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Young MF, Oaks BM, Rogers HP, Tandon S, Martorell R, Dewey KG, Wendt AS. Maternal low and high hemoglobin concentrations and associations with adverse maternal and infant health outcomes: an updated global systematic review and meta-analysis. BMC Pregnancy Childbirth 2023; 23:264. [PMID: 37076797 PMCID: PMC10114461 DOI: 10.1186/s12884-023-05489-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 03/02/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Growing evidence suggests low and high maternal hemoglobin (Hb) concentrations may have adverse consequences for maternal and child health. There remain questions on specific Hb thresholds to define anemia and high Hb as well as how cutoffs may vary by anemia etiology and timing of assessment. METHODS We conducted an updated systematic review (using PubMed and Cochrane Review) on low (< 110 g/L) and high (≥ 130 g/L) maternal Hb concentrations and associations with a range of maternal and infant health outcomes. We examined associations by timing of Hb assessment (preconception; first, second, and third trimesters, as well as at any time point in pregnancy), varying cutoffs used for defining low and high hemoglobin concentrations and performed stratified analyses by iron-deficiency anemia. We conducted meta-analyses to obtain odds ratios (OR) and 95% confidence intervals. RESULTS The updated systematic review included 148 studies. Low maternal Hb at any time point in pregnancy was associated with: low birthweight, LBW (OR (95% CI) 1.28 (1.22-1.35)), very low birthweight, VLBW (2.15 (1.47-3.13)), preterm birth, PTB (1.35 (1.29-1.42)), small-for-gestational age, SGA (1.11 (1.02-1.19)), stillbirth 1.43 (1.24-1.65)), perinatal mortality (1.75 (1.28-2.39)), neonatal mortality (1.25 (1.16-1.34), postpartum hemorrhage (1.69 (1.45-1.97)), transfusion (3.68 (2.58-5.26)), pre-eclampsia (1.57 (1.23-2.01)), and prenatal depression (1.44 (1.24-1.68)). For maternal mortality, the OR was higher for Hb < 90 (4.83 (2.17-10.74)) than for Hb < 100 (2.87 (1.08-7.67)). High maternal Hb was associated with: VLBW (1.35 (1.16-1.57)), PTB (1.12 (1.00-1.25)), SGA (1.17 (1.09-1.25)), stillbirth (1.32 (1.09-1.60)), maternal mortality (2.01 (1.12-3.61)), gestational diabetes (1.71 (1.19-2.46)), and pre-eclampsia (1.34 (1.16-1.56)). Stronger associations were noted earlier in pregnancy for low Hb and adverse birth outcomes while the role of timing of high Hb was inconsistent. Lower Hb cutoffs were associated with greater odds of poor outcomes; for high Hb, data were too limited to identify patterns. Information on anemia etiology was limited; relationships did not vary by iron-deficiency anemia. CONCLUSION Both low and high maternal Hb concentrations during pregnancy are strong predictors of adverse maternal and infant health outcomes. Additional research is needed to establish healthy reference ranges and design effective interventions to optimize maternal Hb during pregnancy.
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Affiliation(s)
- Melissa F Young
- Hubert Department of Global Health, Emory University, 1518 Clifton Road NE, 30322, Atlanta, GA, USA.
