Article

Emergency airway management in geriatric and younger patients: analysis of a multicenter prospective observational study

Emergency airway management in geriatric and younger patients: analysis of a multicenter prospective

observational study?,??,???,?,??

Taichi Imamura MD a,?, Calvin A. Brown III MD b, Hisashi Ofuchi MD a, Hiroshi Yamagami MD a, Joel Branch MD a, Yusuke Hagiwara MD, MPH c,

David F.M. Brown MD d, Kohei Hasegawa MD b,d

on behalf of the Japanese Emergency Medicine Research Alliance Investigators

aDepartments of Emergency Medicine, Shonan Kamakura General Hospital, Okamoto 13701, Kamakura,

Kanagawa 2478533, Japan

bDepartments of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115, USA

cDepartment of Emergency Medicine, Tokyo Metropolitan Children’s Medical Center, Mushashidai 2-8-29, Fuchu,

Tokyo 1838561, Japan

dDepartments of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street Boston, Massachusetts 02114, USA

Received 21 June 2012; revised 29 June 2012; accepted 5 July 2012

Abstract

Objectives: There is little information on Geriatric EMergency airway management. We sought to describe intubation practices and outcomes for emergency department (ED) geriatric and younger patients in Japan.

Method: We formed the Japanese Emergency Airway Network, a consortium of 11 medical centers, and prospectively collected data on ED intubations between 2010 and 2011. All patients 18 years or older who underwent emergent airway management were included in our study. Patients were divided to into 2 groups: 18 to 64-year olds and 65 years or older. We present descriptive data as proportions with 95% confidence intervals (CI).

Results: The database recorded 3277 patients (capture rate 96%), and 3178 met the inclusion criteria. Of 3178 patients, 1844 (58%) were 65 years or older, 1334 (42%) were 18 to 64 years old, 809 (25%) were 80 years or older, and 407 (50%) of them were in the state of cardiac arrest. The geriatric group, compared to the younger group, had a higher success rate on the initial attempt (71% vs 64%; difference

? Role of funding source: This study was supported by a grant for emergency medicine research from Harvard Affiliated Emergency Medicine Residency and a grant from St. Luke’s Life Science Institute. The study sponsors have no involvement in the study design; in the collection, analysis or interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication.

?? Presentation information: Abstract was presented at the Society of Academic Emergency Medicine Annual Meeting, Chicago, IL, May 2012.

??? Conftict of interest statement: There are no confticts of interest to declare.

? Never been published.

?? Author Contributions: KH and DFMB conceived the study. KH obtained research funding. KH, YH, and CAB supervised the conduct of the trial and

data collection. YH managed the data, including quality control. YH provided statistical advice on study design and analyzed the data. KH chaired the data

oversight committee. TI drafted the manuscript, and all authors contributed substantially to its revision. TI takes responsibility for the paper as a whole.

* Corresponding author. Tel.: +81 467 46 1717.

E-mail address: [email protected] (T. Imamura).

0735-6757/$ – see front matter (C) 2013 http://dx.doi.org/10.1016/j.ajem.2012.07.008

7%; 95% CI 4%-10%;) and in 2 attempts (90% vs 88%; difference 3%; 95% CI 1%-5%) or less. There was no significant difference in the Adverse event rates by age group (difference 0%; 95% CI -2% to 3%). Conclusion: In our multicenter study involving a large Geriatric population, we found that Geriatric patients were intubated with a higher success rate, compared to younger patients. These data provide implications

for the geriatric ED airway practice that may lead to better patient-centered emergency care.

(C) 2013

Introduction

Background

Japan has the highest proportion of elderly citizens of any developed country. Japanese Census data estimates that 35 million (28%) of the overall population will be aged 65 or older by the year 2020 [1]. The United States is expected to age more gradually because the birth rate remains higher compared with other developed countries. Nevertheless, the elderly population in the United States, 65 years or older, will comprise 55 million (16%) of the nation’s population in 2020 and a projected 72 million (19%) in 2030 [2,3].

emergency intubation is a life-saving procedure. Aging brings a number of physiologic changes that affect respiratory and Cardiovascular function and which may complicate airway management. There are several reports about drug use with intubation for geriatric patients, but most of them are perioperative studies within single institutions [4-10]. To our knowledge, there are no multicenter prospective studies investigating emergency airway man- agement for geriatric patients.

