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Howlett JG, Stebbins A, Petrie MC, Jhund PS, Castelvecchio S, Cherniavsky A, Sueta CA, Roy A, Piña IL, Wurm R, Drazner MH, Andersson B, Batlle C, Senni M, Chrzanowski L, Merkely B, Carson P, Desvigne-Nickens PM, Lee KL, Velazquez EJ, Al-Khalidi HR. CABG Improves Outcomes in Patients With Ischemic Cardiomyopathy: 10-Year Follow-Up of the STICH Trial. JACC. HEART FAILURE 2019; 7:878-887. [PMID: 31521682 PMCID: PMC7375257 DOI: 10.1016/j.jchf.2019.04.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/08/2019] [Accepted: 04/14/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVES The authors investigated the impact of coronary artery bypass grafting (CABG) on first and recurrent hospitalization in this population. BACKGROUND In the STICH (Surgical Treatment for Ischemic Heart Failure) trial, CABG reduced all-cause death and hospitalization in patients with and ischemic cardiomyopathy and left ventricular ejection fraction <35%. METHODS A total of 1,212 patients were randomized (610 to CABG + optimal medical therapy [CABG] and 602 to optimal medical therapy alone [MED] alone) and followed for a median of 9.8 years. All-cause and cause-specific hospitalizations were analyzed as time-to-first-event and as recurrent event analysis. RESULTS Of the 1,212 patients, 757 died (62.4%) and 732 (60.4%) were hospitalized at least once, for a total of 2,549 total all-cause hospitalizations. Most hospitalizations (66.2%) were for cardiovascular causes, of which approximately one-half (907 or 52.9%) were for heart failure. More than 70% of all hospitalizations (1,817 or 71.3%) were recurrent events. The CABG group experienced fewer all-cause hospitalizations in the time-to-first-event (349 CABG vs. 383 MED, adjusted hazard ratio [HR]: 0.85; 95% confidence interval [CI]: 0.74 to 0.98; p = 0.03) and in recurrent event analyses (1,199 CABG vs. 1,350 MED, HR: 0.78, 95% CI: 0.65 to 0.94; p < 0.001). This was driven by fewer total cardiovascular (CV) hospitalizations (744 vs. 968; p < 0.001, adjusted HR: 0.66, 95% CI: 0.55 to 0.81; p = 0.001), the majority of which were due to HF (395 vs. 512; p < 0.001, adjusted HR: 0.68, 95% CI: 0.52-0.89; p = 0.005). We did not observe a difference in non-CV events. CONCLUSIONS CABG reduces all-cause, CV, and HF hospitalizations in time-to-first-event and recurrent event analyses. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595).
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Affiliation(s)
- Jonathan G Howlett
- Libin Cardiovascular Institute and University of Calgary Medical Centre, Calgary, Canada.
