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Berkovic D, Vallance P, Harris IA, Naylor JM, Lewis PL, de Steiger R, Buchbinder R, Ademi Z, Ackerman IN. Barriers and enablers to the implementation and sustainability of short-stay arthroplasty programs for elective primary total hip and knee replacement: A systematic review with qualitative evidence synthesis. Musculoskeletal Care 2024; 22:e1897. [PMID: 38831253 DOI: 10.1002/msc.1897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 05/13/2024] [Indexed: 06/05/2024]
Abstract
INTRODUCTION We aimed to systematically review contemporary evidence on the barriers and enablers to implementing and sustaining short-stay arthroplasty programs for elective primary total hip and knee replacement from the perspectives of patients, health professionals, carers, healthcare administrators, funders and policymakers and to map the findings to the Theoretical Domains Framework (TDF). METHODS Medline, Cumulative Index to Nursing and Allied Health Literature, EMBASE, and the Cochrane Central Register of Controlled Trials were searched (up to 19 August 2023). Primary qualitative or mixed-methods studies reporting on perspectives relating to the review aims that utilised a short-stay programme were eligible for inclusion. Study quality was assessed using the qualitative critical appraisal tool from the Joanna Briggs Institute. Data were analysed inductively. The final themes were mapped to the TDF. The confidence in the findings was assessed using GRADE CERQual. RESULTS Fifteen studies were included. Twelve barrier themes and twelve enabler themes were identified. Three themes were graded with high confidence, 10 were graded with moderate confidence, three were graded with low confidence, and eight were graded with very low confidence. The most pertinent domains that the themes were mapped to for patients were beliefs about capabilities, reinforcement, and the environmental context and resources. Health professionals identified knowledge, environmental context and resources as important domains. Two domains were identified for carers: (1) social/professional role and identity and (2) memory, attention, and decision processes. CONCLUSION We identified key barrier and enabler themes linked to the TDF that can be used to guide implementation initiatives and promote the sustainability of short-stay arthroplasty programs.
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Affiliation(s)
- Danielle Berkovic
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Patrick Vallance
- Department of Physiotherapy, Podiatry, Prosthetics and Orthotics, School of Allied Health, Human Service and Sport, La Trobe University, Melbourne, Victoria, Australia
- Department of Physiotherapy, School of Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia
| | - Ian A Harris
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Justine M Naylor
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Peter L Lewis
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
- Faculty of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Richard de Steiger
- Department of Surgery, Epworth HealthCare, University of Melbourne, Melbourne, Victoria, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Health Economics and Policy Evaluation Research (HEPER), Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Ilana N Ackerman
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Wallis JA, Shepperd S, Makela P, Han JX, Tripp EM, Gearon E, Disher G, Buchbinder R, O'Connor D. Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis. Cochrane Database Syst Rev 2024; 3:CD014765. [PMID: 38438114 PMCID: PMC10911892 DOI: 10.1002/14651858.cd014765.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
BACKGROUND Worldwide there is an increasing demand for Hospital at Home as an alternative to hospital admission. Although there is a growing evidence base on the effectiveness and cost-effectiveness of Hospital at Home, health service managers, health professionals and policy makers require evidence on how to implement and sustain these services on a wider scale. OBJECTIVES (1) To identify, appraise and synthesise qualitative research evidence on the factors that influence the implementation of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home, from the perspective of multiple stakeholders, including policy makers, health service managers, health professionals, patients and patients' caregivers. (2) To explore how our synthesis findings relate to, and help to explain, the findings of the Cochrane intervention reviews of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home services. SEARCH METHODS We searched MEDLINE, CINAHL, Global Index Medicus and Scopus until 17 November 2022. We also applied reference checking and citation searching to identify additional studies. We searched for studies in any language. SELECTION CRITERIA We included qualitative studies and mixed-methods studies with qualitative data collection and analysis methods examining the implementation of new or existing Hospital at Home services from the perspective