Professional Documents
Culture Documents
of Multiple
Rib Fractures*
, ,
B. Sc. of multiple mask
Hon.;
M.Med.
We
patients
studied
the treatment
rib fractures
in NIC,
(24/33),
respectively.
Infections
caused
the
difference
in
comparing two
ventilatory with who were randomly (1) a CPAP (n 36); ventilation with
nonventilatory methods in 69 allocated to one ofthe following combined with regional and meoutcome days intubation 33). Clinical
treatments:
complications, primarily pneumonias, which occurred in 14 percent (5/36) of the group with CPAP but in 48 percent (16/33) of the intubated group. We conclude that treatment with shorten through intubation a CPA? and and mask simplify mechanical combined treatment infection with rate, regional when and (Chest NIC
score
=
in these
as follows:
(p
=
mean
of treatment,
4.5 2.3
a decreased
0M003);
CPAP and 7.3 3.7 days for the intubated mean number of days spent in intensive respectively 8.4 7. 1 days and patients and 73 percent
ventilation,
this treatment
in patients
similar
to our sample.
care, 5.32.9 days and 9.54.4 days, (p = <0.0001); mean period ofhospitalization, and 14.6 8.6 days, respectively (p 0.0019); developing complications: 28 percent (10/36)
nonpenetrating
injury
to the
chest;
ISS
T
four the
he treatment
undergone decades 1930s by
0
of multiple
radical and changes is still stabilization sandbags, external utilization hooks,
rib evolving. of of
has to until
the
risks
invoived
05,06
with
intubatioon
and
mechanical not
ventilation.
Pain
sent
relief
prooblems,
the the
was
and
due
pretoo
in a
achieved devices
systemically desired patient respiratory temic analgesia of pain blocks means nerve in breathing
is ooften however, depression Therefore, by local are feasibility they oor lacked were the the analgesia of multiple mechanical
was
patients drive
a be
such radically
as wires,
screws,
fashionable
the stabilization
over
the
next
20 years.
During
the
1950s dein-
different
concept
of internal
pneumatic
veloped.23
tubation
The have
ventilation
Previous
ventilatory
The
chest
ill
evoolution
effects wall
gas
the
injury
understanding
directed ofthe the underlying and has since
of the
attentio)n king
NIC,
ioolo)glc
of NIC
retrospective,05 or randoomization
o)nly
too the
exchange
disturbances
co)mplicatio)ns becoome
treatment
randomized CPAP fractures, lation with
CPAP
04,
05.22
We
trial with
therefore
too compare regioonal and
coonducted
use too the rib ventiin I)atietlts with less ventilatioun. the coompli-
a
of a
as
the
ARDS.4#{176}#{176} ventilatioun
Mechanical
cepted
and of this
as
foorm
flail chests; invasive
oof treatment
however, form
for
with
multiple
the
rib
widespread
I)arootrauma,
fractures
of treatment,
t2
complications
that
respiratory
sepsis,
treatment cause
tracheal
Recently, modes CPAP
stenoosis
there treatment, a tightly
O)f
became
has such fitting
evident.
been a return as ooptimal face mask too mooninvasive pain relief and the too increase
catio)ns
via
ANI)
FRC.13.t4
principle
*From
Manuscript
The
Respiratory
use
of CPAP
pneumatic
Intensive Hospital,
Juoly 20;
via a mask
stabilizatioon
Care Cape
Unit,
maintains
but
(of internal 2.
the
avoids
Pb;ulation Between
sequentially
ofinternal
the Tygenheng
received
Janutarv ICU
randomized
1988 with
1989, nil)
to) either
to)
Department
Medicine,
Town,
accepted
Soouith Africa.
Octuher
CPAP
revision
regional
analgesia
inttohatioon
and
CHEST
I 97
I 4 I
APRIL
1990
943
Infourmed the
coonsent Patients
was with
The Faculty
study
had in the
been stiody
cm
H2O;
greaten greater
of level
than than
6.5 35/mm;
kPa
mm
less
hg)
and
rising;
ouf Medicine
(3) respiratory
than
10 mI/kg; dyspnea
preexisting
ennoulled tahuolation:
and (5)
prior to
oof coonsciousness.