| | - Brietta M Oaks
- Department of Nutrition and Food Sciences, University of Rhode Island, 02881, Kingston, United States
| | - Hannah Paige Rogers
- Hubert Department of Global Health, Emory University, 1518 Clifton Road NE, 30322, Atlanta, GA, USA
| | - Sonia Tandon
- Hubert Department of Global Health, Emory University, 1518 Clifton Road NE, 30322, Atlanta, GA, USA
| | - Reynaldo Martorell
- Hubert Department of Global Health, Emory University, 1518 Clifton Road NE, 30322, Atlanta, GA, USA
| | - Kathryn G Dewey
- Department of Nutrition, University of California, Davis, 95616, Davis, United States
| | - Amanda S Wendt
- Research Department 2, Potsdam Institute for Climate Impact Research (PIK), Member of the Leibniz Association, PO Box 60 12 03, 14412,, Potsdam, Germany
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Guha Sapir D, Ogbu JT, Scales SE, de Almeida MM, Donneau AF, Diep A, Bernstein R, al-Masnai A, Rodriguez-Llanes JM, Burnham G. Civil war and death in Yemen: Analysis of SMART survey and ACLED data, 2012-2019. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000581. [PMID: 36962390 PMCID: PMC10022117 DOI: 10.1371/journal.pgph.0000581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 06/07/2022] [Indexed: 05/04/2023]
Abstract
Conflict in Yemen has displaced millions and destroyed health infrastructure, resulting in the world's largest humanitarian disaster. The objective of this paper is to examine mortality in Yemen to determine whether it has increased significantly since the conflict began in 2015 compared to the preceding period. We analysed 91 household surveys using the Standardized Monitoring and Assessment of Relief and Transitions methodology, covering 2,864 clusters undertaken from 2012-2019, and deaths from Armed Conflict Location & Event Data Project database covering the conflict period 2015-2019. We used a Poisson-Gamma model to estimate pre-conflict (μp, baseline value) and conflict period (μc) mean death rates using household survey data from 2012-2019. To analyse changes in the distribution of deaths and estimate nationwide excess deaths, we applied pre- and post-conflict death rates to total population numbers. Further, we tested for association between excess death and security levels by governorate. The national estimated crude death rate/10,000 in the conflict period was 0.20 (95% CI: 0.17, 0.24), which is meaningfully higher than the estimated baseline rate of 0.19 (95% CI: 0.17, 0.22). Applying the conflict period rate to the Yemeni population, we estimated 168,212 excess deaths that occurred between 2015 and 2019. There was an 17.8% increase in overall deaths above the baseline during the conflict period. A large share (67.2%) of the excess deaths were due to combat-related violence. At the governorate level, posterior crude death rate varied across the country, ranging from 0.03 to 0.63 per 10,000 per day. Hajjah, Ibb, and Al Jawf governorates presented the highest total excess deaths. Insecurity level was not statistically associated with excess deaths. The health situation in Yemen was poor before the crisis in 2015. During the conflict, intentional violence from air and ground strikes were responsible for more deaths than indirect or non-violent causes. The provision of humanitarian aid by foreign agencies may have helped contain increases in indirect deaths from the conflict.
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Affiliation(s)
- Debarati Guha Sapir
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Université catholique de Louvain, Brussels, Belgium
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Jideofor Thomas Ogbu
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Université catholique de Louvain, Brussels, Belgium
| | - Sarah Elizabeth Scales
- Epidemiology Program, College of Health Sciences, University of Delaware, Newark, Delaware, United States of America
| | - Maria Moitinho de Almeida
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Université catholique de Louvain, Brussels, Belgium
| | | | - Anh Diep
- Public Health Department, Biostatistics Unit, University of Liege, Liege, Belgium
| | | | | | | | - Gilbert Burnham
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Liyew AD, Molla M, Azene ZN. Risk Factors of Stillbirth Among Women Who Gave Birth in Amhara Region Referral Hospitals, Ethiopia, in 2019: A Case-Control Study. Int J Womens Health 2021; 13:557-567. [PMID: 34149288 PMCID: PMC8205615 DOI: 10.2147/ijwh.s305786] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/26/2021] [Indexed: 11/26/2022] Open
Abstract
Background Worldwide, 2.6 million stillbirths occur annually and more than three-quarters of them are recorded in South Asia and Sub-Saharan Africa. Thus, the aim of this study was to identify risk factors of stillbirth among women who gave birth in Amhara region referral hospitals found in northwest and northcentral, Ethiopia in 2019. Methods A multi-center institution-based unmatched case-control study was conducted among 456 mothers who gave birth in Amhara region referral hospitals from October 1 to December 30, 2019. Consecutive and simple random sampling was used to select the cases and controls, respectively. A semi-structured, interviewer-administered questionnaire and patient chart reviews were used to collect the data. Epidemiological (Epi) data version 4.4.2.1 and Statistical Package for the Social Sciences (SPSS) version 25.0 were used for data entry and analysis, respectively. Binary logistic regression was employed. An adjusted odds ratio with a 95% confidence interval was used to declare statistically significant variables on the basis of p-value<0.05 in the multivariable binary logistic regression model. Results Alcohol drinking (adjusted odds ratio (AOR)=3.02, 95% confidence interval (CI)=1.24–7.35), antepartum hemorrhage (AOR=5.74, 95% CI=2.67–12.33), premature rupture of membrane (AOR=2.21, 95% CI=1.09–4.44), meconium-stained amniotic fluid (AOR=8.18, 95% CI=4.29–15.60), non-use of partograph for labor follow-up (AOR=3.89, 95% CI=2.12–7.17), induction of labor (AOR=2.12, 95% CI=1.09–4.11), previous history of stillbirth (AOR=2.15, 95% CI=1.08–4.26), and birthweight less than 2,500 grams (AOR=7.36, 95% CI=3.43–15.81) increase the odds of stillbirth. Conclusion Stillbirth was higher among women who drank alcohol during their pregnancy, experienced antepartum hemorrhage, premature rupture of membrane, meconium-stained amniotic fluid, induction of labor, labor not followed by partograph, previous history of stillbirth, and birthweight less than 2,500 grams. As such, education to stop alcohol drinking during pregnancy, monitoring the progress of labor with partograph, and improving the quality of care for mothers and newborns at the time of pregnancy and childbirth will contribute to preventing stillbirth.
