclampsia [adjusted odds ratio (AOR) = 1.032, 95%CI = 1.004-1.060, p = 0.024], neonatal hypoglycemia [adjusted odds ratio (AOR) = 1.047, 95%CI = 1.022-1.072, p < 0.001] and respiratory distress outcomes (AOR = 1.034, 95%CI = 1.011-1.058, p = 0.004) respectively. The area under ROC curve (AUC) for prediction of preeclampsia by SF combined with serum calcium, age, pre-pregnancy BMI and gestational weight gain (GWG) was 0.658 (95% CI = 50.8-80.8%, p = 0.028) with the cut-off value of 24.45 ng/mL, and the sensitivity and specificity were 58.8.0% and 64.3%, respectively. To predict neonatal hypoglycemia, the clinical point value of SF was 27.43 ng/mL with AUC was 0.800, sensitivity and specificity was 90.5% and 68.0% respectively. Predicting neonatal respiratory distress, the AUC value of the SF level was 0.730, with a cut-off value of 27.37 ng/mL and the sensitivity and specificity were 52.0% and 86.5%, respectively. Conclusions Higher level of SF in mid-pregnancy was significantly associated with the risk of GDM and GDM-relate adverse pregnancy outcomes. Moreover, SF levels have moderate clinical value in predicting the adverse outcomes of maternal preeclampsia, neonatal hypoglycemia and respiratory distress.
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Affiliation(s)
- Xizhenzi Fan
- Research Center for Clinical Medical Sciences, The Fourth Hospital of Shijiazhuang, 050000, China
| | - Lingli Wang
- Research Center for Clinical Medical Sciences, The Fourth Hospital of Shijiazhuang, 050000, China
- School of Public Health, Hebei Medical University, Shijiazhuang, 050000, China
| | - Ruifen Jiao
- Department of Obstetrics, The Fourth Hospital of Shijiazhuang, Shijiazhuang, 050000, China
| | - Wenhui Song
- Research Center for Clinical Medical Sciences, The Fourth Hospital of Shijiazhuang, 050000, China
| | - Yumeng Liu
- Research Center for Clinical Medical Sciences, The Fourth Hospital of Shijiazhuang, 050000, China
- School of Public Health, Hebei Medical University, Shijiazhuang, 050000, China
| | - Tianxiao Yu
- Research Center for Clinical Medical Sciences, The Fourth Hospital of Shijiazhuang, 050000, China
- Corresponding author.
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Fang Z, Zheng S, Xie Y, Lin S, Zhang H, Yan J. Correlation between serum ferritin in early pregnancy and hypertensive disorders in pregnancy. Front Nutr 2023; 10:1151410. [PMID: 37139443 PMCID: PMC10149942 DOI: 10.3389/fnut.2023.1151410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 03/29/2023] [Indexed: 05/05/2023] Open
Abstract
Objective To explore the correlation between serum ferritin (SF) in early pregnancy and the risk of hypertensive disorders in pregnancy (HDP). Method A retrospective cohort study was conducted on 43,421 pregnant women with singleton pregnancies who underwent antenatal checkups at Fujian Provincial Maternal and Child Health Hospital from January 2018 to December 2020. Based on pregnancy records, women were classified as non-hypertensive, having gestational hypertension, preeclampsia and preeclampsia with severe features according to the degree of the disease. General baseline data, and SF levels in the early (up to 12 gestational weeks) and late (after 28 weeks of gestation) stages of pregnancy were collected. The significance of the characteristic variables was assessed using a random forest algorithm, and the correlation between early pregnancy SF levels and the incidence of HDP was further analyzed using logistics regression adjusted for confounders. A generalized additive model (GAM) was fitted to a smoothed graph of the relationship between early pregnancy SF levels and HDP, and a threshold effect analysis was performed to find the threshold values of early pregnancy SF for iron supplementation therapy. Result A total of 30,703 pregnant women were included. There were 1,103 women who were diagnosed with HDP. Of them, 418 had gestational hypertension, 12 had chronic hypertension without SPE, 332 - preeclampsia and 341 women had preeclampsia with severe features. Levels of SF in early and late pregnancy were significantly higher (p < 0.001) in women with HDP compared to non-hypertensive women and the difference was more pronounced in early pregnancy. The random forest algorithm showed that early pregnancy SF was more effective in predicting HDP compared to late pregnancy SF levels and was also an independent risk factor for HDP (adjusted odds ratio (AOR) = 1.07, 95% CI [1.05,1.09]) after correction for confounding factors. Early pregnancy SF >64.22 mg/l was associated with higher risk of developing hypertensive disorders. Conclusion Risk of pregnancy-related hypertensive disorders increases with increasing early pregnancy SF levels. SF levels may therefore be used to further develop guidelines for iron supplementation therapy in pregnant women.