Variables
defined according
(1) dyspnea
classification;
baseline
(2)
pulmoonary
disease
any
clinical
symnptomns signs
docupen gnoouops
(4)
Incluosion (all oof the folloowimig): Moore than three rib fractures Admissioon too houspital within 24 hoours after injury Insufficient coough mechanism dume to) pain or preexisting pnlmnonany disease (our both) Excluision (any (of the fullousuing): Depressed level oof counscioousness Important facial injuries (excluding tolenance ouf CPAP mask) Fracttores too l)ase ouf skull Severe luong contusion (alveolar infiltrate umidenlying rib fractuores on admissioun chest x-ray film and PaO2-(8 kPa oun 40 percent (oxygen mask)
Need for initial tipper laparotomy our other majoun surgery
mented
disease;
signs
(3)
as well
smooker
-
as nadiougraphic cumnnent
less
puolmounany
smoking
six
day hong
or daily conttosion
pipe
smouking,
=
ex-smo)kens
mounths prior
smouking
too admission;
to the
trauma (diagnoosed bronchitis
fractuored
-
organs
acute
clinically,
=
s(unoognaplucally,
laparootomy);
punolent with
pulmoonary high-poower
infiltrate, field
=
(on both)
with
microorganisms
for
regional
aoialgesia
(bleeding
ten-
with
new puilmiinany infiltrate (not explained at least two oof the folIoowing: purtmlent (>38.3#{176}C [100.9#{176}F]), raised mm and 80 percent (or booth); white neuotr(Ophils), (8) septicemia (b) fever
[96.1#{176}F],
oxount
PTVCCdUWS
and (all
positive (>38.3#{176}C
and Measunments
to the ICU physical
chemistry,
sputum , all patients previoous examination; full levels blouod on cell rooom received coondition count, air and the following kings; analx-ray percent best underrelief was with by
(of following)
stain
On woorktop:
admissioon detailed
ouf infection,
(<35.6#{176}C
history
of injury; blood
regarding
[100.9#{176}F],
rectal)
rectal),
circumstances
and laboratory
tachycardia greaten least altered level at least (>2 one one than
(d) four an
bboood
cell and
arterial
was
amid FVC
o)f
mentation
to patients (ooutptot
ouliguria
<30
ml or <0.5
mi/kg
fon
of a luombar
Statistical
of physioloogic We estimated
in oorder 95 percent
soltmtioun.
epidural catheter
vooltome the
sample
dtoration
size
at 30 patients
ouf the of mechanical ICU
per
stay
gnotmp
at the
of segments
imisertion
a oomme-dav
neductioumu
the ml.
fnom needs,
rib by
1.5
line
ventilati(on
(OWn previous
The pain
0 (no with paimi) The the nerve
level ntomloer
was
oun a straight
was
likely
to be
seven
to) eight
days
according between
too 10 (maximum muinimuom blocks per nb CPAP with douse) fractures mask
recoords.
analgesia. imitercoostal
depended
The criteria
(of treatment
used
were
twoo methods
or
of treatment
(CPAP
, duiratioon were
mask
mechanical distributed.
differences
ventilatioon),
and
duration tests
X test
of hoospitalizatkon,
(maximum,
NIC, The
9(X) C,
150 ing
presence statistical
and
oofcomplicatiouns. were
Ion categorical
mion-mally f-test
Significant
were and
The
variables
Studento
four countintoous
assigned intubated
were In histor
dyspnea
level.
stratified according to) smoking
( (
The
Bird) amid received systemic pain 1 mmig/kg/day) and sedatioon with midazolam
1.5 mg/kg/day)
F1o2 amid adequoate level
CPAP
ouf preexisting
Analysis
disease
between
and the by
grade analysis
of of
(woo grooups
as mieeded.
ouf CPAP oxvgenatioun
They
were
were
adjusted (arterial
kept
for
these
pootential
confotonders
performed
both
grouuips
variance.
maiimtaimm
sattonatioun
kPa
[45 mmii hgj). daily and were for both until (60 mm 30/mm, stability discharged of gas levels
blooood
RESU Of group chest the with x-ray by 70 patients CPAP films had showed entered too be
LTS
physiootherapy and than ofless rate (4) Patients arterial blood films)
ventilating
mouboilized
patient
as early
the
one
in the serial
excluded
because
(1) a PaO2
(2) a nespiratory 15 mI/kg, and after and
fewer
fractures.
oon 40 Ircermt FVC the oof more pulse ICU The daily
bacteriodogic
Finally,
36 patients
endotracheal
were
treated
by CPAP
mechanical
mask,
and
venti-
hemoudynamic were
(noormal
treatment. analyzed
co)tttit,
rate pain
bloood 24 FVC,
pressttre).
