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Gidl A, Füreder A, Benesch M, Dworzak M, Engstler G, Jones N, Kropshofer G, Pötschger U, Poyer F, Tamesberger M, Witt V, Mann G, Attarbaschi A. Incidence and Risk Factors of Venous Thromboembolism in Childhood Acute Lymphoblastic Leukaemia - a Population-Based Analysis of the Austrian Berlin-Frankfurt-Münster (BFM) Study Group. Pediatr Hematol Oncol 2023; 40:181-191. [PMID: 35848787 DOI: 10.1080/08880018.2022.2089791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Venous thromboembolism (VTE) is a well-known complication of the treatment of pediatric acute lymphoblastic leukemia (ALL). We analyzed 1026 ALL patients 1-18-years-old, who were enrolled into the AIEOP-BFM ALL 2000 or 2009 studies in Austria, with regard to the incidence and risk factors of VTE. The 2.5-year cumulative incidence (CI) of VTE ≥ grade 2 was 4%±1% (n = 36/1026). Twenty VTE (56%) were found in the central nervous system (19 cerebral venous sinus and 1 cortical vein thrombosis), and 16 (44%) at other sites (7 deep vein thromboses (DVT) of the lower extremity, 4 DVT of the upper extremity, 4 central venous line-thromboses, 1 pulmonary embolism). Most VTE occurred during induction and early consolidation therapy (81%) and were associated with L-asparaginase within 4 and corticosteroids withing 1 week(s) preceding the event (89 and 86%, respectively). In multivariable analysis, two independent risk factors were found. Patients 10-18-years-old had an increased (hazard-ratio: 2.156, p = 0.0389), whereas treatments in trial AIEOP-BFM ALL 2009 had a lower risk for VTE (hazard-ratio: 0.349, p = 0.0270). In conclusion, the 2.5-year CI of VTE among our pediatric patient cohort was <5% and adolescent age was the main patient-related risk factor. This older age group might benefit from primary prophylactic measures.
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Affiliation(s)
- Anna Gidl
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Anna Füreder
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Martin Benesch
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Michael Dworzak
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria.,St. Anna Children's Cancer Research Institute, Vienna, Austria
| | - Gernot Engstler
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Neil Jones
- Department of Pediatrics and Adolescent Medicine, University Clinics Salzburg, Salzburg, Austria
| | - Gabriele Kropshofer
- Division of Pediatric Hematology and Oncology and Stem Cell Transplantation, Department of Pediatrics and Adolescent Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Fiona Poyer
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Melanie Tamesberger
- Department of Pediatrics and Adolescent Medicine, Kepler University Hospital Linz, Linz, Austria
| | - Volker Witt
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Georg Mann
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria.,St. Anna Children's Cancer Research Institute, Vienna, Austria
| | - Andishe Attarbaschi
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
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Mantziou S, Markopoulos G, Thrasyvoulou S, Noutsopoulos D, Gkartziou F, Vartholomatos G, Tzavaras T. Tinzaparin inhibits VL30 retrotransposition induced by oxidative stress and/or VEGF in HC11 mouse progenitor mammary cells: Association between inhibition of cancer stem cell proliferation and mammosphere disaggregation. Oncol Rep 2021; 46:241. [PMID: 34558648 PMCID: PMC8485018 DOI: 10.3892/or.2021.8192] [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: 04/21/2021] [Accepted: 07/15/2021] [Indexed: 02/07/2023] Open
Abstract
Tinzaparin is an anticoagulant and antiangiogenic drug with inhibitory properties against tumor growth. VEGF stimulates angiogenesis, while an association between reactive oxygen species (ROS) and angiogenesis is involved in tumor progression. The present study aimed to investigate the effect of tinzaparin on VL30 retrotransposition-positive mouse HC11 mammary stem-like epithelial cells, previously reported to be associated with induced mammosphere/cancer stem cell (CSC) generation and tumorigenesis. Under 24 h serum starvation, 15.2% nominal retrotransposition frequency was increased to 29%. Additionally, while treatment with 3–12 ng/ml VEGF further induced retrotransposition frequency in a dose-dependent manner (up to 40.3%), pre-incubation with tinzaparin (2 IU/ml) for 0.5–4 h reduced this frequency to 18.3% in a time-dependent manner, confirmed by analogous results in NIH3T3 fibroblasts. Treatment with 10–40 pg/ml glucose oxidase (GO) for 24 h induced HC11 cell retrotransposition in a dose-dependent manner (up to 82.5%), while a 3 h pre-incubation with tinzaparin (1 or 2 IU/ml) elicited a 13.5 or 25.5% reduction in retrotransposition, respectively. Regarding tumorigenic VL30 retrotransposition-positive HC11 cells, treatment with 2 IU/ml tinzaparin for 5 days reduced proliferation rate in a time-dependent manner (up to ~55%), and after 3 weeks, disaggregated soft agar-formed foci, as well as low-adherent mammospheres, producing single mesenchymal-like cells with a ~50% reduced retrotransposition. With respect to the VL30 retrotransposition mechanism: While 12 ng/ml VEGF increased the level of VL30 and endogenous reverse transcriptase (enRT) transcripts ~1.41- and ~1.16-fold, respectively, subsequent tinzaparin treatment reduced both endogenous/ROS- and VEGF-induced levels 1.15- and 0.40-fold (VL30) and 0.60- and 0.52-fold (enRT), respectively. To the best of our knowledge, these data demonstrate for the first time, the novel inhibition activity of tinzaparin against ROS- and VEGF-induced VL30 retrotransposition, and the proliferation and/or aggregation of mouse HC11 mammosphere/tumor-initiating CSCs, thus contributing to the inhibition of VL30 retrotransposition-induced primary tumor growth.
