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Akhtar SS, Wani BA, Bano ZA, Salim KP, Handoo FA. 5-Fluorouracil-Induced Severe but Reversible Cardiogenic Shock: A Case Report. TUMORI JOURNAL 2018; 82:505-7. [PMID: 9063536 DOI: 10.1177/030089169608200522] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
5-fluorouracil cardiotoxicity is increasingly recognized with variable presentation. We report a patient who developed cardiogenic shock due to high-dose 5-fluorouracil infusion (1,000 mg/m2 every 24 hr for 96 hr). There was no evidence of myocardial necrosis. The patient recovered completely without any residual cardiac dysfunction. The exact cause of 5-fluorouracil toxicity remains to be determined. The case highlights the need for careful monitoring of patients who receive high-dose 5-fluorouracil for the development of cardiotoxicity.
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Affiliation(s)
- S S Akhtar
- Department of Medical Oncology, S.K. Institute of Medical Sciences, Soura Srinagar, Kashmir, India
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Raina A, Ferrante F, Bisol A, Fiori G, Galeone M. Cardiotoxicity during Chemotherapy for Advanced Gastroenteric Tumors. TUMORI JOURNAL 2018; 73:359-61. [PMID: 3660474 DOI: 10.1177/030089168707300407] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The authors report two cases of patients with advanced gastroenteric carcinoma, which developed different cardiotoxicity patterns after the administration of cytotoxic drugs. The firsts patient showed a picture of dilatative cardiomyopathy with associated symptoms of angina pectoris and congestive heart failure; the second patient presented a cardiac arrhythmia after several administrations of S-fluorouracil. The possible mechanisms of these toxic effects, as well as the drug interactions are briefly discussed. Cardiotoxicity of cytotoxic drugs should be considered by oncologists even in patients with no previous history of cardiac disease.
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Affiliation(s)
- A Raina
- Ospedale Sesto S. Giovanni, Centro Studi e Ricerche, A. Oldrini, Sesto S. Giovanni, Milano, Italia
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3
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Abstract
BACKGROUND The syndrome of 5-fluorouracil (5-FU)-associated cardiotoxicity remains poorly defined. PATIENTS AND METHODS We performed a literature review (1969 - 2007) and compiled data derived from 377 evaluable cases out of 448 reported cases. RESULTS Patient age ranged from 14 to 86 years. Of the patients 65% were 55 years old and the male:female ratio was 1.5:1. The most commonly treated tumors were gastrointestinal (60%), head and neck (22%) and breast (4%). Of the patients 14% had a history of heart disease whereas cardiac risk factors were found in 37%. Mode of administration included: continuous infusion (72%); bolus (22.5%); intermediate infusion (3%); oral (2%); and intraperitoneal (1 patient). The dosages of 5-FU used were < 750 mg/m(2)/day (36%), 751 - 999 (16%), 1,000 (26%), 1,001 - 1,499 (4%) and 1,500 (16%). Of the patients 54% received 5-FU in combination with other chemotherapeutic agents (cisplatin 44%) whereas 51% received 5-FU alone or with leucovorin. Only 4% patients had undergone previous or concomitant radiation therapy to the mediastinum. Of cardiac incidents that happened 69% were seen during or within 72 h of the first cycle of 5-FU. Angina occurred in 45% of patients whereas myocardial infarction was seen in 22%, arrhythmias in 23, acute pulmonary edema in 5, cardiac arrest and pericarditis in 1.4 and heart failure in 2. Electro-cardiographic evidence of ischemia or ST-T changes were recorded in 69% of patients, but abnormal cardiac enzymes were found in only 12%. The cardiac symptoms were reproducible in 47%, including in one patient subsequently treated with 5-FU p.o. Symptoms were also elicited when the same patients were treated with lower doses or different schedules. Of the patients 68% responded to conservative anti-anginal therapy, although prophylactic coronary vasodilators had limited efficacy. Overall, 8% of patients showing cardiotoxicity on 5-FU administration died. Furthermore, 13% reexposed to 5-FU died. CONCLUSIONS Our review suggests that 5-FU cardiotoxicity is an infrequent but real phenomenon that is independent of dose and may be related to a continuous infusion schedule. The presence of cardiac risk factors is not predictive. Patients should be observed closely and 5-FU administration discontinued if cardiac symptoms develop. A rechallenge with 5-FU should be reserved only for those patients in whom there is no reasonable alternative therapy and should be performed in the setting of aggressive prophylaxis and close monitoring.
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Affiliation(s)
- M Wasif Saif
- Yale University School of Medicine, FMP 116, CT 06520, New Haven, USA.