Objectives

We sought to characterize ED airway management for geriatric patients in Japan using a large multi-center registry. Specifically, we characterized emergency intubation in- dications, methods used for intubation, devices and medica- tion regimens used, Operator characteristics, success rates, and adverse event rates in younger versus geriatric patients.

Methods

Study design and setting

JEAN (Japanese Emergency Airway Network) Registry is a prospective observational multicenter data registry, with all data collection planned a priori. This is a secondary analysis of the ongoing prospective multicenter registry which interim analysis was published previously [11].

The study setting, methods of measurement, and measured variables have been reported previously[11]. In summary, JEAN was a consortium of 11 academic and community medical centers from different Geographic regions across Japan. All 11 EDs were staffed by emergency

attending physicians, and 10 had affiliations with emergency medicine residency training programs. The participating institutions were certified as Level I (n=9) or Level II equivalent (n=2) trauma centers. They had a median ED census of 30,000 patient visits per year (range, 9000-42000). The institutional review board of each participating center approved the protocol with waiver of informed consent before data collection.

Selection of participants

All patients, 18 years or older, who presented to one of these institutions and underwent emergency endotracheal intubation were eligible for inclusion in this study.

Data collection and processing

Case ascertainment was passive, relying on self-reporting by intubating physicians on duty in the ED. We monitored compliance continuously. To verify that all intubations performed in the ED during the study period were captured in our database, the professional billing codes were cross- referenced with the intubation data forms. When a patient who underwent an intubation but for whom we had received no data collection form was identified, the intubating physician was interviewed by one of the investigators to fill out the data form. After each intubation, the intubating physician completed a standardized form that included the patient’s age, sex, weight, indication for intubation, methods of intubation, names and dosages of all medications used to facilitate intubation, operator level of training and specialty, number of attempts, success or failure, and adverse events. Adverse event variables were recorded using a pre-specified list, with free comments if necessary.

During the development phase, key definitions were agreed on. “Weight” was estimated by appearance, instead of actual measurement, although in some cases, the weight of the patient was provided by family members. We defined a “method” as a single set of medications or devices, such as rapid sequence intubation with a Macintosh laryngoscope. An oral “attempt” was defined as a single insertion of the laryngoscope (or other device) past the teeth. For nasal intubations, an attempt was defined as a single insertion of an endotracheal tube past the turbinates. An attempt was successful if it resulted in an endotracheal tube being placed through the vocal cords. Each encounter could have one or more methods, and each method could have one or more

attempts. This allowed us to track different methods in sequence. “Adverse events” were a priori defined as airway management-associated events with two categories: major and minor adverse events. A major adverse event was defined as a cardiac arrest, hypotension, hypoxemia, dysrhythmia, regurgitation, or Esophageal intubation with delayed recognition [12]. Cardiac arrest included asystole, bradycardia, or dysrhythmia with nonmeasurable blood pressure and cardiopulmonary resuscitation required during or after intubation. Hypotension was defined as a systolic blood pressure less than 90 mm Hg. Hypoxemia was defined as pulse oximetry saturation b90%. Regurgitation was defined as gastric contents that required suction removal during laryngoscopy in a previously clear airway. Esopha- geal intubation was defined as misplacement of the tracheal tube in the upper esophagus or hypopharynx with a lapse of time and clinical deterioration (such as desaturation) before the removal of the misplaced tube [13]. Minor adverse events include main-stem bronchial intubation, dental or lip trauma, airway trauma, and allergic reaction. We described each encounter by “method” and number of “attempts.”

Primary data analysis

For the purposes of this analysis, the patients were divided into two groups: 18 to 64 years old and 65 years or older. We report information about the distribution of patient charac- teristics, methods used to intubate including devices and medication regimens, intubating physician characteristics, success rates, and adverse event rates. We analyzed the compiled data with simple descriptive statistics. Continuous

Table 1 Baseline characteristics of 3178 patients who underwent emergent airway management a

data are presented as means and SD or medians and IQRs as appropriate based on distribution of the data. Categorical data are reported as proportions and 95% CIs. We performed all analyses using the statistical package SPSS (Version 17.0; SPSS, Chicago, IL).