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Affiliation(s)
- Stefania Mantziou
- Laboratory of General Biology, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
| | - Georgios Markopoulos
- Laboratory of General Biology, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
| | - Soteroula Thrasyvoulou
- Laboratory of General Biology, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
| | - Dimitrios Noutsopoulos
- Laboratory of General Biology, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
| | - Foteini Gkartziou
- Laboratory of General Biology, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
| | - Georgios Vartholomatos
- Molecular Biology Unit, Hematology Laboratory, University Hospital of Ioannina, 45110 Ioannina, Greece
| | - Theodore Tzavaras
- Laboratory of General Biology, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
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Levy-Mendelovich S, Barg AA, Kenet G. Thrombosis in pediatric patients with leukemia. Thromb Res 2018; 164 Suppl 1:S94-S97. [PMID: 29703491 DOI: 10.1016/j.thromres.2018.01.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/07/2018] [Accepted: 01/10/2018] [Indexed: 10/17/2022]
Abstract
Acute lymphoblastic leukemia (ALL) is the most common type of cancer diagnosed in children. It is reportedly the most common malignancy associated with thromboembolism in the pediatric age group. Over the last 2 decades, venous thromboembolism (VTE) has been increasingly diagnosed among pediatric ALL patients with an estimated incidence ranging from about 5% (for symptomatic cases) to about 30-70% (following sequential imaging studies in asymptomatic children). The etiology is multifactorial and may stem from alterations of the hemostatic system following various chemotherapy protocols (including use of l-Asparaginase), the presence of central venous lines (CVL), as well as comorbidities, e.g. inherited thrombophilia risk factors. Most symptomatic thrombotic events occur in the upper venous system or in the central nervous system (CNS). Prospective studies on the establishment of guidelines for treatment or prevention are lacking. The following review will address the epidemiology, etiology and risk factors for thrombosis, describe the currently available evidence, and address issues associated with diagnosis and treatment.
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Affiliation(s)
- Sarina Levy-Mendelovich
- The Israeli National Hemophilia Center and Thrombosis Unit with The Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Israel
| | - Assaf Arie Barg
- The Israeli National Hemophilia Center and Thrombosis Unit with The Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Israel
| | - Gili Kenet
- The Israeli National Hemophilia Center and Thrombosis Unit with The Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Israel.
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Athale UH, Laverdiere C, Nayiager T, Delva YL, Foster G, Thabane L, Chan AKC. Evaluation for inherited and acquired prothrombotic defects predisposing to symptomatic thromboembolism in children with acute lymphoblastic leukemia: a protocol for a prospective, observational, cohort study. BMC Cancer 2017; 17:313. [PMID: 28472942 PMCID: PMC5418710 DOI: 10.1186/s12885-017-3306-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 04/27/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thromboembolism (TE) is a serious complication in children with acute lymphoblastic leukemia (ALL). The incidence of symptomatic thromboembolism is as high as 14% and case fatality rate of ~15%. Further, development of thromboembolism interferes with the scheduled chemotherapy with potential impact on cure rates. The exact pathogenesis of ALL-associated thromboembolism is unknown. Concomitant administration of asparaginase and steroids, two important anti-leukemic agents, is shown to increase the risk of ALL-associated TE. Dana-Farber Cancer Institute (DFCI) ALL studies reported ~10% incidence of thrombosis with significantly increased risk in older children (≥10 yrs.) and those with high-risk ALL. The majority (90%) of thromboembolic events occurred in the Consolidation phase of therapy with concomitant asparaginase and steroids when high-risk patients (including all older patients) receive higher dose steroids. Certain inherited and acquired prothrombotic defects are known to contribute to the development of TE. German investigators documented ~50% incidence of TE during therapy with concomitant asparaginase and steroids, in children with at least one prothrombotic defect. However, current evidence regarding the role of prothrombotic defects in the development of ALL-associated TE is contradictory. Although thromboprophylaxis can prevent thromboembolism, ALL and it's therapy can increase the risk of bleeding. For judicious use of thromboprophylaxis, identifying a population at high risk for TE is important. The risk factors, including prothrombotic defects, predisposing to thrombosis in children with ALL have not been defined. METHODS This prospective, observational cohort study aims to evaluate the prevalence of inherited prothrombotic defects in children with ALL treated on DFCI 05-01 protocol and the causal relationship of prothrombotic defects in combination with patient and disease-related factors to the development of TE. We hypothesize that the combination of prothrombotic defects and the intensive therapy with concomitant high dose steroids and asparaginase increases the risk of TE in older patients and patients with high-risk ALL. DISCUSSION The results of the proposed study will help design studies of prophylactic anticoagulant therapy. Thromboprophylaxis given to a targeted population will likely reduce the incidence of TE in children with ALL and ultimately improve their quality of life and prospects for cure.
