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Bella Z, Erdelyi E, Szalenko-Tőkés Á, Kiricsi Á, Gaál V, Benedek P, Rovó L, Nagy E. Peritonsillar abscess: an 8-year retrospective, culture based evaluation of 208 cases. J Med Microbiol 2022; 71. [DOI: 10.1099/jmm.0.001576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction. Peritonsillar abscess (PTA) is a common infection which requires surgical intervention and suitable antibiotic therapy.
Hypotheses/Gap Statement. Beside
Streptococcus pyogenes
and
Fusobacterium necrophorum
several other mostly anaerobic bacteria can be cultured from the properly taken pus samples of PTA, the clinical significance of which is still not fully understood.
Aim. This study focused on the culture-based microbiological evaluation of PTA cases, compared to surgical intervention and empirical antibiotic management.
Methodology. A retrospective analysis of PTA cases was performed between 2012 and 2019. Data about the aerobic and anaerobic culture results of the samples taken during different surgical interventions were summarized and the coverage of the empirically selected antibiotics was evaluated. The patient’s history, the development of complications and the recurrence rate were also evaluated.
Results. The microbiological culture results were available for 208 of 320 patients with clinically diagnosed PTA. Incision and drainage (I and D) and immediate tonsillectomy were the leading surgical interventions. Ninety-five
Fusobacterium
species (including 44
Fusobacterium necrophorum
), 52
Actinomyces
species and 47
Streptococcus pyogenes
were obtained from PTA samples alone or together with polymicrobial flora.
S. pyogenes
(33.7 %, n=28) and
F. necrophorum
(22.9 %, n=19) were the dominating pathogens in the 83 monobacterial PTA samples. In >60 % of the patients polymicrobial infection was demonstrated, involving a great variety of anaerobic bacteria. In 22 out of 42 cases where intravenous cefuroxime was empirically started, the therapy should be changed to properly cover the culture-proven anaerobic flora. There were no serious complications, abscess recurrence was detected in two cases (0.96 %).
Conclusion. PTAs are often polymicrobial infections including a great variety of anaerobes. Targeted antibiotic therapy, in conjunction with adequate surgical drainage eliminating the anaerobic milieu, can accelerate the healing process and radically reduce the complication and recurrence rate.
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Affiliation(s)
- Zsolt Bella
- Department of Oto-Rhino-Laryngology and Head-Neck Surgery, Faculty of Medicine, University of Szeged, Hungary
| | - Eszter Erdelyi
- Department of Oto-Rhino-Laryngology and Head-Neck Surgery, Faculty of Medicine, University of Szeged, Hungary
| | - Ágnes Szalenko-Tőkés
- Department of Oto-Rhino-Laryngology and Head-Neck Surgery, Faculty of Medicine, University of Szeged, Hungary
| | - Ágnes Kiricsi
- Department of Oto-Rhino-Laryngology and Head-Neck Surgery, Faculty of Medicine, University of Szeged, Hungary
| | - Veronika Gaál
- Department of Pediatric-ENT, Faculty of Medicine, University of Pécs, Pécs, Hungary
| | | | - László Rovó
- Department of Oto-Rhino-Laryngology and Head-Neck Surgery, Faculty of Medicine, University of Szeged, Hungary
| | - Elisabeth Nagy
- Department of Medical Microbiology, Faculty of Medicine, University of Szeged, Szeged, Hungary
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Vanhapiha N, Sanmark E, Blomgren K, Wikstén J. Minor salivary gland infection as origin of peritonsillitis - novel theory and preliminary results. Acta Otolaryngol 2022; 142:182-186. [PMID: 35073502 DOI: 10.1080/00016489.2022.2026003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Peritonsillitis (PT) is defined as cellulitis in peritonsillar tissue without pus. The pathogenesis of peritonsillar infections is controversial. OBJECTIVE To explore whether minor salivary glands are involved in the development of PT and to identify clinical findings that predict the evolution of PT to peritonsillar abscess (PTA). MATERIAL AND METHODS We included 146 adult patients treated for acute tonsillitis (AT; n = 54), PT (n = 34), or PTA (n = 58) at the Helsinki University Hospital. The treating physician recorded tonsillar, oropharyngeal, and dental findings. We analysed serum C-reactive protein (S-CRP) and amylase (S-Amyl). For PTA, pus samples were analysed; for AT and PT, throat cultures were collected. Patients with PT or PTA (PT/PTA; n = 92) were classified into groups with or without tonsillar exudate or hyperaemia (tonsillar findings). RESULTS The PT group without tonsillar findings had lower S-CRP than the PT group with tonsillar findings (p=.0275). The PT/PTA group without tonsillar findings had higher S-Amyl than the PT/PTA group with tonsillar findings (p=.0278). Three out of 34 (8.8%) patients with PT returned to the emergency department; 1 (2.9%) developed PTA. CONCLUSIONS Elevated S-Amyl in the PT/PTA group without tonsillar findings suggests that minor salivary glands are sometimes involved in the development of peritonsillar infections.