Results

During the 22-month period, there were 3417 subjects requiring emergency airway management. Among these, the database recorded 3277 intubations (capture rate 96%). Ninety-nine pediatric patients excluded from the study. The remaining 3178 patients were analyzed in the study. Of the 3178 patients, 1844 (58%) patients were 65 years or older, and 1334 (42%) patients were aged between 18 to 64 years old.

Baseline characteristics of patients and primary indications

The characteristics of patient baseline data are shown in Table 1. Age group and primary indication appear in Fig. 1. The overall mean age was 65 years old (range, 18-109). Of the 3178 patients, one quarter of the cases were 80 years old or above, and nearly half of them were in the state of cardiac arrest. Intubation was performed for Medical emergencies in 83% (n = 2633), and for trauma in 17% (n = 545). Failure of the cardioPulmonary system was the primary indication in geriatric patients, whereas airway protection was more common in younger patients. The proportion of trauma in younger patients was twice as much as in geriatric patients.

Patient characteristics

All patients (N = 3178)

18-64 years old

(n = 1334)

?65 years old (n = 1844)

Difference between groups (95% CI)

Age, mean (SD), y

65 (19)

47 (13)

78 (8)

31 (30.2 to 31.8)

Female sex (%)

1253 (39)

452 (34)

801 (43)

9.6 (6.2 to 13)

Weight (SD), kg

59 (14)

63 (14)

56 (13)

7.5 (6.5 to 8.4)

Primary indication (%)

Medical encounters

2633 (83)

1019 (76)

1614 (88)

11.1 (8.4 to 13.9)

Cardiac arrest

992 (31)

280 (21)

712 (39)

17.6 (14.5 to 20.7)

Altered mental status

819 (26)

474 (36)

345 (19)

16.8 (13.7 to 19.9)

Respiratory failure

449 (14)

142 (11)

307 (17)

6 (3.6 to 8.4)

Shock

271 (9)

80 (6)

191 (10)

4.4 (2.5 to 6.2)

Airway obstruction

72 (2)

22 (2)

50 (3)

1.1 (0.1 to 2.1)

Asthma

13 (0)

8 (1)

5 (0)

0.3 (-0.1 to 0.8)

Other medical

17 (1)

13 (1)

4 (0)

0.8 (0.2 to 1.3)

Trauma encounters

545 (17)

315 (24)

230 (12)

11.1 (8.4 to 13.9)

Traumatic arrest

182 (6)

110 (8)

72 (4)

4.3 (2.6 to 6.1)

Head trauma

152 (5)

88 (7)

64 (3)

3.1 (1.6 to 4.7)

Shock

99 (3)

55 (4)

44 (2)

1.7 (0.5 to 3)

Facial/Neck trauma

47 (1)

24 (2)

23 (1)

0.6 (-0.3 to 1.4)

Burn/inhalation

36 (1)

20 (1)

16 (1)

0.6 (-0.1 to 1.4)

Other trauma

29 (1)

18 (1)

11 (1)

0.8 (0 to 1.5)

a Percentages may not equal 100 due to rounding.

Fig. 1 Primary indication of emergency airway management by age group.

Table 2 Initial ED Airway Management Characteristics in 3178 Study Patients

Initial ED airway management characteristics

ED airway management for the two groups appears in Table 2. Direct laryngoscopy was the major device used in both groups. Surgical cricothyroidotomy was performed on 3 patients in the geriatric group (0.2%) and 8 patients in the younger group (0.6%). The proportion of propofol use was less in the geriatric group whereas benzodiazepines were administered similarly to the younger group. Regardless of type, paralytics were used less commonly in the geriatric group. In the geriatric patients, 15% (280/ 1844; 95% CI 14%-17%) underwent rapid sequence

intubation and 21% (387/1334; 95% CI 19%-23%) under- went orotracheal intubation with sedation but without paralysis on the initial attempt. In the younger patients, 22% (291/1334; 95% CI 20%-24%) underwent rapid

Management

All patients (N = 3178)

18-64 years old

(N = 1334)

?65 (N =

years old 1844)

Difference between groups (95% CI)

Initial method (%)

Oral without medication

1755

(55)

634

(48)

1121

(61)

13.3 (9.8-16.8)