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Canale ML, Camerini A, Stroppa S, Porta RP, Caravelli P, Mariani M, Balbarini A, Ricci S. A case of acute myocardial infarction during 5-fluorouracil infusion. J Cardiovasc Med (Hagerstown) 2007; 7:835-7. [PMID: 17060812 DOI: 10.2459/01.jcm.0000250874.09273.9b] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cardiac toxicity is an uncommon side-effect of 5-fluorouracil (5-FU) treatment, consisting mainly of chest pain episodes with or without electrocardiographic changes and dysrhythmias. Here, we describe the case of a 56-year-old male patient with a diagnosis of advanced colorectal cancer who developed an acute myocardial infarction during 5-FU infusion. The patient was not affected by prior heart disease and did not show any classic risk factors for coronary heart disease. Coronary angiography examination revealed no evidence of coronary stenosis, supporting the hypothesis of a coronary artery spasm related to 5-FU infusion. Given the great number of cancer patients receiving 5-FU containing chemotherapeutic regimens, this rare but severe cardiac side-effect may be observed in both cardiologic and oncologic clinical practice. We suggest a tight clinical monitoring of all patients receiving 5-FU infusions, even in those without a prior history of heart disease.
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Affiliation(s)
- Maria Laura Canale
- U.O. Malattie Cardiovascolari I Universitaria, Dipartimento Cardiotoracico, Italy.
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Abstract
Among the various deleterious effects of cancer chemotherapy, vascular toxicity is the least well recognized. This lack of recognition may be because the vasculotoxic phenomena are not unique to antineoplastic agents, can occur in patients without exposure to these agents, and the fact cancer itself may produce a hypercoagulable state. As a result, many vascular events either go unnoticed, are ignored, and/or are attributed to the underlying malignancy. Many antineoplastic therapies are associated with various vascular phenomena that range from simple phelibitis to lethal microangiopathy. Recognition of these events is important to minimize the morbidity and even prevent unnecessary deaths. Herein we review the vascular syndromes that have been reported in association with antineoplastic agents.
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Affiliation(s)
- Nasir Shahab
- Department of Medicine, Division of Hematology-Medical Oncology, Ellis Fischel Cancer Center, University of Missouri-Columbia, Columbia, MO 65203, USA.
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Luján J, García De Burgos F, Jordán A, García M, Reyes F, Espinosa MD. [Angina related to 5-Fluorouracil]. Rev Esp Cardiol 2002; 55:764-7. [PMID: 12113705 DOI: 10.1016/s0300-8932(02)76696-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Treatment with 5-fluorouracil is common in oncological patients. Side effects on bone marrow, skin, and mucous membranes have been reported. Cardiotoxicity, which is less predictable, can be life-threatening. Manifestations include angina, arrhythmias, infarction, heart failure and cardiogenic shock. The toxic mechanisms that might be involved have been much discussed but have not yet been clearly established. Current evidence supports the possibility of a metabolic effect in common with the cascade secondary to ischemia due to coronary disease. Based on a case report, we discuss the usual clinical presentation, treatment and prognosis. Finally we make recommendations for managing patients being treated with 5-fluorouracil.
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Affiliation(s)
- Juan Luján
- Sección de Cardiología, Servicio de Medicina Interna, Hospital General Universitario de Elche, Alicante, Spain
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7
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Kuropkat C, Griem K, Clark J, Rodriguez ER, Hutchinson J, Taylor SG. Severe cardiotoxicity during 5-fluorouracil chemotherapy: a case and literature report. Am J Clin Oncol 1999; 22:466-70. [PMID: 10521060 DOI: 10.1097/00000421-199910000-00009] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The chemotherapeutic agent 5-fluorouracil (5-FU) is a widely accepted part of many cancer treatment protocols. Its cardiotoxic potential is known, but considered uncommon and usually not life threatening, although some cases of severe cardiotoxicity related to 5-FU have been reported. The pathogenesis of cardiotoxicity caused by 5-FU is not clear. We report a case of sudden onset of severe cardiac failure, without ischemic symptoms or signs, during 5-FU treatment with serious consequences, in a previously healthy 23-year-old patient with squamous cell carcinoma of the tongue. Endomyocardial biopsy showed proliferation of the sarcoplasmic reticulum with marked vacuolization, similar to that found with doxorubicin cardiotoxicity. Because 5-FU cardiotoxicity is unpredictable and can have potentially fatal consequences, it requires, in our opinion, further clarification. With this well-documented case, including an endomyocardial biopsy, we hope to encourage additional efforts to investigate the pathophysiologic mechanisms of 5-FU cardiotoxicity.