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Affiliation(s)
- Nelli Vanhapiha
- Department of Otorhinolaryngology—Head and Neck Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Enni Sanmark
- Department of Otorhinolaryngology—Head and Neck Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Karin Blomgren
- Department of Otorhinolaryngology—Head and Neck Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Johanna Wikstén
- Department of Otorhinolaryngology—Head and Neck Surgery, Helsinki University Hospital, Helsinki, Finland
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Kim AS, Boyko NV, Stagnieva IV, Panchenko SN. [Small salivary glands in the paratonsillar space in children]. Vestn Otorinolaringol 2021; 86:41-45. [PMID: 33720650 DOI: 10.17116/otorino20218601141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Was to study the changes in the small salivary glands in chronic tonsillitis and paratonsillar abscess in children. A histological examination of the palatine tonsils of 22 children aged 5 to 14 years old who had a paratonsillar abscess and 18 children suffering from chronic tonsillitis was carried out. Fragments of small salivary glands, located both superficially, in the mucous membrane between the stratified squamous non-keratinizing epithelium and the lymphoid tissue of the palatine tonsils, and between the muscles of the amygdala were found in 42 of the 80 (52.5%) tonsils studied. Along with the unchanged glandular structure, 26 (61.9%) samples revealed areas of destruction foci in small salivary glands with signs of inflammatory and compensatory regenerative activity. The presence of separate interlobular ducts of the salivary glands with pronounced periductal lymph - macrophage infiltration was noted. The subepithelial lymph-macrophage infiltrates found in the lamina propria are associated with the exit of the excretory ducts of the salivary glands to the surface of the mucous membrane. Many thin-walled veins are surrounded by perivascular lymphocellular infiltrates. The inflammatory and post-inflammatory changes in the small salivary glands revealed by us in children with chronic tonsillitis do not exclude their participation in the pathogenesis of paratonsillitis. At the same time, inflammation in the salivary gland can be both primary, as a result of its infection with live microorganisms from the tissues of the tonsil, and secondary, due to the compression of the excretory ducts by the edematous tissue of the tonsil in acute tonsillitis.
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Affiliation(s)
- A S Kim
- Rostov State Medical University, Rostov-on-Don, Russia
| | - N V Boyko
- Rostov State Medical University, Rostov-on-Don, Russia
| | - I V Stagnieva
- Rostov State Medical University, Rostov-on-Don, Russia
| | - S N Panchenko
- Rostov State Medical University, Rostov-on-Don, Russia
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Human Papillomavirus (HPV)-Related Carcinoma of the Oropharynx with Squamous Cell and Adenoid Cystic Carcinoma-Like Features: Report of a Case. Head Neck Pathol 2020; 15:1007-1016. [PMID: 33048304 PMCID: PMC8384984 DOI: 10.1007/s12105-020-01233-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/06/2020] [Indexed: 12/14/2022]
Abstract
We describe the heretofore unreported case of an HPV-related carcinoma of the palatine tonsil with distinct areas of squamous cell- and adenoid cystic carcinoma-like differentiation in a 54-year old patient. The morphological, immunophenotypic and molecular findings of the tumor are illustrated. We discuss the parallels between the tumor and HPV-related multiphenotypic sinonasal carcinoma (HMSC) which is well-known to exhibit adenoid cystic carcinoma-like features. A review of the literature of high-risk HPV-associated non-squamous carcinomas of the oropharynx is presented.
