Topics

STEMI and coronary artery disease are major but underappreciated killers of Australian women

This issue of the Journal includes confronting data about inequities in the treatment and outcomes for men and women with ST-elevation myocardial infarction (STEMI).1 Khan and colleagues report that the 6-month mortality for women presenting with STEMI is twice that of men, a difference that persists after statistical correction for age and comorbid conditions. The article relates worrying evidence of a disparity in the delivery of evidence-based treatment, raising many important questions: What barriers are preventing women from presenting for treatment earlier? Why are there delays in providing women with recognised life-saving treatments? Why are women as a group treated less intensively than men despite having higher Global Registry of Acute Coronary Events (GRACE) risk scores? What biological differences require distinct therapeutic approaches and dedicated clinical trials?

1 St Vincent's Hospital Melbourne, Melbourne, VIC
2 Kolling Institute of Medical Research, Sydney, NSW

Correspondence: andrew.macisaac@svha.org.au

Competing interests:

No relevant disclosures.

1. Khan E, Brieger D, Amerena J, et al. Differences in management and outcomes for men and women with ST-elevation myocardial infarction. Med J Aust 2018; 209: 118-123.
2. Heart Foundation. 2018. Women and heart disease. 2018. https://www.heartfoundation.org.au/your-heart/women-and-heart-disease (viewed 21 June 2018).
3. Wei J, Mehta PK, Grey E, et al. Sex-based differences in quality of care and outcomes in a health system using a standardized STEMI protocol. Am Heart J 2017; 191: 30-36.
4. Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Med J Aust 2016; 205: 128-133. <MJA full text>
5. Bavishi C, Bangalore S, Patel D, et al. Short and long-term mortality in women and men undergoing primary angioplasty: a comprehensive meta-analysis. Int J Cardiol 2015; 198: 123-130.
6. Bugiardini R, Ricci B, Cenko E, et al. Delayed care and mortality among women and men with myocardial infarction. J Am Heart Assoc 2017; 6: doi: 10.1161/JAHA.117.005968.
7. Zimmermann S, Ruthrof S, Nowak K, et al. Short-term prognosis of contemporary interventional therapy of ST-elevation myocardial infarction: does gender matter? Clin Res Cardiol 2009; 98: 709-715.
8. Vaccarino V, Parsons L, Peterson ED, et al. Sex differences in mortality after acute myocardial infarction: changes from 1994 to 2006. Arch Intern Med 2009; 169: 1767-1774.

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Perspectives

Potential implications of the new American hypertension guidelines in Australia

Garry LR Jennings, Bronwyn A Kingwell and Erin Hoare

Med J Aust 2018; 209 (3): . || doi: 10.5694/mja18.00104
Published online: 6 August 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Cardiovascular diseases

Pharmaceutical preparations

Environment and public health

There are significant population health and economic implications if Australia were to adopt recently revised American guidelines

There are few things more controversial in medicine than when authoritative bodies shift the goalposts for common conditions and redefine normal values. This is particularly the case when the normative values for common chronic disease risk factors in the community, such as blood pressure or cholesterol, are made more stringent. In the stroke of a pen, millions of people have a disease or a risk factor they did not have the day before. Is this “the medicalisation of life” referred to by Illich?1

1 University of Sydney, Sydney, NSW
2 Baker Heart and Diabetes Institute, Melbourne, VIC
3 Food and Mood Centre, Deakin University, Geelong, VIC
4 Centre for Innovation in Mental and Physical Health and Clinical Treatment, Deakin University, Geelong, VIC

Correspondence: garry.jennings@sydney.edu.au

Acknowledgements:

This work was supported by funding from the Australian National Health and Medical Research Council (NHMRC) (Program Grant #1036352, and Centre for Research Excellence Grant #1000986) and the Victorian Government’s Operational Infrastructure Support Program (Garry Jennings and Bronwyn Kingwell). Erin Hoare was supported by an Australian Rotary Health Postdoctoral Research Fellowship. Bronwyn Kingwell was supported by an NHMRC Senior Principal Research Fellowship (NHMRC #1059454).

Competing interests:

Garry Jennings is Chief Medical Advisor of the Heart Foundation.