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Affiliation(s)
- Zhuanji Fang
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, China
- College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian, China
| | - Shuisen Zheng
- College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian, China
- Fujian Medical University, Fujian, China
| | - Yi Xie
- College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian, China
- Fujian Medical University, Fujian, China
| | - Shunhe Lin
- College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian, China
- Department of Gynecology, Fujian Maternity, and Child Health Hospital, Fuzhou, Fujian, China
| | - Huale Zhang
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, China
- College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian, China
- Laboratory of Maternal-Fetal Medicine, Fujian Clinical Research Center for Maternal-Fetal Medicine, Fuzhou, Fujian, China
- *Correspondence: Huale Zhang,
| | - Jianying Yan
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian, China
- College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, Fujian, China
- Laboratory of Maternal-Fetal Medicine, Fujian Clinical Research Center for Maternal-Fetal Medicine, Fuzhou, Fujian, China
- Jianying Yan,
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Lefizelier E, Misbert E, Brooks M, Le Thuaut A, Winer N, Ducarme G. Preterm Birth and Small-for-Gestational Age Neonates among Prepregnancy Underweight Women: A Case-Controlled Study. J Clin Med 2021; 10:5733. [PMID: 34945028 PMCID: PMC8709329 DOI: 10.3390/jcm10245733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/28/2021] [Accepted: 12/03/2021] [Indexed: 12/27/2022] Open
Abstract
The aim of our study was to investigate whether prepregnancy underweight body mass index (BMI) is associated with preterm birth (PTB) and small-for-gestational age (SGA). This retrospective case-control study included 814 women with live singleton fetuses in vertex presentation that gave birth between January 2016 and November 2016 in two tertiary care hospitals. The study group (n = 407) comprised all women whose prepregnancy BMI was underweight (<18.5 kg/m2) and who delivered during the study period. A control group (n = 407) was established with women whose prepregnancy BMI was normal (18.5-24.9 kg/m2) by matching age and parity. Univariate and multivariate analyses were performed to compare PTB and SGA associated with prepregnancy underweight BMI. Compared with the control group, the study group had higher rates of overall PTB (10.1% vs. 5.7%, p = 0.02), iatrogenic PTB (4.2% vs. 1.5%, p = 0.02), and SGA (22.1% vs. 11.1%, p < 0.001). In a multivariable analysis, prepregnancy underweight BMI was associated with PTB (aOR 2.32, 95% CI 1.12-4.81) and with SGA (aOR 2.38, 95% CI 1.58-3.58). In singleton pregnancies, women's prepregnancy underweight compared with normal BMI was associated with an increase in PTB and in SGA neonates. Identifying this specific high-risk group is pragmatic and practical for all physicians, and they should be aware about perinatal outcome among underweight women.
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Affiliation(s)
- Emelyne Lefizelier
- Department of Obstetrics and Gynaecology, Centre Hospitalier Departemental, 85000 La Roche sur Yon, France; (E.L.); (M.B.)
| | - Emilie Misbert
- Department of Obstetrics and Gynaecology, Nantes University Hospital, 44000 Nantes, France; (E.M.); (N.W.)
| | - Marion Brooks
- Department of Obstetrics and Gynaecology, Centre Hospitalier Departemental, 85000 La Roche sur Yon, France; (E.L.); (M.B.)
| | - Aurélie Le Thuaut
- Plateforme de Méthodologie et Biostatistique, CHU Nantes, 44093 Nantes, France;
| | - Norbert Winer
- Department of Obstetrics and Gynaecology, Nantes University Hospital, 44000 Nantes, France; (E.M.); (N.W.)
| | - Guillaume Ducarme
- Department of Obstetrics and Gynaecology, Centre Hospitalier Departemental, 85000 La Roche sur Yon, France; (E.L.); (M.B.)