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Affiliation(s)
| | - Mihretu Molla
- Department of Clinical Midwifery, School of Midwifery, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Zelalem Nigussie Azene
- Department of Women's and Family Health, School of Midwifery, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Mekonnen Dagne H, Takele Melku A, Abdurkadir Abdi A. Determinants of Stillbirth Among Deliveries Attended in Bale Zone Hospitals, Oromia Regional State, Southeast Ethiopia: A Case-Control Study. Int J Womens Health 2021; 13:51-60. [PMID: 33447092 PMCID: PMC7802824 DOI: 10.2147/ijwh.s276638] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 12/05/2020] [Indexed: 12/14/2022] Open
Abstract
Background Stillbirth is one of the adverse outcomes of pregnancy, and it is among the major public health problems in developing countries including Ethiopia. Stillbirth has wide-reaching consequences for parents, care providers, community and society at large. Purpose To assess the determinant of stillbirth among deliveries attended in Bale zone hospitals Southeast Ethiopia. Methods An institution-based unmatched case-control study was conducted. Cases were deliveries whose birth outcome was stillbirth and controls were deliveries with live birth. A pretested and structured checklist was used to collect data from a sample of 402 (134 cases and 268 controls). Systematic random sampling was used to recruit samples from a list of charts in the delivery registration book. Data were entered into EpiData version 4.2 and exported to SPSS version 20 for analysis. Crude and adjusted odds ratio with 95%CI was calculated and P-value <0.05 was used to declare statistical significance. Results A total of 402 charts of mothers (134 cases and 268 controls) were included in the analysis. Preceding birth interval <24 months (AOR: 2.991; 95%CI: 1.351-6.621), antenatal visit started at third trimester (AOR: 2.739; 95%CI: 1.048-7.158), referred from other health facility (AOR: 3.215; 95%CI: 1.430-7.229), labor length ≥24 h (AOR: 3.169; 95%CI: 1.241-8.091), presence of meconium stained amniotic fluid (AOR: 2.670; 95%CI: 1.082-6.592) and giving birth to a baby <2500 g (AOR: 3.155; 95%CI: 1.235-8.07) were determinants of stillbirth. Conclusion Preceding birth interval of <24 months, antenatal visit started at third trimester, referred from other health facility, presence of meconium stained amniotic fluid, labor length ≤24 h and giving birth to a baby <2500 g were found the determinants of stillbirth. Intrapartum care, early identification of labor complications and referral system are required.