| | - Amanda Stebbins
- Duke Clinical Research Institute and Department of Biostatistics and Bioinformatics, Durham, North Carolina
| | - Mark C Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Serenella Castelvecchio
- Istituto Di Ricovero e Cura a Carattere Scientifico Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Alexander Cherniavsky
- E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - Carla A Sueta
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Ambuj Roy
- All India Institute of Medical Sciences, New Delhi, India
| | - Ileana L Piña
- Albert Einstein College of Medicine, Montefiore Medical Center, New York City, New York
| | | | - Mark H Drazner
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bert Andersson
- Department of Cardiology, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Carmen Batlle
- Centro de Investigación Cardiovascular Uruguayo Casa De Galicia, Montevideo, Uruguay
| | | | | | - Bela Merkely
- Semmelweis University, Budapest, Budapest, Hungary
| | | | - Patrice M Desvigne-Nickens
- Division of Cardiovascular Sciences, National Institutes of Health, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Kerry L Lee
- Duke Clinical Research Institute and Department of Biostatistics and Bioinformatics, Durham, North Carolina
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute and Department of Biostatistics and Bioinformatics, Durham, North Carolina
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Tarricone R, Callea G, Ogorevc M, Prevolnik Rupel V. Improving the Methods for the Economic Evaluation of Medical Devices. HEALTH ECONOMICS 2017; 26 Suppl 1:70-92. [PMID: 28139085 DOI: 10.1002/hec.3471] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 10/30/2016] [Accepted: 11/23/2016] [Indexed: 05/12/2023]
Abstract
Medical devices (MDs) have distinctive features, such as incremental innovation, dynamic pricing, the learning curve and organisational impact, that need to be considered when they are evaluated. This paper investigates how MDs have been assessed in practice, in order to identify methodological gaps that need to be addressed to improve the decision-making process for their adoption. We used the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist supplemented by some additional categories to assess the quality of reporting and consideration of the distinctive features of MDs. Two case studies were considered: transcatheter aortic valve implantation (TAVI) representing an emerging technology and implantable cardioverter defibrillators (ICDs) representing a mature technology. Economic evaluation studies published as journal articles or within Health Technology Assessment reports were identified through a systematic literature review. A total of 19 studies on TAVI and 41 studies on ICDs were analysed. Learning curve was considered in only 16% of studies on TAVI. Incremental innovation was more frequently mentioned in the studies of ICDs, but its impact was considered in only 34% of the cases. Dynamic pricing was the most recognised feature but was empirically tested in less than half of studies of TAVI and only 32% of studies on ICDs. Finally, organisational impact was considered in only one study of ICDs and in almost all studies on TAVI, but none of them estimated its impact. By their very nature, most of the distinctive features of MDs cannot be fully assessed at market entry. However, their potential impact could be modelled, based on the experience with previous MDs, in order to make a preliminary recommendation. Then, well-designed post-market studies could help in reducing uncertainties and make policymakers more confident to achieve conclusive recommendations. © 2017 The Authors. Health Economics published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Rosanna Tarricone
- Department of Policy Analysis and Public Management, Bocconi University, Milan, Italy
- Centre for Research on Health and Social Care Management (CERGAS), Bocconi University, Milan, Italy
| | - Giuditta Callea
- Centre for Research on Health and Social Care Management (CERGAS), Bocconi University, Milan, Italy
| | - Marko Ogorevc
- Institute for Economic Research, Ljubljana, Slovenia
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García-Pérez L, Pinilla-Domínguez P, García-Quintana A, Caballero-Dorta E, García-García FJ, Linertová R, Imaz-Iglesia I. Economic evaluations of implantable cardioverter defibrillators: a systematic review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2015; 16:879-893. [PMID: 25323413 DOI: 10.1007/s10198-014-0637-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 09/22/2014] [Indexed: 06/04/2023]
Abstract
The aim of this paper was to review the cost-effectiveness studies of implantable cardioverter defibrillators (ICD) for primary or secondary prevention of sudden cardiac death (SCD). A systematic review of the literature published in English or Spanish was performed by electronically searching MEDLINE and MEDLINE in process, EMBASE, NHS-EED, and EconLit. Some keywords were implantable cardioverter defibrillator, heart failure, heart arrest, myocardial infarction, arrhythmias, syncope, sudden death. Selection criteria were the following: (1) full economic evaluations published after 1995, model-based studies or alongside clinical trials (2) that explored the cost-effectiveness of ICD with or without associated treatment compared with placebo or best medical treatment, (3) in adult patients for primary or secondary prevention of SCD because of ventricular arrhythmias. Studies that fulfilled these criteria were reviewed and data were extracted by two reviewers. The methodological quality of the studies was assessed and a narrative synthesis was prepared. In total, 24 studies were included: seven studies on secondary prevention and 18 studies on primary prevention. Seven studies were performed in Europe. For secondary prevention, the results showed that the ICD is considered cost-effective in patients with more risk. For primary prevention, the cost-effectiveness of ICD has been widely studied, but uncertainty about its cost-effectiveness remains. The cost-effectiveness ratios vary between studies depending on the patient characteristics, methodology, perspective, and national settings. Among the European studies, the conclusions are varied, where the ICD is considered cost-effective or not dependent on the study.