Sedation without paralysis

697

(22)

310

(23)

387

(21)

2.3 (-0.7 to 5.2)

Rapid sequence intubation

571

(18)

291

(22)

280

(15)

6.6 (3.9-9.4)

Paralysis without sedation

117

(4)

74

(6)

43

(2)

3.2 (1.8-4.6)

surgical cricothyrotomy

11

(0)

8

(1)

3

(0)

0.4 (0-0.9)

Nasotracheal intubation

25

(1)

16

(1)

9

(0)

0.7 (0-1.4)

Other a

2

(0)

1

(0)

1

(0)

0 (-0.2 to 0.2)

Initial device (%)

direct laryngoscope

3066

(96)

1275

(96)

1791

(97)

1.5 (0.2-2.9)

Video laryngoscope

57

(2)

27

(2)

30

(2)

0.4 (-0.6 to 1.3)

Bronchoscope

18

(1)

6

(0)

12

(1)

0.2 (-0.3 to 0.7)

Other b

37

(1)

26

(2)

11

(1)

1.4 (0.5-2.2)

Sedative (%)

No sedatives

1957

(62)

753

(56)

1204

(65)

8.8 (5.4-12.3)

Benzodiazepine

663

(21)

294

(22)

369

(20)

2 (-0.8 to 4.9)

Propofol

423

(13)

222

(17)

201

(11)

5.7 (3.3-8.2)

Ketamine

99

(3)

43

(3)

56

(3)

0.2 (-1 to 1.4)

Other c

36

(1)

22

(2)

14

(1)

0.9 (0.1-1.7)

Paralytic (%)

No paralytics

2494

(78)

971

(73)

1523

(83)

9.8 (6.9-12.8)

Rocuronium

457

(14)

249

(19)

208

(11)

7.4 (4.8-9.9)

Vecuronium

153

(5)

79

(6)

74

(4)

1.9 (0.4-3.5)

Succinylcholine

74

(2)

35

(3)

39

(2)

0.5 (-0.6-1.6)

Specialty of first intubator (%)

Transitional year resident d

1294

(41)

507

(38)

787

(43)

4.7 (1.2 to 8.1)

Emergency medicine resident

925

(29)

440

(33)

485

(26)

6.7 (3.5 to 9.9)

Emergency physician

616

(19)

255

(19)

361

(20)

0.5 (-2.3 to 3.2)

other specialties e

343

(11)

132

(10)

211

(11)

1.5 (-0.6 to 3.7)

a Defined as oral intubation using topical anaesthesia, lidocaine, atropin, or paralytics, without sedatives.

b Defined as nasotracheal intubation, light stylet or combination with direct laryngoscope and Gum elastic bougie or video laryngoscope.

c Defined as administration of thiopental, haloperidol, or combination with any of the included sedative categories.

d Defined as postgraduate year 1 and 2.

e Defined as surgery, anaesthesia, paediatrics, cardiology, or internal medicine.

Fig. 2 intubation success rate of the geriatric and younger patients.

sequence intubation and 23% (310/1334; 95% CI 21%- 26%) underwent orotracheal intubation with sedation but without paralysis on the initial attempt.

Success and adverse events

Intubation was ultimately successful in 99.7% (3168/ 3178; 95% CI 99.5%-99.9%) of all encounters. Intubation success rate in first, <=2, and <=3 attempts by age group appears in Fig. 2. Overall, the geriatric group, compared to

the younger group, had a higher success rate on the initial attempt (71% vs 64%; difference 7%; 95% CI 4%-10%) and

in <=2 attempts (90% vs 88%; difference 3%; 95% CI 1%- 5%), but a similar success rate in <=3 attempts (97% vs 96%; difference 1%; 95% CI -1% to 2%). In medical non-cardiac- arrest encounters, geriatric patients had a higher success rate

on the initial attempt (68% vs 62%; difference 6%; 95% CI 2% to 9%). However, the success rate was similar to the both

Table 3 Unadjusted Adverse Event Rates by Age Group

groups in <=2 attempts (88% vs. 86%; difference 1%; 95% CI

-2% to 5%) and <=3 attempts (96% vs 95%; difference 0%;

95% CI – 3% to 4%). In trauma non-cardiac arrest encounters, geriatric patients had a similar success rate on the initial attempt (59% vs. 61%; difference 2%; 95% CI – 9% to 12%), <=2 attempts (87% vs. 86%; difference 1%; 95% CI -6% to 8%) and <=3 attempts (94% vs 95%; difference

1%; 95% CI -4% to 6%).