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Affiliation(s)
| | | | - Adem Abdurkadir Abdi
- Department of Public Health, Madda Walabu University Goba Referral Hospital School of Health Science, Bale Goba, Ethiopia
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McDiehl RP, Boatin AA, Mugyenyi GR, Siedner MJ, Riley LE, Ngonzi J, Bebell LM. Antenatal Care Visit Attendance Frequency and Birth Outcomes in Rural Uganda: A Prospective Cohort Study. Matern Child Health J 2020; 25:311-320. [PMID: 33201450 DOI: 10.1007/s10995-020-03023-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Antenatal care (ANC) is designed to improve pregnancy outcomes by providing screening and treatment for preventable and treatable diseases. However, data are lacking on whether ANC affects stillbirth risk. We hypothesized stillbirth risk in Uganda is lower in women attending the recommended ≥ 4 ANC visits compared to those attending ≤ 3. METHODS We performed a secondary analysis of subset of 1,785 women enrolled in a prospective cohort of postpartum infection who presented to a regional referral hospital for delivery. Our primary outcome was documented stillbirth; a secondary composite poor birth outcome included stillbirth, early neonatal death, low birth weight (< 2500 g), and 5-min APGAR score < 7. We performed multivariable logistic regression analyses to identify independent correlates of stillbirth and poor birth outcome. RESULTS Of 1,785 participants, 58 (3%) pregnancies resulted in stillbirth and 198 (11%) had a poor birth outcome. Of 1,236 women attending ≥ 4 ANC visits, 31 (2.5%) had a stillbirth, compared to 27/510 (5.2%) attending ≤ 3. In multivariable analyses controlling for age, parity, distance traveled, referral status to hospital, malaria prophylaxis, and syphilis infection; attending ≥ 4 ANC visits was associated with significantly reduced odds of stillbirth (aOR 0.5, 95% CI 0.3-0.9, P = 0.02) and poor birth outcome (aOR 0.66, 95% CI 0.4-0.96, P = 0.03). Malaria prophylaxis was also independently associated with reduced odds of stillbirth (aOR 0.05, 95% CI 0.2-1.0, P = 0.04). CONCLUSIONS Attending ≥ 4 ANC visits was associated with reduced odds of stillbirth and poor birth outcomes in this Ugandan cohort, which may be related to more comprehensive infection screening, treatment, and prevention services.
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Affiliation(s)
- Rachel P McDiehl
- Emory University School of Medicine Department of Gynecology and Obstetrics, Glenn Building, 4th Floor - 412B, 69 Jesse Hill Jr Drive SE, Atlanta, GA, 30303, USA.
| | - Adeline A Boatin
- Massachusetts General Hospital Department of Obstetrics and Gynecology, 55 Fruit St, Boston, MA, 02114, USA.,Massachusetts General Hospital Center for Global Health, Suite 722, 125 Nashua St, Boston, MA, 02114, USA
| | - Godfrey R Mugyenyi
- Mbarara University of Science and Technology Department of Obstetrics and Gynaecology, P.O. Box 1410, Mbarara, Uganda
| | - Mark J Siedner
- Massachusetts General Hospital Center for Global Health, Suite 722, 125 Nashua St, Boston, MA, 02114, USA.,Massachusetts General Hospital Division of Infectious Diseases and Medical Practice Evaluation Center, 55 Fruit St and 100 Cambridge St, Boston, MA, 02114, USA
| | - Laura E Riley
- Weill Cornell Medical Center Department of Obstetrics and Gynecology, New York, NY, USA
| | - Joseph Ngonzi
- Mbarara University of Science and Technology Department of Obstetrics and Gynaecology, P.O. Box 1410, Mbarara, Uganda
| | - Lisa M Bebell
- Massachusetts General Hospital Center for Global Health, Suite 722, 125 Nashua St, Boston, MA, 02114, USA.,Massachusetts General Hospital Division of Infectious Diseases and Medical Practice Evaluation Center, 55 Fruit St and 100 Cambridge St, Boston, MA, 02114, USA
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Tappis H, Elaraby S, Elnakib S, AlShawafi NAA, BaSaleem H, Al-Gawfi IAS, Othman F, Shafique F, Al-Kubati E, Rafique N, Spiegel P. Reproductive, maternal, newborn and child health service delivery during conflict in Yemen: a case study. Confl Health 2020; 14:30. [PMID: 32514295 PMCID: PMC7254736 DOI: 10.1186/s13031-020-00269-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 03/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Armed conflict, food insecurity, epidemic cholera, economic decline and deterioration of essential public services present overwhelming challenges to population health and well-being in Yemen. Although the majority of the population is in need of humanitarian assistance and civil servants in many areas have not received salaries since 2016, many healthcare providers continue to work, and families continue to need and seek care. METHODS This case study examines how reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH+N) services have been delivered since 2015, and identifies factors influencing implementation of these services in three governorates of Yemen. Content analysis methods were used to analyze publicly available documents and datasets published since 2000 as well as 94 semi-structured