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Affiliation(s)
- Lidia García-Pérez
- Servicio de Evaluación del Servicio Canario de la Salud (SESCS), Camino Candelaria Nº 44, 1ª planta, El Rosario, 38109, Santa Cruz De Tenerife, Canary Islands, Spain.
- Fundación Canaria de Investigación y Salud (FUNCIS), Canary Islands, Spain.
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain.
- Centro de Investigaciones Biomédicas de Canarias (CIBICAN), Universidad de La Laguna, La Laguna, Spain.
| | - Pilar Pinilla-Domínguez
- Servicio de Evaluación del Servicio Canario de la Salud (SESCS), Camino Candelaria Nº 44, 1ª planta, El Rosario, 38109, Santa Cruz De Tenerife, Canary Islands, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Antonio García-Quintana
- Servicio de Cardiología, Hospital Universitario de Gran Canaria Dr Negrín, Canary Islands, Spain
| | - Eduardo Caballero-Dorta
- Servicio de Cardiología, Hospital Universitario de Gran Canaria Dr Negrín, Canary Islands, Spain
| | - F Javier García-García
- Unidad de Calidad y Seguridad del Paciente, Hospital Universitario Nuestra Señora de Candelaria, Canary Islands, Spain
| | - Renata Linertová
- Servicio de Evaluación del Servicio Canario de la Salud (SESCS), Camino Candelaria Nº 44, 1ª planta, El Rosario, 38109, Santa Cruz De Tenerife, Canary Islands, Spain
- Fundación Canaria de Investigación y Salud (FUNCIS), Canary Islands, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
- Centro de Investigaciones Biomédicas de Canarias (CIBICAN), Universidad de La Laguna, La Laguna, Spain
| | - Iñaki Imaz-Iglesia
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
- Agencia de Evaluación de Tecnologías Sanitarias (AETS), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
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Abstract
Despite advances in evidence-based treatments, the morbidity and mortality of congestive heart failure remain exceedingly high. In addition, the costs associated with recurrent hospitalizations and advanced therapies, such as implantable cardiac defibrillators (ICDs), left ventricular assist devices, and heart transplantation, place a substantial financial burden on the health care system. The present criteria for risk stratification in patients with heart failure are inadequate and often prevent the allocation of appropriate treatment. Patients who have received ICDs as primary prevention for sudden cardiac death often receive no device therapy in their lifetime, whereas other patients with left ventricular dysfunction die suddenly without meeting criteria for ICD implantation.
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Colquitt JL, Mendes D, Clegg AJ, Harris P, Cooper K, Picot J, Bryant J. Implantable cardioverter defibrillators for the treatment of arrhythmias and cardiac resynchronisation therapy for the treatment of heart failure: systematic review and economic evaluation. Health Technol Assess 2015; 18:1-560. [PMID: 25169727 DOI: 10.3310/hta18560] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND This assessment updates and expands on two previous technology assessments that evaluated implantable cardioverter defibrillators (ICDs) for arrhythmias and cardiac resynchronisation therapy (CRT) for heart failure (HF). OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of ICDs in addition to optimal pharmacological therapy (OPT) for people at increased risk of sudden cardiac death (SCD) as a result of ventricular arrhythmias despite receiving OPT; to assess CRT with or without a defibrillator (CRT-D or CRT-P) in addition to OPT for people with HF as a result of left ventricular systolic dysfunction (LVSD) and cardiac dyssynchrony despite receiving OPT; and to assess CRT-D in addition to OPT for people with both conditions. DATA SOURCES Electronic resources including MEDLINE, EMBASE and The Cochrane Library were searched from inception to November 2012. Additional studies were sought from reference lists, clinical experts and manufacturers' submissions to the National Institute for Health and Care Excellence. REVIEW METHODS Inclusion criteria were applied by two reviewers independently. Data extraction and quality assessment were undertaken by one reviewer and checked by a second. Data were synthesised through narrative review and meta-analyses. For the three populations above, randomised controlled trials (RCTs) comparing (1) ICD with standard therapy, (2) CRT-P