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González-Fernández D, Nemeth E, Pons EDC, Rueda D, Sinisterra OT, Murillo E, Sangkhae V, Starr LM, Scott ME, Koski KG. INTERGROWTH-21 Identifies High Prevalence of Low Symphysis-Fundal Height in Indigenous Pregnant Women Experiencing Multiple Infections, Nutrient Deficiencies, and Inflammation: The Maternal Infections, Nutrient Deficiencies, and Inflammation (MINDI) Cohort. Curr Dev Nutr 2021; 5:nzab012. [PMID: 33898918 PMCID: PMC8053398 DOI: 10.1093/cdn/nzab012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 01/20/2021] [Accepted: 02/17/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND In the absence of ultrasound, symphysis-fundal height (SFH) can assess maternal-fetal well-being as it is associated with gestational age, fetal weight, and amniotic fluid volume. However, other modifiers of SFH, including maternal infections, nutrient deficiencies, and inflammation (MINDI), have not been widely explored. OBJECTIVES Our objectives were 2-fold: 1) to assess prevalence of low SFH in indigenous Panamanian women using both Pan-American Health Organization (PAHO) and INTERGROWTH-21 standards and 2) to explore associations of SFH with maternal health indicators: infections (oral, skin, urogenital, nematode infections), nutrient deficiencies [protein and iron indicators (ferritin, serum iron, serum transferrin receptor, hepcidin), folate, and vitamins A, D, and B-12], and inflammation [leukocytes, C-reactive protein (CRP), cytokines]. METHODS For this cross-sectional study, low-SFH-for-gestational-age was assessed using PAHO and INTERGROWTH <10th centile in 174 women at ≥16 weeks of gestation. Bootstrapping selected MINDI variables for inclusion in multivariable fractional polynomial (MFP) logistic regressions for low SFH. Associations of MINDI variables with hepcidin were also investigated. RESULTS Prevalence of low SFH was 8% using PAHO, but using INTERGROWTH, 50.6% had SFH <10th centile, including 37.9% <3rd centile. Both PAHO-SFH <10th centile and INTERGROWTH-SFH <3rd centile were associated with higher hepcidin (OR = 1.12, P = 0.008, and OR = 3.04, P = 0.001, respectively) and with lower TNF-α (OR = 0.73, P = 0.012, and OR = 0.93, P = 0.015, respectively). Wood-smoke exposure increased the odds of PAHO-SFH <10th centile (OR = 1.19, P = 0.009), whereas higher BMI decreased the odds of INTERGROWTH-SFH <3rd centile (OR = 0.87, P = 0.012). Lower pulse pressure (OR = 0.90, P = 0.009) and lower inflammatory responses [lower lymphocytes (OR = 0.21, P = 0.026), IL-17 (OR = 0.89, P = 0.011)] distinguished SFH <3rd centile from SFH ≥3rd to <10th centiles using INTERGROWTH-21 standards. The MFP regression for hepcidin controlling for SFH (adjusted R 2 = 0.40, P = 0.001) revealed associations with indicators of inflammation (CRP, P < 0.0001; IL-17, P = 0.012), acidic urinary pH (P = 0.008), and higher intake of supplements (P = 0.035). CONCLUSIONS Associations of low SFH with MINDI variables, including hepcidin, highlight its potential for early detection of multicausal in utero growth faltering.
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Affiliation(s)
- Doris González-Fernández
- School of Human Nutrition, McGill University (Macdonald Campus), Ste-Anne-de-Bellevue, Quebec, Canada
| | - Elizabeta Nemeth
- Center for Iron Disorders, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | | | - Delfina Rueda
- “Comarca Ngäbe-Buglé” Health Region, Ministry of Health, San Félix, Chiriquí Province, Panama
| | | | - Enrique Murillo
- Department of Biochemistry, University of Panama, Panama City, Panama
| | - Veena Sangkhae
- Center for Iron Disorders, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Lisa M Starr
- Institute of Parasitology, McGill University (Macdonald Campus), Ste-Anne-de-Bellevue, Quebec, Canada
| | - Marilyn E Scott
- Institute of Parasitology, McGill University (Macdonald Campus), Ste-Anne-de-Bellevue, Quebec, Canada
| | - Kristine G Koski
- School of Human Nutrition, McGill University (Macdonald Campus), Ste-Anne-de-Bellevue, Quebec, Canada
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