Table 3 lists intubation-associated adverse events.

Adverse events were identified in 11% of the geriatric patients (202/1844) and 11% of the younger patients (152/ 1334). There was no significant difference in the adverse event rates by age group (difference 0%; 95% CI -2% to 3%), although the number of events may have been too few

to detect a significant difference.

Discussion

The United Nations reported that the total world population is aging [2]. In developed countries, a large number of geriatric patients visit the emergency department, and most of them require an emergency procedure [14]. Aging brings a number of physiologic changes that affect respiratory and cardiovascular function and can lead to complicated airway management in EDs. There are several studies about geriatric airway management; however, most of them are perioperative in their setting and small in size. Given the emergency circumstances of ED airway manage- ment, the anesthesia viewpoint may not be relevant in the ED populations. Furthermore, indications for intubation for geriatric patients and ethical issues are not considered in detail, if at all, by previous studies. Despite the increased number of geriatric patients, the emergency medicine literature, to date, has not addressed this growing issue. To our knowledge, our study is the first attempt to prospectively describe ED intubation for geriatric patients at multiple

Adverse events

All Patients (N = 3178)

18-64 years old

(N = 1334)

?65 years old (N = 1844)

Difference Between Groups (95% CI)

No. (% rate) [95% CI]

All groups combined a

354 (11)

152

(11)

202 (11)

0.4 (-1.8 to 2.7)

Major events a (%)

208 (7)

87

(7)

121 (7)

0 (-1.7 to 1.8)

Oesophageal intubation with delayed recognition

134 (4)

56

(4)

78 (4)

0 (-1.4 to 1.4)

Hypotension

44 (1)

10

(1)

34 (2)

1.1 (0.3 to 1.9)

Regurgitation

35 (1)

23

(2)

12 (1)

1.1 (0.3 to 1.9)

Hypoxemia?

5 (0)

3

(0)

2 (0)

0.1 (-0.2 to 0.4)

Dysrhythmia

2 (0)

2

(0)

0 (0)

0.1 (-0.1 to 0.4)

Cardiac arrest

4 (0)

2

(0)

2 (0)

0 (-0.2 to 0.3)

Minor events a (%)

157 (5)

72

(5)

85 (5)

0.8 (-0.8 to 2.3)

Dental/lip trauma

92 (3)

47

(4)

45 (2)

1.1 (-0.1 to 2.3)

Mainstem Bronchus intubation

60 (2)

22

(2)

38 (2)

0.4 (-0.5 to 1.4)

Airway trauma

6 (0)

4

(0)

2 (0)

0.2 (-0.1 to 0.5)

a Patients may have more than 1 adverse event.

hospitals. Indeed, most patients were 65 years or older in this multicenter registry. We believe that this study helps emergency physicians understand the major problems to be solved in aging societies.

Intubation success is a common measure of ED airway management quality. The overall initial success rate of 71% is not satisfactory compared to a previous study [15]. This may be partially related to the low overall use of paralytics in this registry. Rapid sequence intubation provides superior intubating conditions compared to sedation alone [15-17]. These data suggest, in this registry, that First-pass success is suboptimal and may be related to the low use of Neuromuscular blockade in Japan. The success rate on the

first attempt and in <=2 attempts among geriatric patients was higher than that of younger patients, although there may have

been relevant patient differences at baseline. Many elderly patients arrived in cardiac arrest, obviating the need for paralytics, at the same time resulting in a higher First pass success rate than in the younger population. Additionally, in this cohort, the young group was twice as likely to be intubated for trauma, compared to the geriatric group. Traumatic airways are often more difficult due to facial injuries and the use of cervical collars. This also may have contributed to a higher first pass success rate in the geriatric group. In addition, this study is purely descriptive and did not measure or adjust for potential confounders, such as body mass index, procedural experience, training background, differences in ED staffing, airway difficulty and indication of intubation. Therefore, we can make no assumptions about the reasons for the observed difference in intubation performance and independent effect of age on the success rates. This is another goal of our future study.