1. Illich I. Medical nemesis: the expropriation of health. New York: Pantheon Books, 1976.
2. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017; 13: 24430.
3. Maddox TM, Borden WB, Tang F, et al. Implications of the 2013 ACC/AHA cholesterol guidelines for adults in contemporary cardiovascular practice: insights from the NCDR PINNACLE registry. J Am Coll Cardiol 2014; 64: 2183-2192.
4. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Guidelines for preventing and treating vitamin D deficiency and insufficiency revisited. J Clin Endocrinol Metab 2012; 97: 1153-1158.
5. SPRINT Research Group. A randomized trial of intensive versus standard blood- pressure control. N Engl J Med 2015; 373: 2103-2116.
6. Muntner P, Carey RM, Gidding S, et al. Potential US population impact of the 2017 ACC/AHA high blood pressure guideline. J Am Coll Cardiol 2018; 71: 109-118.
7. Gabb GM, Mangoni AA, Anderson CS, et al. Guideline for the diagnosis and management of hypertension in adults — 2016. Med J Aust 2016; 205: 85-89. <MJA full text>
8. Wang JG, Liu L. Global impact of 2017 American College of Cardiology/American Heart Association Hypertension guidelines: a perspective from China. Circulation 2018; 137: 546-548.
9. Schiffrin EL. Global impact of the 2017 American College of Cardiology/American Heart Association Hypertension guidelines: a perspective from Canada. Circulation 2018; 137: 883-885.
10. Wander GS, Ram CVS. Global impact of the 2017 American College of Cardiology/American Heart Association Hypertension guidelines: a perspective from India. Circulation 2018; 137: 549-550.
11. Australian Bureau of Statistics. National Health Survey: first results, 2014–15 (Cat. No. 4364.0.55.001). Canberra: ABS, 2015. http://www.abs.gov.au/ausstats/abs@.nsf/mf/4364.0.55.001 (viewed May 2018).
12. Hoare E, Kingwell BA, Jennings GLR. Blood pressure Down Under, but down under what? US and Australian hypertension guideline conversation. Hypertension 2018; 71: 972-975.
13. Gee ME, Campbell N, Sarrafzadegan N, et al. Standards for the uniform reporting of hypertension in adults using population survey data: recommendations from the World Hypertension League Expert Committee. J Clin Hypertens (Greenwich) 2014; 16: 773-781.
14. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey; 2013–2014 data documentation, codebook, and frequencies; blood pressure [website]. Atlanta, GA: CDC, 2015. https://wwwn.cdc.gov/Nchs/Nhanes/2013-2014/BPX_H.htm (viewed Mar 2018).
15. National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. Melbourne: National Stroke Foundation, 2012. https://www.heartfoundation.org.au/images/uploads/publications/Absolute-CVD-Risk-Full-Guidelines.pdf (viewed May 2018).
16. Karakaya G, Van Tielen R, Umbach I. [OP.6C.02] Risk factors associated with medication non-compliance in arterial hypertension. J Hypertens 2016; 34: e72.
17. American Academy of Family Physicians. Guidelines developed by external organizations not endorsed by the AAFP [website]. AAFP, 2017. https://www.aafp.org/patient-care/clinical-recommendations/non-endorsed.html (viewed Mar 2018).
18. Hoare E, Stavreski B, Kingwell BA, Jennings GL. Australian adults’ behaviours, knowledge and perceptions of risk factors for heart disease: a cross-sectional study. Prev Med Rep 2017; 8: 204-209.
19. Australian Institute of Health and Welfare. Australian burden of disease study: impact and causes of illness and death in Australia 2011. Canberra: AIHW, 2016. https://www.aihw.gov.au/getmedia/d4df9251-c4b6-452f-a877-8370b6124219/19663.pdf.aspx?inline=true (viewed May 2018).
20. Rose G. Sick individuals and sick populations. Int J Epidemiol 2001; 30: 427-432.

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Perspectives

Glycaemic control apps for diabetes: lifting the lid

Rahul Barmanray and Esther Briganti

Med J Aust 2018; 209 (10): . || doi: 10.5694/mja18.00066
Published online: 30 July 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Endocrine system diseases

Information science

Pharmaceutical preparations

Ethics and law

The rapidly expanding diabetes app market presents new challenges for patients, health care providers and regulators

The medical technology industry’s explosive growth has set the stage for medical mobile applications (apps) to assist with the management of many chronic diseases. Diabetes mellitus is the archetypal example: its management requires optimising diet, physical activity, blood glucose self-monitoring, and safe medication use. As a multifaceted condition affecting so many people, diabetes is the perfect target for developers of medical apps to realise the promise of the digital revolution.

1 Royal Melbourne Hospital, Melbourne, VIC
2 Monash University, Melbourne, VIC

Correspondence: rahul.barmanray@mh.org.au

Competing interests:

No relevant disclosures.