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Affiliation(s)
- C Kuropkat
- Rush Cancer Institute, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois, USA
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Aziz SA, Tramboo NA, Mohi-ud-Din K, Iqbal K, Jalal S, Ahmad M. Supraventricular arrhythmia: a complication of 5-fluorouracil therapy. Clin Oncol (R Coll Radiol) 1999; 10:377-8. [PMID: 9890539 DOI: 10.1016/s0936-6555(98)80033-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
5-Fluorouracil is an S-phase-specific, synthetic pyrimidine antimetabolite, which is used as a cytostatic agent for a variety of malignant lesions, either singly or in multidrug regimens. Gastrointestinal toxicity and myelosuppression are the most common adverse reactions, but, of late, clinical cardiotoxicity has been reported in both prospective and retrospective studies. We present our experience of clinical cardiotoxicity in five patients.
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Affiliation(s)
- S A Aziz
- Sheri Kashmir Institute of Medical Sciences, Srinagar, India
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9
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Wang WS, Hsieh RK, Chiou TJ, Liu JH, Fan FS, Yen CC, Tung SL, Chen PM. Toxic cardiogenic shock in a patient receiving weekly 24-h infusion of high-dose 5-fluorouracil and leucovorin. Jpn J Clin Oncol 1998; 28:551-4. [PMID: 9793028 DOI: 10.1093/jjco/28.9.551] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
A 54-year-old man was treated with weekly 24-h infusion of high-dose 5-fluorouracil (2600 mg/m2) and leucovorin (100 mg/m2) for metastatic colon cancer. At first, he tolerated the treatment well and no significant toxicity was identified. After a total of eight courses of treatment, a stable disease was observed, but mild shortness of breath was found on occasion. The patient had no previous history of cardiac disease and the heart performance assessed by left ventricular ejection fraction before treatment was normal. Unfortunately, acute pulmonary edema with lethal cardiogenic shock occurred during the ninth course of treatment, in spite of intensive medical treatment. The chest X-ray showed extreme cardiomegaly. Repeated assessment of his heart function by echocardiogram and ventricular ejection fraction revealed a very poor cardiac performance. Toxic cardiogenic shock during weekly 24-h infusion of high-dose 5-fluorouracil and leucovorin is extremely rare. To the best of our knowledge, no case has been reported in the English literature. We report a case and the relevant literature about the incidence, clinical picture and possible pathophysiology on 5-fluorouracil-related cardioxicity is reviewed.
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Affiliation(s)
- W S Wang
- National Yang-Ming University School of Medicine, Taipei, Taiwan
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10
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Hamill NJ, Freije JE, Fedok FG. Complications of 5-fluorouracil therapy in head and neck cancer patients. Am J Otolaryngol 1995; 16:74-7. [PMID: 7717477 DOI: 10.1016/0196-0709(95)90013-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- N J Hamill
- Division of Otolaryngology, Pennsylvania State University Hospital, Hershey, USA
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Abstract
OBJECTIVE To review the clinical manifestations, postulated mechanisms, and therapeutic implications of fluorouracil-induced cardiac toxicity. DATA SOURCE A MEDLINE search was used to identify pertinent literature. STUDY SELECTION Studies and case reports on fluorouracil cardiotoxicity were identified through a MEDLINE search. A manual review of bibliographies of identified articles was performed to ensure that all pertinent articles were included. DATA EXTRACTION Data pertaining to all aspects of fluorouracil cardiac toxicity, including pathogenesis, predisposing factors, clinical manifestations, and therapeutic implications, were evaluated. DATA SYNTHESIS Estimates from large series suggest a 1.6-2.3 percent incidence of clinically demonstrated cardiotoxicity. Predisposing factors include the presence of coronary artery disease and concurrent radiotherapy. Postulated mechanisms include direct myocardial ischemia, coronary spasm, or cardiotoxic impurities in fluorouracil formulation. Clinical manifestations include chest pain, nausea, diaphoresis with typical ischemic electrocardiographic (ECG) changes, relieved to normal after stopping the drug therapy. Nitrates and calcium-channel blockers do not protect against cardiotoxicity. CONCLUSIONS Fluorouracil cardiotoxicity may be much more common and clinically significant than previously thought. A high index of suspicion for cardiotoxicity must be maintained when the drug is administered, especially in the presence of heart disease and concomitant radiation therapy. In the presence of chest pain, it is mandatory to stop the infusion and, if possible, to replace fluorouracil with another chemotherapeutic agent.