or CRT-D with each other or with OPT and (3) CRT-D with OPT, CRT-P or ICD were eligible. Outcomes included mortality, adverse events and quality of life. A previously developed Markov model was adapted to estimate the cost-effectiveness of OPT, ICDs, CRT-P and CRT-D in the three populations by simulating disease progression calculated at 4-weekly cycles over a lifetime horizon. RESULTS A total of 4556 references were identified, of which 26 RCTs were included in the review: 13 compared ICD with medical therapy, four compared CRT-P/CRT-D with OPT and nine compared CRT-D with ICD. ICDs reduced all-cause mortality in people at increased risk of SCD, defined in trials as those with previous ventricular arrhythmias/cardiac arrest, myocardial infarction (MI) > 3 weeks previously, non-ischaemic cardiomyopathy (depending on data included) or ischaemic/non-ischaemic HF and left ventricular ejection fraction ≤ 35%. There was no benefit in people scheduled for coronary artery bypass graft. A reduction in SCD but not all-cause mortality was found in people with recent MI. Incremental cost-effectiveness ratios (ICERs) ranged from £14,231 per quality-adjusted life-year (QALY) to £29,756 per QALY for the scenarios modelled. CRT-P and CRT-D reduced mortality and HF hospitalisations, and improved other outcomes, in people with HF as a result of LVSD and cardiac dyssynchrony when compared with OPT. The rate of SCD was lower with CRT-D than with CRT-P but other outcomes were similar. CRT-P and CRT-D compared with OPT produced ICERs of £27,584 per QALY and £27,899 per QALY respectively. The ICER for CRT-D compared with CRT-P was £28,420 per QALY. In people with both conditions, CRT-D reduced the risk of all-cause mortality and HF hospitalisation, and improved other outcomes, compared with ICDs. Complications were more common with CRT-D. Initial management with OPT alone was most cost-effective (ICER £2824 per QALY compared with ICD) when health-related quality of life was kept constant over time. Costs and QALYs for CRT-D and CRT-P were similar. The ICER for CRT-D compared with ICD was £27,195 per QALY and that for CRT-D compared with OPT was £35,193 per QALY. LIMITATIONS Limitations of the model include the structural assumptions made about disease progression and treatment provision, the extrapolation of trial survival estimates over time and the assumptions made around parameter values when evidence was not available for specific patient groups. CONCLUSIONS In people at risk of SCD as a result of ventricular arrhythmias and in those with HF as a result of LVSD and cardiac dyssynchrony, the interventions modelled produced ICERs of < £30,000 per QALY gained. In people with both conditions, the ICER for CRT-D compared with ICD, but not CRT-D compared with OPT, was < £30,000 per QALY, and the costs and QALYs for CRT-D and CRT-P were similar. A RCT comparing CRT-D and CRT-P in people with HF as a result of LVSD and cardiac dyssynchrony is required, for both those with and those without an ICD indication. A RCT is also needed into the benefits of ICD in non-ischaemic cardiomyopathy in the absence of dyssynchrony. STUDY REGISTRATION This study is registered as PROSPERO number CRD42012002062. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Jill L Colquitt
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Diana Mendes
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Andrew J Clegg
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Petra Harris
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Keith Cooper
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Joanna Picot
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Jackie Bryant
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
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Mylotte D, Quenneville SP, Kotowycz MA, Xie X, Brophy JM, Ionescu-Ittu R, Martucci G, Pilote L, Therrien J, Marelli AJ. Long-term cost-effectiveness of transcatheter versus surgical closure of secundum atrial septal defect in adults. Int J Cardiol 2014; 172:109-14. [DOI: 10.1016/j.ijcard.2013.12.144] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 12/02/2013] [Accepted: 12/26/2013] [Indexed: 11/29/2022]
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Gialama F, Prezerakos P, Maniadakis N. The cost effectiveness of implantable cardioverter defibrillators: a systematic review of economic evaluations. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2014; 12:41-9. [PMID: 24243517 DOI: 10.1007/s40258-013-0069-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