of different stakeholders. DATA COLLECTION AND ANALYSIS Two authors independently selected the studies, extracted study characteristics and intervention components, assessed the methodological limitations using the Critical Appraisal Skills Checklist (CASP) and assessed the confidence in the findings using GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research). We applied thematic synthesis to synthesise the data across studies and identify factors that may influence the implementation of Hospital at Home. MAIN RESULTS From 7535 records identified from database searches and one identified from citation tracking, we included 52 qualitative studies exploring the implementation of Hospital at Home services (31 Early Discharge, 16 Admission Avoidance, 5 combined services), across 13 countries and from the perspectives of 662 service-level staff (clinicians, managers), eight systems-level staff (commissioners, insurers), 900 patients and 417 caregivers. Overall, we judged 40 studies as having minor methodological concerns and we judged 12 studies as having major concerns. Main concerns included data collection methods (e.g. not reporting a topic guide), data analysis methods (e.g. insufficient data to support findings) and not reporting ethical approval. Following synthesis, we identified 12 findings graded as high (n = 10) and moderate (n = 2) confidence and classified them into four themes: (1) development of stakeholder relationships and systems prior to implementation, (2) processes, resources and skills required for safe and effective implementation, (3) acceptability and caregiver impacts, and (4) sustainability of services. AUTHORS' CONCLUSIONS Implementing Admission Avoidance and Early Discharge Hospital at Home services requires early development of policies, stakeholder engagement, efficient admission processes, effective communication and a skilled workforce to safely and effectively implement person-centred Hospital at Home, achieve acceptance by staff who refer patients to these services and ensure sustainability. Future research should focus on lower-income country and rural settings, and the perspectives of systems-level stakeholders, and explore the potential negative impact on caregivers, especially for Admission Avoidance Hospital at Home, as this service may become increasingly utilised to manage rising visits to emergency departments.
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Affiliation(s)
- Jason A Wallis
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Cabrini Health, Malvern, Australia
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Petra Makela
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jia Xi Han
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Evie M Tripp
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Emma Gearon
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Gary Disher
- New South Wales Ministry of Health, St Leonards, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Denise O'Connor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Zangrilli J, Gouda N, Voskerijian A, Wang ML, Beredjiklian PK, Rivlin M. A Multimodal Pain Management Regimen for Open Treatment of Distal Radius Fractures: A Randomized Blinded Study. Hand (N Y) 2022; 17:1187-1193. [PMID: 33356569 PMCID: PMC9608278 DOI: 10.1177/1558944720975146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Adequate pain control is critical after outpatient surgery where patients are not as closely monitored. A multimodal pain management regimen was compared to a conventional pain management method in patients undergoing operative fixation for distal radius fractures. We hypothesized that there would be a decrease in the amount of narcotics used by the multimodal group compared to the conventional pain management group, and that there would be no difference in bone healing postoperatively. METHODS Forty-two patients were randomized into 2 groups based on pain protocols. Group 1, the control, received a regional block, acetaminophen, and oxycodone. Group 2 received a multimodal pain regimen consisting of daily doses of pregabalin, celecoxib, and acetaminophen up until postoperative day (POD) #3. They also received a regional block with oxycodone for breakthrough pain. RESULTS From POD#3 to week 1, there was a significant increase in oxycodone use in the study group correlating with the point in time when the multimodal regimen was discontinued. The shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) scores taken at 2 weeks postoperation showed a significantly lower average score in the study group compared to the control. There was no difference in bone healing. CONCLUSIONS The 2 regimens yielded similar pain control after surgery. The rebound increase in narcotic use after the multimodal regimen was discontinued, and significant difference in QuickDASH scores seen at 2 weeks postoperatively supported that multimodal regimens may not necessarily lead to decreased narcotic use in outpatient upper extremity surgery, but in the short term are shown to improve functional status.