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Affiliation(s)
- A J Anand
- Department of Medicine, Nassau County Medical Center, East Meadow, NY 11554
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Abstract
BACKGROUND A case of reversible cardiogenic shock linked to 5-fluorouracil (5-FU) was observed. Recognizing the increasing use of 5-FU, the authors tried to map this syndrome. METHODS They reviewed 134 additional case reports, retrieved information from literature searches, focused on clinical features, and discussed possible pathophysiologic findings and prevention of this syndrome. RESULTS Although angina and electrocardiographic changes were common and reproducible (approximately 90% each), coronary artery disease was found in a few patients. A total of 33 patients had severe left ventricular dysfunction, 28 without evidence of myocardial infarction. The symptoms were responsive to conservative management (90%). CONCLUSIONS Cardiac toxicity is a little known complication of 5-FU therapy, with an unknown but significant incidence. It is highly treatable.
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Affiliation(s)
- N C Robben
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710
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Gradishar W, Vokes E, Schilsky R, Weichselbaum R, Panje W. Vascular events in patients receiving high-dose infusional 5-fluorouracil-based chemotherapy: the University of Chicago experience. MEDICAL AND PEDIATRIC ONCOLOGY 1991; 19:8-15. [PMID: 1990260 DOI: 10.1002/mpo.2950190103] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In a retrospective review, 22 of a total of 244 patients (9%) patients with head and neck or gastrointestinal cancer who were treated with infusional 5-fluorouracil (5-FU)-based chemotherapy regimens experienced thrombotic vascular events. These events occurred concurrently with treatment or several months following the completion of therapy and consisted mainly of cardiac arrhythmias, myocardial infarction, sudden death, and thromboembolism. The temporal relationship of these vascular events to the time of treatment suggests that infusional 5-FU may have been the underlying cause.
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Affiliation(s)
- W Gradishar
- Department of Medicine, University of Chicago, IL
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14
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Abstract
5-Fluorouracil is a commonly administered chemotherapy agent that has infrequently been associated with cardiotoxicity. This review highlights the clinical features of this syndrome as described in reports from the medical literature. Clinical and laboratory evidence supporting proposed underlying mechanisms are reviewed.
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Affiliation(s)
- W J Gradishar
- Department of Medicine, Pritzker School of Medicine, University of Chicago
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Affiliation(s)
- S Chaudary
- San Diego Cardiac Center, Sharp Memorial Hospital, University of California
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Millward MJ, Ganju V, Buck M. Cardiac arrest--a manifestation of 5-fluorouracil cardiotoxicity. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1988; 18:693-5. [PMID: 3245824 DOI: 10.1111/j.1445-5994.1988.tb00153.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
We report a case of cardiac arrest occurring during an infusion of 5-fluorouracil where electrocardiograms suggested coronary artery spasm as the underlying event. Treatment with vasodilators and diltiazem, proved effective. This clinical presentation of 5-fluorouracil cardiotoxicity has not previously been described.
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Affiliation(s)
- M J Millward
- Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, WA
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Abstract
Cardiac symptoms, including hypotension, developed in three patients with advanced colorectal carcinoma while being treated with cisplatin (CDDP) and 5-fluorouracil (5-FU). In two patients, hypotension was associated with severe left ventricular dysfunction. All three patients required therapy discontinuation. Cardiac enzymes remained normal despite transient electrocardiographic (EKG) changes. The presentation and cardiac evaluation (hemodynamic, echocardiographic, and scintigraphic) of these patients suggest new manifestations of 5-FU cardiotoxicity that may be influenced by CDDP. The possible pathophysiologic mechanisms are discussed.
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Affiliation(s)
- A A Jakubowski
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York 10021
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Patel B, Kloner RA, Ensley J, Al-Sarraf M, Kish J, Wynne J. 5-Fluorouracil cardiotoxicity: left ventricular dysfunction and effect of coronary vasodilators. Am J Med Sci 1987; 294:238-43. [PMID: 3661619 DOI: 10.1097/00000441-198710000-00004] [Citation(s) in RCA: 68] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Seven patients developed clinical features simulating myocardial ischemia less than 72 hours after 12 of 13 separate intravenous 5-fluorouracil administrations; 9 episodes were associated with chest pain, 3 with hypotension, 3 with ventricular tachycardia and 1 with cardiogenic shock. Left ventricular dysfunction was demonstrated by echocardiography in 5 separate episodes, 2 with interval improvement upon repeat echocardiograms. Pretreatment with nitrates and/or calcium channel blockers failed to prevent recurrence of cardiotoxicity during 5 of 6 repeat 5-fluorouracil administrations. Therapy with 5-fluorouracil is associated with cardiotoxicity simulating myocardial ischemia with left ventricular dysfunction. Pretreatment with coronary vasodilators may not prevent this phenomenon.
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Affiliation(s)
- B Patel
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan
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