33
intubation
within
hotons
discoontinuoation
(white
groups were comparable in respect to sex, of dyspnea prior to the injury, preexisting disease, smoking habits, the FVC before
treatment, mask on of and admission rib fractures, the PaO2 (Table the with 1). proportions of 40 percent
were
every
third
day
for
indicated
and
clinical oofthe
oxygen
cootorse
Criteria
mask 8 kPa
regimen (60 mm
were big)
oone
or moe
foolloowing:
(1) PaO2
number
on 40 percent
and CPAP
of 10
patients
with
hemothorax
Treatment
(pneumothorax),
of Multiple
Rib Fractures
pulmonary
(Bo!Iigeo
944
Van Eeden)
Table
1 -Clinical
Characteristics
on Admission
of 69
Table
2-Comparison
Data
ofOutcome
(PAP
36
in 69 Patients
lmmtuoboautiomm
3.3
with
io
.
NIC
Patients
1)ata No. Meami I)vspnea
disease Smnookers
with
CPAP
36
NIC
!Ilausk
Mask
Iiotuoboatomi 3.3 22
p \tlute* No.
ufpatieimts
. . .
I)uvs
Days
ouftreatumetmt
iim intemmsive immimospital caro-
4.5
5.3
2.3 7. 1
7.3 9.5
Sex (No.
26
NSf
14.9 NS NSt NSt
2.9
15.7
47.8
I)avs No.
13.4 with
14.6
8
12
6
8
ofpatiemots (.lonmplicati0001st
10
24
Pno.existitog I)tillmio)rmarY
*t_test 28 22 NSt
(moicaim
SD).
iii Table
FVC/L
PaO with
1.530.63 40
loerco-mit boy mumask
1.480.66
NS
amialvsis
sis.
3.
ooxvgeim
kPa
mon
15.74.2
Jig
fractures (pioeuomnoothoorax)
14.23.4
106.525.5
6.92.3 i7
NS
. .
117.831.5
6.92.2 16
ouf clinical
0)11
ooutc(ome
were intubated
as
No.
oufnib
NS NSt
specific
and 7.3
treatment,
3.7 ito
4.5 2.3
I Ienooutlmoorax
Ptolnioomiarv No. oofputietits additiounal ISS *NS Score not
analysis.
6 15 2 11.53.6
5 14 7 14.35.9
NSf NSt
four the
Blumit abodoumminal
NSf
0.021t
14.6
significamit.
0 . O() 19); amid 28 Percent (10/36) Details of the are H2O One lung and lug. listed too the and Patient collapse; vetitilated Tivoo deaths mnati (p>O.05).
iii
1)atieiits and 73
develiuping coOtill)l ications, 1)ercelit (24133) (p = O.()02). during the CPAP grouup
witil
tx2
t-test
complications
in
perioud
in the
(mneamm SD).
ICU
delivered
dl
Table
group
3. The
receiving
average
level
ouf CPAP
5.4 2.3 1.3 cm a
lnjuony
severity
store.
was
6.6
to) the
tile
intul)ated
group
was
contusion,
additional
fractures
o)utside
the
trauma
rib did
cage not
H2O
( Fig
show groups of different
1), and,
any either. 11.53.6
finally,
significant When amid
blunt
using
al)doominal
the (p ISS,t which 0.02
CPAP
differences
14.35.9, level
between
we
the
found significantly
two)
values
ni ttltifactorial
(aicoohool had tou i)e successful intui)ated o)i)strtictive and failure a 70-vear-ould autopsy suti)dtlral and befoore
were 12).
at a 5 percent
74-year-old
chroonic failure,
niounary
disease
died died a
who
suddenly
had
acute
i)roonchitis
CPAP
n:36
MASK
2110
INTUBATION
n::33
oof injury
wouniato revealed
in cardiac
contusiom
Table
3-Complications
in 69
Patients
with
intitloatiomi
N1C
J) \altio
. .