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Pediatric tonsillectomy: A short-term and long-term comparison of intracapsular versus extracapsular techniques. Int J Pediatr Otorhinolaryngol 2020; 133:109970. [PMID: 32197185 DOI: 10.1016/j.ijporl.2020.109970] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/22/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To review a cohort of over 2500 patients and investigate the short and long-term outcomes of intracapsular as compared to extracapsular tonsillectomy, and show if the complication rates are comparable between methods. STUDY DESIGN A multicenter, retrospective chart review was conducted, evaluating pediatric tonsillectomies performed from 2004 to 2014. The electronic medical record was reviewed through December 2018, providing up to 14 years of follow-up data. SETTING Two tertiary care, academic medical centers. SUBJECTS AND METHODS A retrospective chart review was conducted to identify children undergoing tonsillectomy and adenotonsillectomy. A chart review was first performed of patients by a single surgeon (MEG) and then the analysis was repeated using enterprise data warehouse (EDW) to search for complications and interventions using International Classification of Diseases, ninth revision, (ICD-9) and Current Procedural Terminology (CPT) codes. The second surgeon's patients (JLC) patients were added to increase the cohort. Patients were excluded from the review of long-term outcomes if there was less than two-year follow-up. Short-term outcomes examined included rate of post-tonsillectomy hemorrhage and re-presentation for dehydration, while long-term outcomes included rates of peritonsillar abscess and tonsillar regrowth requiring revision tonsillectomy. RESULTS A total of 2508 pediatric patients were identified who had undergone tonsillectomy or adenotonsillectomy. In 1456 (58.1%) of these patients, the intracapsular technique was used and in 1052 (41.9%) patients, the extracapsular technique was used. The mean documented follow-up time was 8.2 years. Thirty-five patients (1.4%) were identified with post-tonsillectomy hemorrhage, 2 of these patients (5.7%) with primary hemorrhage and 33 patients (94.3%) with secondary hemorrhage. 11 underwent intracapsular tonsillectomy and 24 underwent extracapsular tonsillectomy (p = 0.0042). The rate of post-tonsillectomy hemorrhage with intracapsular tonsillectomy was 0.76%, compared to 2.3% in the extracapsular group. Three patients (0.12%) undergoing intracapsular tonsillectomy required revision tonsillectomy; no patients in the extracapsular group required revision surgery. Three patients (0.12%) developed peritonsillar abscess post-operatively, two following intracapsular tonsillectomy and one following extracapsular tonsillectomy. CONCLUSION This retrospective review comparing the intracapsular and extracapsular techniques for tonsillectomy provides further evidence of the benefits of this technique. It is worthwhile to continue offering intracapsular tonsillectomy to patients and their families during pre-operative discussions.
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Peritonsillar abscess may not always be a complication of acute tonsillitis: A prospective cohort study. PLoS One 2020; 15:e0228122. [PMID: 32243441 PMCID: PMC7122714 DOI: 10.1371/journal.pone.0228122] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/09/2020] [Indexed: 11/19/2022] Open
Abstract
The present study aimed to specify diagnostics for peritonsillar abscesses (PTAs) and to clarify the role of minor salivary glands. This prospective cohort study included 112 patients with acute tonsillitis (AT) and PTA recruited at a tertiary hospital emergency department between February and October 2017. All patients completed a questionnaire concerning their current disease. Serum amylase (S-Amyl) and C-reactive protein (S-CRP) levels, tonsillar findings, and pus aspirate samples and throat cultures were analyzed. Eight of 58 PTA patients (13.8%) had no signs of tonsillar infection. The absence of tonsillar erythema and exudate was associated with low S-CRP (p<0.001) and older age (p<0.001). We also observed an inverse correlation between S-Amyl and S-CRP levels (AT, r = -0.519; PTA, r = -0.353). Therefore, we observed a group of PTA patients without signs of tonsillar infection who had significantly lower S-CRP levels than other PTA patients. These findings support that PTA may be caused by an etiology other than AT. Variations in the S-Amyl levels and a negative correlation between S-Amyl and S-CRP levels may indicate that minor salivary glands are involved in PTA development.