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Affiliation(s)
- Uma H. Athale
- Division of Hematology/ Oncology, McMaster Children’s Hospital, Hamilton Health Sciences, 1280 Main Street West, Room HSC 3N27, Hamilton, ON L8S 4K1 Canada
- Department of Pediatrics, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Caroline Laverdiere
- Department of Pediatrics, Hematology Oncology Service, CHU Ste-Justine, University of Montréal, 3175, Côtes-Sainte-Catherine, Montréal, QC H3T 1C5 Canada
| | - Trishana Nayiager
- Department of Pediatrics, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Yves-Line Delva
- Department of Pediatrics, Hematology Oncology Service, CHU Ste-Justine, University of Montréal, 3175, Côtes-Sainte-Catherine, Montréal, QC H3T 1C5 Canada
| | - Gary Foster
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 50 Charlton Ave. E, Hamilton, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 50 Charlton Ave. E, Hamilton, Canada
| | - Anthony KC Chan
- Division of Hematology/ Oncology, McMaster Children’s Hospital, Hamilton Health Sciences, 1280 Main Street West, Room HSC 3N27, Hamilton, ON L8S 4K1 Canada
- Department of Pediatrics, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
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Abstract
In 1856 Virchow proposed a triad of causes for venous thrombosis, postulating that stasis, changes in the vessel wall or changes in the blood could lead to thrombosis. We now know that abnormally high levels of some coagulation factors and defects in the natural anticoagulants contribute to thrombotic risk. Among these, factor V Leiden, which renders factor Va resistant to activated protein C, is the most prevalent with approximately 5% of the Caucasian population having this genetic alteration. These genetically controlled variants in coagulation factors work in concert with other risk factors, such as oral contraceptive use, to dramatically increase thrombotic risk. While these abnormalities in the blood coagulation proteins are associated with thrombotic disease propensity, they are less frequent contributors to thrombosis than age or cancer. Cancer increases thrombotic risk by producing tissue factor to initiate coagulation, by shedding procoagulant lipid microparticles or by impairing blood flow. Age is the strongest risk factor for thrombosis. Among possible reasons are fragility of the vessels potentially contributing to stasis, increased coagulation factor levels, impaired function of the venous valves, decreases in the efficacy of natural anticoagulants associated with the vessel wall, increased risk of immobilization and increased risk of severe infection.
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Affiliation(s)
- Charles T Esmon
- Oklahoma Medical Research Foundation, Howard Hughes Medical Institute, and Departments of Pathology and Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, United States.
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Chin PKL, Beckert LEL, Gunningham S, Edwards AL, Robinson BA. Audit of anticoagulant thromboprophylaxis in hospitalized oncology patients. Intern Med J 2009; 39:819-25. [PMID: 19220527 DOI: 10.1111/j.1445-5994.2008.01828.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a significant problem in oncology patients. VTE prophylaxis is underutilized in hospitalized medical patients, but there are few data for the appropriateness and frequency of its use in the oncology subgroup. We aimed to document local practice. METHODS A cross-sectional chart review of all hospitalized patients cared for by the Christchurch Hospital Oncology Service was carried out during two defined 4-week periods. Assessment for indications and contraindications to prophylactic anticoagulation was based on the 2004 American College of Chest Physicians evidence-based consensus guidelines. RESULTS Of 113 admissions to the oncology service, 38 (33.6%) had indications for prophylactic anticoagulation. However, 23 of these also had contraindications, leaving only 15 (13%) admissions where prophylactic anticoagulation was deemed appropriate. Only one was appropriately given prophylactic anticoagulation. CONCLUSION Only a minority of hospitalized oncology patients are appropriate for prophylactic anticoagulation. Where it is suitable, however, it is poorly utilized locally. Local promotion of VTE prophylaxis and further study of this subgroup of hospitalized medical patients may improve uptake of this practice and attenuate morbidity from VTE.