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Affiliation(s)
- Julian Zangrilli
- Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Nura Gouda
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Armen Voskerijian
- Jefferson Surgery Center at The Navy Yard, Philadelphia, PA, USA
- United Anesthesia Services, P.C., Bryn Mawr, PA, USA
| | - Mark L. Wang
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Jenkins C, Jackson W, Bottomley N, Price A, Murray D, Barker K. Introduction of an innovative day surgery pathway for unicompartmental knee replacement: no need for early knee flexion. Physiotherapy 2019; 105:46-52. [PMID: 30704751 DOI: 10.1016/j.physio.2018.11.305] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 11/16/2018] [Accepted: 11/21/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the introduction of an innovative rehabilitation protocol, delaying knee flexion, for patients receiving unicompartmental knee replacement. DESIGN Longitudinal cohort. SETTING Specialist Orthopaedic Unit within an NHS Foundation Trust. PARTICIPANTS 669 consecutive patients undergoing unicompartmental knee replacement. INTERVENTION An innovative rehabilitation protocol, delaying knee flexion. MAIN OUTCOME MEASURES Length of stay, range of movement, Surgical Satisfaction Questionnaire. RESULTS There were 669 consecutive primary unilateral unicompartmental knee replacements from September 2016 to February 2018. In total 264 patients (39%) went home on the day of surgery, 253 (38%) on day 1 and 152 (23%) stayed in 2 or more days (range 2 to 28 days). The mean length of stay reduced from 2.6 to 1.2days (median 1day). Mean flexion was 110° (range 30 to 140) at 6 weeks. The surgical satisfaction questionnaire showed that 90% of patients discharged on day 0 were very satisfied with the results of surgery. CONCLUSION Many components of traditional care were altered to introduce this protocol. The most important factors were delayed knee flexion providing benefits in terms of early mobilisation with no short term detriment, physiotherapists working late shifts, a consistent message and patient education. It was safe, effective and patient satisfaction was high.
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Affiliation(s)
- Cathy Jenkins
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7HE, UK.
| | - William Jackson
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7HE, UK
| | - Nicholas Bottomley
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7HE, UK
| | - Andrew Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7HE, UK
| | - David Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7HE, UK
| | - Karen Barker
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7HE, UK
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Alanazi MQ, Al-Jeriasy MI, Al-Assiri MH, Afesh LY, Alhammad F, Salam M. Hospital Performance Indicators and Their Associated Factors in Acute Child Poisoning at a Single Poison Center, Central Saudi Arabia. Medicine (Baltimore) 2015; 94:e2339. [PMID: 26717371 PMCID: PMC5291612 DOI: 10.1097/md.0000000000002339] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Admission rate and length of stay (LOS) are two hospital performance indicators that affect the quality of care, patients' satisfaction, bed turnover, and health cost expenditures. The aim of the study was to identify factors associated with higher admission rates and extended average LOS among acutely poisoned children at a single poison center, central Saudi Arabia.This is a cross-sectional, poison and medical chart review between 2009 and 2011. Exposures were child characteristics, that is, gender, age, body mass index (BMI), health history, and Canadian 5-level triage scale. Poison incident characteristics were, that is, type, exposure route, amount, form, home remedy, and arrival time to center. Admission status and LOS were obtained from records. Chronic poisoning, plant allergies, and venomous bites were excluded. Bivariate and regression analyses were applied. Significance at P < 0.05.Of the 315 eligible cases, (72%) were toddlers with equal gender distribution, (58%) had normal BMI, and (77%) were previously healthy. Poison substances were pharmaceutical drugs (63%) versus chemical products (37%). Main exposure route was oral (98%). Home remedy was observed in (21.9%), which were fluids, solutes, and/or gag-induced vomiting. Almost (52%) arrived to center >1 h. Triage levels: non-urgent cases (58%), less urgent (11%), urgent (18%), emergency (12%), resuscitative (1%). Admission rate was (20.6%) whereas av. LOS was 13 ± 22 h. After adjusting and controlling for confounders, older children (adj.OR = 1.19) and more critical triage levels (adj.OR = 1.35) were significantly associated with higher admission rates compared to younger children and less critical triage levels (adj.P = 0.006) and (adj.P = 0.042) respectively. Home remedy prior arrival was significantly associated with higher av. LOS (Beta = 9.48, t = 2.99), compared to those who directly visited the center, adj.P = 0.003.Hospital administrators are cautioned that acutely poisoned children who received home remedies prior arrival are more likely to endure an extended LOS. This non-conventional practice is not recommended.
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Affiliation(s)
- Menyfah Q Alanazi
- From the Drug Policy and Economics Center (MQA); King Abdullah International Medical Research Center (KAIMRC) (MJ, MHA, LYA, MS); Pharmaceutical Care and King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) (MJ); and Pediatrics Emergency Department (FA); King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Barker KL. How can qualitative research be utilised in the NHS when re-designing and commissioning services? Br J Pain 2015; 9:70-2. [PMID: 26516559 PMCID: PMC4616992 DOI: 10.1177/2049463714544553] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Patient experience is acknowledged as a key quality metric of healthcare quality and can be used to identify problems with healthcare delivery, to drive quality improvements and to inform commissioning of services that promote patient choice. In this article, the contribution of qualitative research studies to inform the redesign and patient-focussed commissioning of services is considered, illustrated with particular reference to elective orthopaedic surgical services. To fully embrace the concept of patient and public involvement (PPI) and to embed it in service delivery, health service design and informing commissioners to purchase healthcare that truly meets patient need and expectations, qualitative research has an increasingly important role to play. Through well-conducted qualitative research exploring patients' experiences, their knowledge and experiences of conditions can be utilised for the benefit of others and the impact of the patient voice truly heard when designing and commissioning healthcare services.