Although indication for intubation does not always depend on patient’s age [18], intubating geriatric patients is closely related to end-of-life care. In our study, of the 3178 patients, 25% were 80 years or older, and nearly half of those were in cardiac arrest. A previous single-site retrospective study in the United Kingdom reported that only 6% of the total patients who were intubated in the ED were 80 years or older [19]. There is clearly a large discrepancy between the 2 studies. This observation may result not only from difference in population but also from other factors. Possible explana- tions include that Advance directives have not yet been accepted by Japanese citizens [20,21] and that UK physicians are not obliged to intubate patients if, in doing so, it is not in the patient’s best interest. An estimated 3% of community-dwelling older adults have completed an ad- vance directive in Japan [22] while 70% have in the United States [23]. In addition, information exchange between emergency physicians and family members or nursing facilities is often poor and hence we fail to be informed of the patient’s advance directive. A system-wide approach to improving the quality of patient-centered geriatric emergen- cy care includes registration of advanced directives for geriatric patients in cooperation with a governmental or nongovernmental agency. Another approach includes devel-

opment of clinical policy statements by professional organizations, setting appropriately considered, evidence- based approaches toward the indication of airway manage- ment for geriatric populations.

Finally, our data inferred that older age is not a predictor for poor performance of emergency airway management. However, we should also promote improving its quality and respect geriatric patient’s advanced directives. Attempting to provide the best possible care to the geriatric population with limited resources is a challenging goal. Improvement of the quality of geriatric emergency care is the responsibility of Japanese national bureaus and professional organizations as well as the EDs themselves. There may be a better chance of improvement of the quality of geriatric patient care throughout Japan if the leadership and direction of governmental and professional agencies are strengthened.

Limitations

Our study has several limitations. First, passive surveillance introduces the potential of reporting bias. Therefore, underestimation of the rate of failed intubations is possible. Active compliance monitoring limited this possibility. Although we performed analyses of patient medical records to complete missing data, validation of existing data is not logistically feasible. Therefore, we relied on hundreds of physicians at many centers to complete the data forms accurately, and our results depend on the accuracy of their reporting.

Second, self-reporting immediately after intubation can result in incomplete or biased reporting of adverse events [24]. Similarly, this descriptive study was not designed to measure patient outcomes after hospitalization such as mortality or to evaluate relationships between ED airway management and outcomes.

Another important limitation is that, as with any observational study, the difference in indication and success rate by age group does not necessarily prove causality and might be confounded by unmeasured factors.

Finally, our data contain problems of external validity. All data were corrected only in Japanese hospitals. Legal and cultural aspects, as well medical systems, could affect the observations especially for indications and methods used. However, this first multicenter prospective study investigat- ing emergency airway management for geriatric patients is nevertheless valuable in aging societies such as the US and European countries.

Conclusion

In this multicenter study of ED airway management involving a large number of geriatric patients, we found that geriatric patients were intubated with a higher success rate compared to younger patients although overall first pass

success was less than what has been reported in other developed emergency medicine systems. These data provide implications for the geriatric ED airway practice that may lead to better patient-centered emergency care.

Acknowledgments

The authors acknowledge the following research person- nel at the study hospitals for their assistance with this project: Fukui University Hospital (Hideya Nagai, MD; Hiroshi Morita, MD), Fukui Prefectural Hospital (Yukinori Kato, MD; Hidenori Higashi, MD), Japanese Red Cross Medical Center of Wakayama (Hiroshi Okamoto, MD), Kameda Medical Center (Kenzo Tanaka, MD), National Center for Global Health and Medicine (Taigo Sakamoto, MD; Shunichiro Nakao, MD), Nagoya Ekisaikai Hospital (Shi- geki Tsuboi, MD), Nigata City General Hospital (Nobuhiro Sato, MD), Obama Municipal Hospital (Takuyo Chiba, MD), Okinawa Chubu Prefectural Hospital (Masashi Okubo, MD), Osaka Saiseikai Senri Hospital (Kazuaki Shigemitsu, MD; Shuho Sato, MD), and Oregon Health and Science University (Hiroko Watase, MD). Finally, we are grateful to our many emergency physicians and residents for their perseverance in pursuing new knowledge about this vital resuscitative procedure.

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