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Affiliation(s)
- P K L Chin
- Diabetes Centre, Christchurch Hospital, Christchurch, New Zealand.
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ten Cate-Hoek AJ, Prins MH. Low molecular weight heparins in cancer. Thromb Res 2008; 122:584-98. [DOI: 10.1016/j.thromres.2006.12.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Revised: 10/16/2006] [Accepted: 12/12/2006] [Indexed: 12/21/2022]
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Abstract
BACKGROUND Thromboembolism (TE) is a common complication and cause of death in adults with cancer. Cancer has been identified as a major risk factor in children with TE. However, the information regarding the epidemiology of TE in children with cancer, especially in association with childhood solid tumors, is scant. OBJECTIVE To define the prevalence and epidemiology of TE in children with sarcoma. PROCEDURE Hospital records of children </=18 years of age with sarcoma diagnosed and treated at McMaster Children's Hospital during January 1990 to December 2005 were reviewed for demographic details, details of diagnosis and therapy for sarcoma, and details of diagnosis and management of TE. Statistical analysis was performed using Fisher's exact t-test. RESULTS Ten of 70 (14.3%; 95% CI; 7.1, 24.7) patients with sarcoma developed symptomatic TE. Patients with CVL-dysfunction (n = 9) were at significantly higher risk for symptomatic TE compared to those without CVL dysfunction (n = 61) (55.5 vs. 8.2%; P = 0.002, 95% CI; 14.2, 80.5). Patients with pulmonary disease (n = 23) had higher prevalence of TE compared to those without pulmonary disease (n = 47) (26 vs.8.5%; P = 0.07, 95% CI; -2.06, 37.2). Older patients, patients with metastatic disease and those with Ewing sarcoma had higher prevalence of TE. CONCLUSIONS TE is a significant complication in children with sarcoma. Over 50% of patients with CVL dysfunction had symptomatic TE; such patients may warrant careful evaluation for associated TE. Large prospective studies are needed to define the epidemiology and identify risk factors predisposing to TE in children with sarcoma.
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Affiliation(s)
- Uma Athale
- Department of Pediatrics, Division of Hematology, McMaster University, Hamilton, Ontario, Canada.
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Affiliation(s)
- O Dotsenko
- Thrombosis Research Institute, London UK
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Beyan C. Hypercoagulable State. Med J Armed Forces India 2006; 62:306. [PMID: 27407921 PMCID: PMC4922904 DOI: 10.1016/s0377-1237(06)80040-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Cengiz Beyan
- Gulhane Military Medical Academy, Department of Hematology, 06010 Etlik, Ankara, Turkey
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Abstract
The involvement of the vascular system in malignancy encompasses not only angiogenesis, but also systemic hypercoagulability and a pro-thrombotic state, and there is increasing evidence that pathways of blood coagulation and angiogenesis are reciprocally linked. In fact, cancer atients often display hypercoagulability resulting in markedly increased thromboembolism, which requires anti-coagulant treatment using heparins, for example. Clinical trials reveal that treatment with various low-molecular-weight heparins (LMWHs) improves the survival time in cancer patients receiving chemotherapy compared with those receiving unfractionated standard heparin (UFH) or no heparin treatment, as well as in cancer patients receiving LMWH as thrombosis prophylaxis during primary surgery. This anti-tumor effect of the heparins appears to be unrelated to their anti-coagulant activity, but the mechanisms involved are not fully understood. Tumor growth and spread are dependent on angiogenesis and it is noteworthy that the most potent endogenous pro- and anti-angiogenic factors are heparin-binding proteins that may be affected by systemic treatment with heparins. Heparin and other glycosaminoglycans play a role in vascular endothelial cell function, as they are able to modulate the activities of angiogenic growth factors by facilitating the interaction with their receptor and promoting receptor activation. To date, preclinical studies have demonstrated that only LMWH fragments produced by the heparinase digestion of UFH, i.e. tinzaparin, exert anti-angiogenic effects in any type of tissue in vivo. These effects are fragment-mass-specific and angiogenesis-type-specific. Data on the effect of various LMWHs and UFH on endothelial cell capillary tube formation and proliferation in vitro are also presented. We hope that this paper will stimulate and facilitate future research designed to elucidate whether the anti-angiogenic or anti-tumor effects of commercial LMWHs in their own right are agent specific and whether anti-angiogenic properties increase the anti-tumor properties of the LMWHs in the clinic.
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Affiliation(s)
- Klas Norrby
- Department of Pathology, Sahlgrenska Academy, Göteborg University, Sweden.
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