1. Wu Y, Yao X, Vespasiani G, et al. Mobile app-based interventions to support diabetes self-management: a systematic review of randomized controlled trials to identify functions associated with glycemic efficacy. JMIR Mhealth Uhealth 2017; 5: e35.
2. Arnhold M, Quade M, Kirch W. Mobile applications for diabetics: a systematic review and expert-based usability evaluation considering the special requirements of diabetes patients age 50 years or older. J Med Internet Res 2014; 16: e104.
3. Bonoto BC, de Araújo VE, Godói IP, et al. Efficacy of mobile apps to support the care of patients with diabetes mellitus: a systematic review and meta-analysis of randomized controlled trials. JMIR Mhealth Uhealth 2017; 5: e4.
4. Chaudhury A, Duvoor C, Reddy Dendi VS, et al. Clinical review of antidiabetic drugs: implications for type 2 diabetes mellitus management. Front Endocrinol (Lausanne) 2017; 8: 6.
5. Rossi MC, Nicolucci A, Lucisano G, et al; DID Study Group. Impact of the “Diabetes Interactive Diary” telemedicine system on metabolic control, risk of hypoglycemia, and quality of life: a randomized clinical trial in type 1 diabetes. Diabetes Technol Ther 2013; 15: 670-679.
6. Charpentier G, Benhamou PY, Dardari D, et al; TeleDiab Study Group. The Diabeo software enabling individualized insulin dose adjustments combined with telemedicine support improves HbA1c in poorly controlled type 1 diabetic patients: a 6-month, randomized, open-label, parallel-group, multicenter trial (TeleDiab 1 Study). Diabetes Care 2011; 34: 533-539.
7. Huckvale K, Adomaviciute S, Prieto JT, et al. Smartphone apps for calculating insulin dose: a systematic assessment. BMC Med 2015; 13: 106.
8. Therapeutic Goods Administration. Australian regulatory guidelines for medical devices (ARGMD), section 5. Conformity assessment overview V1.1 May 2011. https://www.tga.gov.au/sites/default/files/devices-argmd-p1-01.pdf (viewed July 2018).
9. Sansom L, Delaat W, Horvath J. Review of medicines and medical devices regulation: report on the regulatory framework for medicines and medical devices. (Sansom Review; Stage One) March 2015. Commonwealth of Australia; 2015.
10. European Commission. Regulatory Framework. Regulation (EU) 2017/745 of the European Parliament and of the Council of 5 April 2017 on medical devices, amending Directive 2001/83/EC, Regulation (EC) No 178/2002 and Regulation (EC) No 1223/2009 and repealing Council Directives 90/385/EEC and 93/42/EEC. https://ec.europa.eu/growth/sectors/medical-devices/regulatory-framework_en (viewed Jan 2018).

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Narrative review

Thyroid nodules: diagnosis and management

Rosemary Wong, Stephen G Farrell and Mathis Grossmann

Med J Aust 2018; 209 (2): . || doi: 10.5694/mja17.01204
Published online: 16 July 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Endocrine system diseases

Summary

Thyroid nodules are common. Their importance lies in the need to assess thyroid function, degree of and future risk of mass effect, and exclude thyroid cancer, which occurs in 7–15% of thyroid nodules.
There are four key components to thyroid nodule assessment: clinical history and examination, serum thyroid stimulating hormone (TSH) measurement, ultrasound and, if indicated, fine-needle aspiration (FNA).
If the serum TSH is suppressed, a thyroid scan with ⁹⁹Tc can distinguish between a solitary hot nodule, a toxic multinodular goitre or, less commonly, thyroiditis or Graves’ disease within a coexisting nodular thyroid. Scintigraphically cold nodules are evaluated in the same way as in the setting of normal or elevated serum TSH levels.
Thyroid ultrasonography should be performed only for palpable goitre and thyroid nodules and by specialists with expertise in thyroid sonography.
Routine thyroid cancer screening is not recommended, except in high risk individuals, as the detection of early thyroid cancer has not been shown to improve survival.
FNA may be performed for nodules ≥ 1.0 cm depending on clinical and sonographic risk factors for thyroid cancer.
FNA specimens should be read by an experienced cytopathologist and be reported according to the Bethesda Classification System.
Molecular analysis of indeterminate FNA samples has potential to better discriminate benign from malignant nodules and thus guide management.
Surgery is indicated for FNA findings of malignancy or indeterminate cytology when there is a high risk clinical context. Surgery may also be indicated for suspicion of malignancy; larger nodules, especially with symptoms of mass effect; and in some patients with thyrotoxicosis.

1 Eastern Health, Melbourne, VIC
2 Austin Health, Melbourne, VIC
3 St Vincent's Hospital, Melbourne, VIC
4 University of Melbourne, Melbourne, VIC

Correspondence: mathisg@unimelb.edu.au

Competing interests:

No relevant disclosures.