3.
No.
(PAP
36
Niaslo
33 1 0 2 1 1 2 i6 3 1
0
1_
104
o
I
Ii
Barotmaumna 2 i
0
NS NS NS NS NS NS <0.(X)5 NS NS
ol
I mifectiomm
Acute
hromicliitist
2 0
0
5 0 1
hiemimatonia I
Septicetmmiat
01
Fictisu:
nomimiloer amool l(ucaliy.atunm offractuoro-s iii each treatt-o.l gnoumj). Meamm mimitmmloer of rib fractuorosin lootlm grouop with (PAP muask aomd intmohated group was 6.9 (247/36 amid 228/33, respectively).
1 . liotal
failmore
1
0 significoimt.
1
2
NS NS NS
NS,
un(ier
not
nmethoools.
CHEST
I 97
I 4 I APRIL,
1990
945
without
signs had
oof the
brain
apparent
the difference when co)mMORTALOTY
two
significant ooutcome
5 percent
paring
with (p>O.O5),
smookers
and without
and
nonsmokers
preexisting greater than 23
(p>O.O5),
pulmonary or equal were
patients
disease to grade given 2 an after (Voltamethods of pain of the
FlcuRE
-
or dyspnea
and
dyspnea
In the group
less
than
with did
(p>O.OS).
CPAP, no)t need injection ward. Both the patients
epidural
and an ren) one initial
catheter,
patient intramuscular emergency good by pain
12 received
intercostal
further pain analgesic the
nerve
relief
blocks,
10 20 30 40 50 70 years 60
of diclofenac amount
INJURY 49
years
SEVERITY
SCORE
in the
OO50-69years
provided experienced
relief,
reducing after
cooughing
application
drug by an average oof 50 percent as assessed by the patient on the linear scale; however, the twoo methoods were no)t used eoually. Intercostal blocks were given preferentially too patients with fewer fractures on oone side oof the chest only. On the average, the epiditral catheters to) seven was 4.4,
was 0.78 Both
2. Injury severity scon& Mean scores for grooump with CPAP (14.3) intersect at almoust identical of age.
four
three
different
age
groups.
severe
grcoups Two
than
and patients
the
did
chest
trauma
the intutbated
in all
duration group
patients
underwent one bladder
of both
early rup-
of treatment.
were left in place for three days (range, two days), the average to)tal nulilber oof injectioons and the average t(otal doose o)f buprenoorphine
mg treated per groups the the absence group with patient. received Noo complications the same intensity were of
laparotoomies
rupture;
ture),
Figure
with
2, 11.5
an uneveniful
it is apparent for the group
postooperative
that with although CPAP and
course.
the 14.3 ISS
Froum
score for the
observed. chest
sedatioon patients
was
physiotherapy,
and in
but
due
ofan CPAP
to
the
could
lack
be
of
initial
the
intitbated regardless
(Of
grooup, of age.
as of than The age that deaths of
both The
both or
endotracheal
tithe, mobilized
70 (Fig
earlier and participated moore actively with otherapist than the patients in the intutbated
DiscUSSION
the
physi-
greater
of younger were
group.
mode
poor a randomized by CPAP mask coontrolled combined and intubation
groups,
oof treatment;
indicatoor
however,
the and condition a detailed grade 0 and
the
ISS was
was
morbidity
a relatively chest.
particular prior evidence to the of of degree
considerable
In this trial with multiple demonstrate be much Previous fractures patient, less severe intubatiom
study,
whose
from to and between the gas criteria
major
age the
site
of injury
sex, we of the history
the
too endotracheal
mechanical
ventilatioun
fractures that
shorter
with
in NIC.