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The presence of minor salivary glands in the peritonsillar space. Eur Arch Otorhinolaryngol 2017; 274:3997-4001. [PMID: 28900734 DOI: 10.1007/s00405-017-4738-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 09/05/2017] [Indexed: 02/07/2023]
Abstract
Peritonsillar abscess (PTA) is traditionally considered only a purulent complication of acute tonsillitis (AT), but may be related to infection of minor salivary glands. We analysed the presence of peritonsillar minor salivary glands and inflammation patterns in 114 adult tonsils representing three patient groups: recurrent AT, chronic tonsillitis (CT), and PTA. Samples acquired from elective tonsillectomies were stored in formalin, and after preparation were microscopically examined for inflammation and fibrotic changes. Clinical features and histological characteristics were compared between the groups. Of all tonsils, the minor salivary glands were present in 77 (67.5%). Glands located near the tonsillar tissue showed signs of infection in 73 (94.8%), while only 3 (15.0%) of 20 glands located deeper in the peritonsillar space were infected. Compared to patients with recurrent AT and CT, those with PTA more often presented with periductal inflammation, p < 0.011 (PTA 82.1%, AT 42.9%, and CT 63.6%). The majority of our 114 tonsillectomy specimens, collected from patients with AT, CT, or PTA, presented with infected minor salivary glands, and inflammation of the peritonsillar space glands was evident. To further elucidate the association between these glands and PTA, tonsillar samples should be collected and analysed from patients during the acute phase of infection.
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Klug TE, Rusan M, Fuursted K, Ovesen T. Peritonsillar Abscess: Complication of Acute Tonsillitis or Weber's Glands Infection? Otolaryngol Head Neck Surg 2016; 155:199-207. [PMID: 27026737 DOI: 10.1177/0194599816639551] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 02/26/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To review the literature concerning the 2 primary hypotheses put forth to explain the pathogenesis of peritonsillar abscess: "the acute tonsillitis hypothesis" (peritonsillar abscess is a complication of acute tonsillitis) and "the Weber gland hypothesis" (peritonsillar abscess is an infection of Weber's glands). DATA SOURCES PubMed, EMBASE. REVIEW METHODS Data supporting or negating one hypothesis or the other were elicited from the literature. CONCLUSIONS Several findings support the acute tonsillitis hypothesis. First, the 2 main pathogens in peritonsillar abscess have been recovered from pus aspirates and bilateral tonsillar tissues with high concordance rates, suggesting that both tonsils are infected in patients with peritonsillar abscess. Second, studies report signs of acute tonsillitis in the days prior to and at the time of peritonsillar abscess. Third, antibiotic treatment reduces the risk of abscess development in patients with acute tonsillitis. However, some findings suggest involvement of the Weber's glands in peritonsillar abscess pathogenesis. First, high amylase levels have been found in peritonsillar pus. Second, the majority of peritonsillar abscesses are located at the superior tonsillar pole in proximity of the Weber's glands. We propose a unified hypothesis whereby bacteria initially infect the tonsillar mucosa and spread via the salivary duct system to the peritonsillar space, where an abscess is formed. IMPLICATIONS FOR PRACTICE Our findings support the rationale for antibiotic treatment of patients with severe acute tonsillitis to reduce the risk of abscess development. Improved understanding of peritonsillar abscess pathogenesis is important for the development of efficient prevention strategies.