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Affiliation(s)
- Karen L Barker
- Orthopaedic Directorate, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Carter EM, Potts HWW. Predicting length of stay from an electronic patient record system: a primary total knee replacement example. BMC Med Inform Decis Mak 2014; 14:26. [PMID: 24708853 PMCID: PMC3992140 DOI: 10.1186/1472-6947-14-26] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 03/15/2014] [Indexed: 12/04/2022] Open
Abstract
Background To investigate whether factors can be identified that significantly affect hospital length of stay from those available in an electronic patient record system, using primary total knee replacements as an example. To investigate whether a model can be produced to predict the length of stay based on these factors to help resource planning and patient expectations on their length of stay. Methods Data were extracted from the electronic patient record system for discharges from primary total knee operations from January 2007 to December 2011 (n = 2,130) at one UK hospital and analysed for their effect on length of stay using Mann-Whitney and Kruskal-Wallis tests for discrete data and Spearman’s correlation coefficient for continuous data. Models for predicting length of stay for primary total knee replacements were tested using the Poisson regression and the negative binomial modelling techniques. Results Factors found to have a significant effect on length of stay were age, gender, consultant, discharge destination, deprivation and ethnicity. Applying a negative binomial model to these variables was successful. The model predicted the length of stay of those patients who stayed 4–6 days (~50% of admissions) with 75% accuracy within 2 days (model data). Overall, the model predicted the total days stayed over 5 years to be only 88 days more than actual, a 6.9% uplift (test data). Conclusions Valuable information can be found about length of stay from the analysis of variables easily extracted from an electronic patient record system. Models can be successfully created to help improve resource planning and from which a simple decision support system can be produced to help patient expectation on their length of stay.
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Affiliation(s)
- Evelene M Carter
- Information Services Department, Oxford University Hospitals NHS Trust, Oxford, UK.
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Jones EL, Wainwright TW, Foster JD, Smith JRA, Middleton RG, Francis NK. A systematic review of patient reported outcomes and patient experience in enhanced recovery after orthopaedic surgery. Ann R Coll Surg Engl 2014; 96:89-94. [PMID: 24780662 PMCID: PMC4474266 DOI: 10.1308/003588414x13824511649571] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2013] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Orthopaedic enhanced recovery after surgery (ERAS) providers are encouraged to estimate the actual benefit of ERAS according to the patient's opinion by using patient generated data alongside traditional measures such as length of stay. The aim of this paper was to systemically review the literature on the use of patient generated information in orthopaedic ERAS across the whole perioperative pathway. METHODS Publications were identified using Embase(™), MEDLINE(®), AMED, CINAHL(®) (Cumulative Index to Nursing and Allied Health Literature), the Cochrane Library and the British Nursing Index. Search terms related to experiences, acceptance, satisfaction or perception of ERAS and quality of life (QoL). FINDINGS Of the 596 abstracts found, 8 papers were identified that met the inclusion criteria. A total of 2,208 patients undergoing elective hip and knee arthroplasty were included. Patient satisfaction was reported in 6 papers. Scores were high in all patients and not adversely affected by length of stay. QoL was reported in 2 papers and showed that QoL scores continued to increase up to 12 months following ERAS. Qualitative methods were used in one study, which highlighted problems with support following discharge. There is a paucity of data reporting on patient experience in orthopaedic ERAS. However, ERAS does not compromise patient satisfaction or QoL after elective hip or knee surgery. The measurement of patient experience should be standardised with further research.
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Affiliation(s)
- E L Jones
- Yeovil District Hospital NHS Foundation Trust, UK
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Jenkins C, Barker K, Reilly K, Pandit H, Dodd C, Murray D. Physiotherapy management of minimally invasive Oxford medial compartment knee arthroplasty: an observational study of 100 patients following an accelerated treatment protocol. Physiotherapy 2006. [DOI: 10.1016/j.physio.2006.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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