PEEP
In our by CPAP fewer that NIC
in patients
sample, mask we prooved
with
could than rib of the had study,
obtained
4 (NYHA),
preexisting
We ratoory used
pulmonary
FVC impairment for were length and exchange.
disease,
as a measurement the Pa02
and
as an outcomes of the
smoking
of initial indicator between different FRC; and stay the
status.
respiof the the treatin the rate of
mechanical
shoowed be managed the trauma.
ventilatioon.
without no)nventilated With a randomized intubatkon
pulmo)nary Our twoo ments ICU; highly that groups (specific to)tal
in general
treatment
too increase
we oobtained
matched The trauma although reached nature important, 946 higher (seven on of this as for all
two
treated
for the
groups
bitt for intubated
which
the ISS
were
(Table can group CPAP), not
well
1). be
oof hoospitalizatioon)
parameters
connplications
significant treatment
in each
difference by CPAP
group.
mask
The
combined
results
with
showed
indicating regional
ISS score
for by greater
direct score. the
accoounted
incidence
group 155 compariso)n in the
cfblunt
with was due this
abdomiinal
which different, quadratic was was not less
vs twoo in the
co)nsiderably
were however, difficult, Dittmann
and
as
significance
with used
other
studies score;
Clinically, blunt
a severity
abdominal
groups
Treatment
whose
of Multiple
severity
Rib Fractures
of chest
(Bo!!igeo
trauma
Van Eeden)
was
the days (Table by days) but study). studies
comparable
ICU, for Trinkle compared not for Despite mentitoned, the with the 4.5
to) our
days length with ventilated tootal well
population.
foor the group, were
Their
nonventilated similar
periods
in
and 1)rouxide
outher
aggressive
Particil)atioulo.
2). The
o)f hospitalizatioll noollVelltilated that difficulties oofoour in can grouttp (31 .3 grooup commoon of NIC
This,
obtaitoed usimig useol
in FRC analgesia
1)aili
satisfactoorv
primarily
institution
the
effective needed
nlajority
in the oonly
ouf douctoors
Buprenourphiole epidural oune too twou 1)ain
techni(Iue.
dramatically.
view during ofour the period co)mplications in the
cifpneumoothorax
sema,
however,
lung
the frequent in
collapse,
number in the 48 (5/36
and
intitbated
bronchitis
adeoiuate depression noot oi)served. in patients chest shooitld regional This and
Clinically
subcutaneous
for both
infectioons was with grooup fistula, oonly occurred group.
groups;
much
NIC
xshoose
group, in the
pneumonia compared with and CPAP septiin the Tougether were the
injury
is
the
percent
patients)
patients),
previoously
ofchuice
mentiooned
treatment
mechanically
additioomial
mnoorbidity,
pneumoonias,
complications
hoospitalizatioon draniatically
ACKN()WIEDG!1ENTS: Barnes four reviewimmg
amoalvsis, amiol E.
factoors group.
the
and
the
longer
period well
due
findings
of complications in an many incidence
high et
of 84
Bademmhoorst
sVo thank Prof. H. Stewart amm(i Mrs. J. article. Prof. D. Kotzo four statistical atid B. Karg four comimpilimig time niammu-
and
to mechanical
02.04,15
script.
ventilation
al#{176} even percent Our
reported
reported (16/19 overall patients) rate
RE FE RE N( ES
1 Fimidlav 38:489 2 Jensen
injuonies
pneumoonia
RT NK.
ofthe
Fractures Recoovery
chest.
of the
scapula
amid ribs.
fumictioon 22:319
Aooi
in their
ventilated of 28
Suing
1937;
of complications
(10/
after
crnshimmg
(24/33) of zero
in the trial in of in the moor-
3 Avery
EE,
D\V. DB,
Critically harris
chests.
Thoorac
4 Ashhauogh poositive syndrome. 5 Blair 6 Garzon chest 7 Craven amid flail bluommt chest AA,
in aduolt
of complications
J Thoorac
C,
Candiovasc Davis
nonventilatory
Trauma 1968;
respectively.
Complicanegligible
B, Kanlson Sting
se were result
L, \so.d
(nasal
tinuation The treated nary possible
pressure
of the stratified groups disease,
sores)
treatment. analysis exchtded and
not
Stoo-kmmmamimm U
JNI. Pioltoiommmarv
pulmo-
109:508-10
commototsiommi. Am
degree
injury
with too severe
as
Surg
confounders.
J,
NT,
Jamimos 0,
Quail
A.