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Affiliation(s)
- Tejs Ehlers Klug
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Maria Rusan
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Aarhus, Denmark Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Kurt Fuursted
- Department of Microbiology and Infection Control, Statens Serum Institut, Copenhagen, Denmark
| | - Therese Ovesen
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Aarhus, Denmark
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El-Saied S, Kaplan DM, Zlotnik A, Abu Tailakh M, Kordeluk S, Joshua BZ. A comparison between amylase levels from peritonsillar, dental and neck abscesses. Clin Otolaryngol 2015; 39:359-61. [PMID: 25117975 DOI: 10.1111/coa.12298] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Pus of peritonsillar abscess (PTA) contains very high amylase levels in some patients. The objective of this study was to further test this finding and to check whether high amylase levels in peritonsillar abscess originate from contamination by saliva during aspiration. STUDY DESIGN Prospective study. SETTING Tertiary care university hospital. PARTICIPANTS The study includes 64 patients with PTA, 8 patients with a neck abscess and 12 patients with a dental abscess. MAIN OUTCOME MEASURE Amylase levels of pus and serum were compared between the groups. Clinical data regarding hospitalisation length, recurrence rate and previous antibiotic treatment were also collected. RESULTS Mean amylase levels in the pus of the PTA group were 3045 U/L (median 59 U/L), 13 U/L in the neck abscess group (P = 0.001) and 22 U/L in the dental abscess group (P = 0.001). Mean serum amylase was higher in the PTA group; PTA - 50 U/L, neck abscess - 37 U/L (P = 0.002) and dental abscess - 26 U/L (P < 0.002). All of the patients with amylase levels above 65 U/L had a first episode of PTA. In contrast, 40% of patients with amylase lower than 65 U/L had recurrent PTA (P = 0.003). CONCLUSION A clear association is seen between minor salivary glands and peritonsillar abscess. The high amylase level in peritonsillar pus is not from contamination with saliva.
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Affiliation(s)
- S El-Saied
- Department of Otolaryngology-Head & Neck Surgery, Soroka University Medical Center, Beer-Sheva, Israel; Faculty of Health Sciences, Clinical Research Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Klug TE. Incidence and microbiology of peritonsillar abscess: the influence of season, age, and gender. Eur J Clin Microbiol Infect Dis 2014; 33:1163-7. [PMID: 24474247 DOI: 10.1007/s10096-014-2052-8] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 01/06/2014] [Indexed: 11/29/2022]
Abstract
To explore the correlations among the incidence, microbiology, season, gender, and age in patients with peritonsillar abscess (PTA) in order to identify risk factors for PTA development. All patients with PTA treated at private ENT practices in Aarhus County and in the Ear-Nose-Throat Departments at Aarhus University Hospital and Randers Hospital from January 2001 to December 2006 were included in the study. Age- and gender-stratified population data for Aarhus County for the same 6 years were obtained. The incidence rate of PTA increased from childhood to peak in teenage life and declined afterward gradually until old age. Girls predominated over boys until the age of 14 years. Subsequently, men were more frequently affected than women. Fusobacterium necrophorum (FN) was significantly more prevalent than group A Streptococcus (GAS) among patients aged 15-24 years (P < 0.001). In contrast, GAS was significantly more frequently recovered among children aged 0-9 years and adults aged 30-39 years compared with FN (P < 0.001 and P = 0.017 respectively). The seasonal variation of PTA was statistically insignificant (P = 0.437). However, GAS was significantly more frequently recovered in the winter and spring than in the summer (P = 0.002 and P = 0.036 respectively). There was a trend toward a higher incidence of FN infection during the summer than the winter (P = 0.165). Although the collected PTA incidence was stable throughout the year, the microbiology fluctuated with seasons. Patients aged 15-24 years are at an increased risk of PTA due to FN, which may have clinical implications for the diagnostic work-up and treatment of patients with acute tonsillitis.
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Affiliation(s)
- T E Klug
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, NBG, Building 10, Noerrebrogade 44, Aarhus C, 8000, Denmark,
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Hultcrantz E, Ericsson E. Factors Influencing the Indication for Tonsillectomy: A Historical Overview and Current Concepts. ACTA ACUST UNITED AC 2013; 75:184-91. [DOI: 10.1159/000342322] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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