individual and group interviews conducted with government officials, humanitarian agency staff and facility-based healthcare providers and six focus group discussions conducted with community health midwives and volunteers in September-October 2018. RESULTS Humanitarian response efforts focus on maintaining basic services at functioning facilities, and deploying mobile clinics, outreach teams and community health volunteer networks to address urgent needs where access is possible. Attention to specific aspects of RMNCAH+N varies slightly by location, with differences driven by priorities of government authorities, levels of violence, humanitarian access and availability of qualified human resources. Health services for women and children are generally considered to be a priority; however, cholera control and treatment of acute malnutrition are given precedence over other services along the continuum of care. Although health workers display notable resilience working in difficult conditions, challenges resulting from insecurity, limited functionality of health facilities, and challenges in importation and distribution of supplies limit the availability and quality of services. CONCLUSIONS Challenges to providing quality RMNCAH+N services in Yemen are formidable, given the nature and scale of humanitarian needs, lack of access due to insecurity, politicization of aid, weak health system capacity, costs of care seeking, and an ongoing cholera epidemic. Greater attention to availability, quality and coordination of RMNCAH services, coupled with investments in health workforce development and supply management are needed to maintain access to life-saving services and mitigate longer term impacts on maternal and child health and development. Lessons learned from Yemen on how to address ongoing primary health care needs during massive epidemics in conflict settings, particularly for women and children, will be important to support other countries faced with similar crises in the future.
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Affiliation(s)
- Hannah Tappis
- Center for Humanitarian Health, Johns Hopkins Center for Humanitarian Health, Baltimore, MD USA
| | - Sarah Elaraby
- Center for Humanitarian Health, Johns Hopkins Center for Humanitarian Health, Baltimore, MD USA
| | - Shatha Elnakib
- Center for Humanitarian Health, Johns Hopkins Center for Humanitarian Health, Baltimore, MD USA
| | | | | | | | | | | | | | | | - Paul Spiegel
- Center for Humanitarian Health, Johns Hopkins Center for Humanitarian Health, Baltimore, MD USA
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Young MF, Oaks BM, Tandon S, Martorell R, Dewey KG, Wendt AS. Maternal hemoglobin concentrations across pregnancy and maternal and child health: a systematic review and meta-analysis. Ann N Y Acad Sci 2019; 1450:47-68. [PMID: 30994929 PMCID: PMC6767572 DOI: 10.1111/nyas.14093] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/05/2019] [Accepted: 03/19/2019] [Indexed: 12/14/2022]
Abstract
Maternal anemia is a well‐recognized global health problem; however, there remain questions on specific hemoglobin (Hb) thresholds that predict health risk or protection for mother and child. We conducted a systematic review and meta‐analysis to examine the associations of maternal Hb concentrations with a range of maternal and infant health outcomes, accounting for the timing of measurement (preconception, and first, second, and third trimesters), etiology of anemia, and cutoff category. The systematic review included 272 studies and the meta‐analysis included 95 studies. Low maternal Hb (<110 g/L) was associated with poor birth outcomes (low birth weight, preterm birth, small‐for‐gestational‐age (SGA), stillbirth, and perinatal and neonatal mortality) and adverse maternal outcomes (postpartum hemorrhage, preeclampsia, and blood transfusion). High maternal Hb (>130 g/L) was associated with increased odds of SGA, stillbirth, preeclampsia, and gestational diabetes. Relationships varied by the timing of measurement and cutoff category (stronger associations with lower cutoffs); limited data were available on anemia etiology. There were insufficient data for other maternal outcomes and long‐term child health outcomes. Current data are insufficient for determining if revisions to current Hb cutoffs are required. Pooled high‐quality individual‐level data analyses, as well as prospective cohort studies, would be valuable to inform the reevaluation of Hb cutoffs.
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Affiliation(s)
- Melissa F Young
- Hubert Department of Global Health, Emory University, Atlanta, Georgia
| | - Brietta M Oaks
- Department of Nutrition and Food Sciences, University of Rhode Island, Kingston, Rhode Island
| | - Sonia Tandon
- Hubert Department of Global Health, Emory University, Atlanta, Georgia
| | | | - Kathryn G Dewey
- Department of Nutrition, University of California, Davis, Davis, California
| | - Amanda S Wendt
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
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