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Narrative review

Chronic idiopathic constipation in adults: epidemiology, pathophysiology, diagnosis and clinical management

Christopher J Black and Alexander C Ford

Med J Aust 2018; 209 (2): . || doi: 10.5694/mja18.00241
Published online: 16 July 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Digestive system diseases

Summary

Chronic idiopathic constipation (CIC) is one of the most common gastrointestinal disorders, with a global prevalence of 14%. It is commoner in women and its prevalence increases with age.
There are three subtypes of CIC: dyssynergic defaecation, slow transit constipation and normal transit constipation, which is the most common subtype.
Clinical assessment of the patient with constipation requires careful history taking, in order to identify any red flag symptoms that would necessitate further investigation with colonoscopy to exclude colorectal malignancy.
Screening for hypercalcaemia, hypothyroidism and coeliac disease with appropriate blood tests should be considered.
A digital rectal examination should be performed to assess for evidence of dyssynergic defaecation. If this is suspected, further investigation with high resolution anorectal manometry should be undertaken.
Anorectal biofeedback can be offered to patients with dyssynergic defaecation as a means of correcting the associated impairment of pelvic floor, abdominal wall and rectal functioning.
Lifestyle modifications, such as increasing dietary fibre, are the first step in managing other causes of CIC. If patients do not respond to these simple changes, then treatment with osmotic and stimulant laxatives should be trialled.
Patients not responding to traditional laxatives should be offered treatment with prosecretory agents such as lubiprostone, linaclotide and plecanatide, or the 5-HT₄ receptor agonist prucalopride, where available.
If there is no response to pharmacological treatment, surgical intervention can be considered, but it is only suitable for a carefully selected subset of patients with proven slow transit constipation.

Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK

Correspondence: A.C.Ford@leeds.ac.uk

Competing interests:

No relevant disclosures.

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Editorials

Severe asthma: implementing game-changing science

Peter G Gibson

Med J Aust 2018; 209 (2): . || doi: 10.5694/mja18.00477
Published online: 16 July 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Respiratory tract diseases

Anatomy and physiology

New assessment and treatment opportunities for people with severe asthma promise better outcomes

“It’s been a long time coming, but I feel great now.” “I feel like I’ve got my life back.” These are statements made by patients with severe asthma who have had positive responses to targeted monoclonal antibody therapy for asthma. Both patients have severe refractory eosinophilic asthma and have experienced many years of persistent symptoms despite daily maintenance prednisone. On monoclonal antibody therapy, they achieved complete symptom control and significant prednisone reduction.

John Hunter Hospital, Newcastle, NSW

Correspondence: peter.gibson@hnehealth.nsw.gov.au

Competing interests:

I have received honoraria for the delivery of independent medical education and grants from GlaxoSmithKline, AstraZeneca and Novartis. I am also a member of the MJA Editorial Advisory Group.

1. Upham JW, Chung LP. Optimising treatment for severe asthma. Med J Aust 2018; 209 (2 Suppl): S22-S27.
2. Lindstrom SJ, Silver JD, Sutherland MF, et al. Thunderstorm asthma outbreak of November 2016: a natural disaster requiring planning. Med J Aust 2017; 207: 235-237. <MJA full text>
3. McDonald VM, Hiles SA, Jones KA, et al. Health-related quality of life burden in severe asthma. Med J Aust 2018; 209 (2 Suppl): S28-S33.
4. Israel E, Reddel HK. Severe and difficult-to-treat asthma in adults. N Engl J Med 2017; 377: 965-976.
5. Tay TR, Lee JW-Y, Hew M. Diagnosis of severe asthma. Med J Aust 2018; 209 (2 Suppl): S3-S10.
6. Chung LP, Johnson P, Summers Q. Models of care for severe asthma: the role of primary care. Med J Aust 2018; 209 (2 Suppl): S34-S40.
7. Bardin PG, Rangaswamy J, Yo SW. Managing comorbid conditions in severe asthma. Med J Aust 2018; 209 (2 Suppl): S11-S17.
8. Ramsahai JM, Wark P. Appropriate use of oral steroids in severe asthma. Med J Aust 2018; 209 (2 Suppl): S18-S21.
9. Department of Health. An outcomes strategy for people with chronic obstructive pulmonary disease (COPD) and asthma in England. London: Department of Health, 2011. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_127974 (accessed May 2018).
10. von Bulow A, Kriegbaum M, Backer V, Porsbjerg C. The prevalence of severe asthma and low asthma control among Danish adults. J Allergy Clin Immunol Pract 2014; 2: 759-767.
11. Hekking PP, Wener RR, Amelink M, et al. The prevalence of severe refractory asthma. J Allergy Clin Immunol 2015; 135: 896-902.
12. Kane B, Cramb S, Hudson V, et al. Specialised commissioning for severe asthma: oxymoron or opportunity? Thorax 2016; 71: 196-198.