BACKGROUND Sudden cardiac death (SCD) is the most common cause of death in developed countries, with more than 3 million people dying yearly. Implantable cardioverter defibrillators (ICDs) are considered to be an effective treatment in the primary and secondary prevention of SCD; however, their cost is considerable and this poses questions regarding whether they are worth the investment relative to less expensive pharmacotherapy. OBJECTIVE The aim of this systematic review is to investigate existing evidence regarding the cost effectiveness of ICD therapy and to identify the key drivers of cost effectiveness, for the purpose of informing interested policy and decision makers. METHODOLOGY A systematic review of the literature concerning the cost effectiveness of ICDs was undertaken. Electronic databases, including PubMed, Cochrane and Health Economic Evaluations Database were searched based on appropriate terms and their combinations. Economic evaluation studies that examined the cost effectiveness of ICDs were selected and 34 were included for evaluation. RESULTS Findings from the present analysis show that ICD therapy, in properly selected patients who are at high risk of sudden cardiac death, is associated with similar or better cost-effectiveness ratios compared with other well accepted conventional treatments. The cost effectiveness of ICDs is influenced by several factors, including ICD efficacy and safety, impact on patient quality of life, device original implantation cost, frequency and cost of battery replacement, patient demographics and risk profile and analysis time horizon. CONCLUSION ICDs may represent a cost-effective option relative to pharmacotherapy in appropriately selected patient groups. The cost-effectiveness ratios appear to be at acceptable and comparable levels to other established treatments in cardiovascular and non-cardiovascular diseases. However, cost effectiveness is highly related to several factors and hence economic efficiency is highly dependent on conditions that need to be fulfilled for each individual case in medical practice. The aforementioned factors and technological advances imply that to ensure cost-effective use of ICD therapy, continuous research is needed.
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Affiliation(s)
- Fotini Gialama
- Health Services Organization and Management, National School of Public Health, 196 Alexandras Avenue, 115 21, Athens, Greece
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Abstract
Heart failure (HF) is a leading cause of morbidity and mortality worldwide. Management of HF involves accurate diagnosis and implementation of evidence-based treatment strategies. Costs related to the care of patients with HF have increased substantially over the past 2 decades, partly owing to new medications and diagnostic tests, increased rates of hospitalization, implantation of costly novel devices and, as the disease progresses, consideration for heart transplantation, mechanical circulatory support, and end-of-life care. Not surprisingly, HF places a huge burden on health-care systems, and widespread implementation of all potentially beneficial therapies for HF could prove unrealistic for many, if not all, nations. Cost-effectiveness analyses can help to quantify the relationship between clinical outcomes and the economic implications of available therapies. This Review is a critical overview of cost-effectiveness studies on key areas of HF management, involving pharmacological and nonpharmacological clinical therapies, including device-based and surgical therapeutic strategies.
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Affiliation(s)
- Luis E Rohde
- Postgraduate Program in Cardiovascular Science, Universidade Federal do Rio Grande do Sul, National Institute for Health Technology Assessment (IATS), CNPq, Av. Bento Gonçalves 9500, Porto Alegre, RS, Brazil
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Bernard ML, Gold MR. Economic Implications and Cost-effectiveness of Implantable Cardioverter Defibrillator and Cardiac Resynchronization Therapy. Heart Fail Clin 2011; 7:241-50, ix. [DOI: 10.1016/j.hfc.2010.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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