Niammagenmo-tot
of
pulmonary be treated
the by mask
failure. Troutmiiemit
Br
Aimaostim
without
intiml)atio)n
outcome as a result in ofthe
and
mechanical
with
PC.
of a fluil
32:475-79
(ilmlAgilOOSa
I . P.uudin,unmas
ro-spirotonv
imofec-tiomms
1967;
mrm-ciianical
J I I vg
imm t-hest
(( oiimio)
irmjmtrv.
nonventilatory
regio)nal the
analgesia,
of which
J,
JK,
Janmes
0, Quail
JA,
A. Relief
Trami
Br KV
have
The problem
been
CPAP,
shown
by in NIC,
to be beneficial
FRC, is contusion
in NIC
aims ofthe
on their
at the
town.
majoor
1973;
45:1136-38
Richandsomom
14 Tnmokle
mechaimical
JL,
Suorg
Grover
of
Fl.,
chiost
Ammo
il#{246}lstnom 15 Shackfiond
FNI(;, SR.
et Smnith
al.
Anti
Niamoagenient
Tlmorac
flail CL,
svithoouit 11W.
underlying
ventilatiourm.
1975;
19:3.55-63 Virgilio
lung,
with
abnormalities
in gas
exchange.#{176} Epidural
I)E,
Zarimms
CK,
Rice
CHEST
I 97
I 4 I APRIL,
1990
947
The
16 Covelli
muanagement
ouf flail
chest:
a coomparisoumi
of ventilatory
132:759-63
and
25
GA,
U, 1985;
liv
DR.
Comparisom
oof lumbar
nom-ventilatoony
treatment.
Am
Sung
1976;
thonacic Anesth
DB.
four relief
analgesia
of postthoracotomy
using epiditral meth-
liD,
airway
\Veled
pnessumre
BJ, Beckman
administered
analgesia.
JF.
Efficacy
mask.
po)sitive 17 18 19
20
by face
Philadelphia:
Welch adoune:
Founimm:
postoperative
81: 147-50 Broniage 1978 Bnomage PR, Camnporesi analgesia. F. ML, ofpain.
foollowing
administratioon
the
lumbar C,
route MacEvilly
for
thonacic M.
pain
PR.
Epidural
WB
Satonders,
relief. 27
Mtmrphv
Anaesthesia
1981;
DF,
Cahill
for
J,
EM, Olshwang
Chestmitot Analg D,
Lamicet
D.
Epiduiral 59:473-80
narcotics
I)5to0Perative
ofanalgesic
l)aim0 relief.
soolutioomis
Atiesth
Analg
foor poostoqwrutive
Anesth
1980; Davidsoon
1979;
Behan
Cotoaclmer D\V
M,
Magora
imm treatnio-mmt ID,
JT PD,
Epidural hleaviside
PR. Spread
site
in the
epidttral
space 1962;
S Afr
m110)rphimlo-
1:527-28
of actiomi:
amid
a statistical
spimmal
stutd
Br
an
Amiaesth
Paes
amialgesi.u
Jao-ouhsemm L,
thooracic
Phillips sumrger
JI).
Eioiobuiral
Ammaesthesia
extrastutd Br
K.
Epidutral
amiaesthesia:
onervies:
1983;
21 (;nmfliths olural
38:546-51
DPC, amialgesia Diamnoommd foHouwing A\ Camneroon surgery: Postouperative a feasibility thooracic
JF,
chest.
Albeit
B,
Bardiom
PC.
Vemitilationin noon-
Aimaesth
TP,
GJ,
Mets
CA, Balk
Gnouop: in the a
treatmnent
of mnultiplo
Management
RA.
The
coomitroolled
.
methylprednisoolone
Med
i regimen
(of epiduorul
huopivacaine
lmitensive
12:311-14
SP, ONeill
a methood
B, Iladdoun
for describing care. emergency
W Long
patients Trauma
24
Efron Biometrika
Forcimig 1971;
a seouiential 58:403-17
experiment
balanced.
with 1974;
evaluoating
East Coast
The
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in Electrocardiography
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heart
Country
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workshop
For (813:894-079(0).
May
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Introduction
This two-day coourse
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Medical
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Treatment
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