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Perspectives

The true price of sugar-sweetened disease: political inertia requires renewed, strategic action

Alessandro Demaio and Alexandra Jones

Med J Aust 2018; 209 (2): . || doi: 10.5694/mja18.00223
Published online: 9 July 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Environment and public health

Health services administration

Nutritional and metabolic diseases

Australia can no longer afford to wait for a tax on sugar-sweetened beverages

Excess free sugars are a major contributor to diet-related diseases, including obesity, type 2 diabetes and tooth decay. Sugar-sweetened beverages (SSBs) provide a significant source of free sugars while offering no other nutritional benefit, making them a reasonable target for public health action.1,2 Governments worldwide are drawing on growing evidence to implement effective pricing policies for SSBs as one cornerstone of a comprehensive policy response.

1 University of Melbourne, Melbourne, VIC
2 EAT Foundation, Oslo, Norway
3 George Institute for Global Health, Sydney, NSW
4 Charles Perkins Centre, University of Sydney, Sydney, NSW

Correspondence: ajones@georgeinstitute.org.au

Acknowledgements:

We thank Thomas Goodwin for his support in the research of this article. The views, opinions and positions expressed in this article are the authors’ own and do not reflect the views of any third party.

Competing interests:

No relevant disclosures.

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Research

Multimorbidity among Aboriginal people in New South Wales contributes significantly to their higher mortality

Deborah A Randall, Sanja Lujic, Alys Havard, Sandra J Eades and Louisa Jorm

Med J Aust 2018; 209 (1): . || doi: 10.5694/mja17.00878
Published online: 2 July 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Indigenous health

General medicine

Mental disorders

Social determinants of health

Abstract

Objectives: To compare the prevalence of multimorbidity and its impact on mortality among Aboriginal and non-Aboriginal Australians who had been hospitalised in New South Wales in the previous 10 years.

Design, setting and participants: Cohort study analysis of linked NSW hospital (Admitted Patient Data Collection) and mortality data for 5 437 018 New South Wales residents with an admission to a NSW hospital between 1 March 2003 and 1 March 2013, and alive at 1 March 2013.

Main outcome measures: Admissions for 30 morbidities during the 10-year study period were identified. The primary outcome was the presence or absence of multimorbidity during the 10-year lookback period; the secondary outcome was mortality in the 12 months from 1 March 2013 to 1 March 2014.

Results: 31.5% of Aboriginal patients had at least one morbidity and 16.1% had two or more, compared with 25.0% and 12.1% of non-Aboriginal patients. After adjusting for age, sex, and socio-economic status, the prevalence of multimorbidity among Aboriginal people was 2.59 times that for non-Aboriginal people (95% CI, 2.55–2.62). The prevalence of multimorbidity was higher among Aboriginal people in all age groups, in younger age groups because of the higher prevalence of mental morbidities, and from age 60 because of physical morbidities. The age-, sex- and socio-economic status-adjusted hazard of one-year mortality (Aboriginal v non-Aboriginal Australians) was 2.43 (95% CI, 2.24–2.62), and 1.51 (95% CI, 1.39–1.63) after also adjusting for morbidity count.

Conclusions: The prevalence of multimorbidity was higher among Aboriginal than non-Aboriginal patients, and this difference accounted for much of the difference in mortality between the two groups. Evidence-based interventions for reducing multimorbidity among Aboriginal and Torres Strait Islander Australians must be a priority.

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1 Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW
2 Sax Institute, Baker IDI Heart and Diabetes Institute, Sydney, NSW

Correspondence: deborah.randall@sydney.edu.au

Acknowledgements:

This investigation was supported by the National Health and Medical Research Council (573113). We acknowledge the NSW Ministry of Health and NSW Register of Births, Deaths and Marriages for allowing access to the data, and the Centre for Health Record Linkage for conducting the probabilistic linkage of records.

Competing interests:

No relevant disclosures.

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Why are women with ST-elevation myocardial infarction treated differently to men?

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Multimorbidity among Aboriginal people in New South Wales contributes significantly to their higher mortality

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Closing the gap in cardiovascular risk for Aboriginal and Torres Strait Islander Australians

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The Medical Journal of Australia endorses the Uluru Statement

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