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The 2003 Canadian recommendations for dyslipidemia management: revisions are needed.

https://arctichealth.org/en/permalink/ahliterature175311
Source
CMAJ. 2005 Apr 12;172(8):1027-31
Publication Type
Article
Date
Apr-12-2005
Author
Douglas G Manuel
Peter Tanuseputro
Cameron A Mustard
Susan E Schultz
Geoffrey M Anderson
Sten Ardal
David A Alter
Andreas Laupacis
Author Affiliation
Institute for Clinical Evaluative Sciences, Toronto, Ont. doug.manuel@ices.on.ca
Source
CMAJ. 2005 Apr 12;172(8):1027-31
Date
Apr-12-2005
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Canada
Cholesterol, LDL - blood
Coronary Disease - mortality - prevention & control
Cost-Benefit Analysis
Health Expenditures
Humans
Hydroxymethylglutaryl-CoA Reductase Inhibitors - therapeutic use
Hyperlipidemias - drug therapy
Hypolipidemic Agents - therapeutic use
Middle Aged
Practice Guidelines as Topic
Risk factors
Notes
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Comment In: CMAJ. 2005 Nov 8;173(10):1210; author reply 121016275979
Comment In: CMAJ. 2005 Nov 8;173(10):1207; author reply 121016275976
Comment In: CMAJ. 2005 Apr 12;172(8):1033-4; discussion 103715824410
Erratum In: CMAJ. 2005 Jul 19;173(2):133
PubMed ID
15824409 View in PubMed
Less detail
Source
CMAJ. 2002 Feb 5;166(3):299-300
Publication Type
Article
Date
Feb-5-2002
Author
Dalia L Rotstein
David A Alter
Dalis L Rotstein
Source
CMAJ. 2002 Feb 5;166(3):299-300
Date
Feb-5-2002
Language
English
Publication Type
Article
Keywords
Adult
Aged
Breast Neoplasms - diagnosis - prevention & control
Canada
Efficiency, Organizational
Female
Humans
Mass Screening - organization & administration
Middle Aged
Time and Motion Studies
Notes
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Erratum In: CMAJ 2002 Apr 30;166(9):1135Rotstein Dalis L [corrected to Rotstein Dalia L]
PubMed ID
11868633 View in PubMed
Less detail

Ambulatory surveillance of patients referred for cardiac rehabilitation following cardiac hospitalization: a feasibility study.

https://arctichealth.org/en/permalink/ahliterature125434
Source
Can J Cardiol. 2012 Jul-Aug;28(4):497-501
Publication Type
Article
Author
David A Alter
Juda Habot
Sherry L Grace
Terry Fair
David Kiernan
Wendy Clark
David Fell
Author Affiliation
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. david.alter@ices.on.ca
Source
Can J Cardiol. 2012 Jul-Aug;28(4):497-501
Language
English
Publication Type
Article
Keywords
Acute Coronary Syndrome - mortality - rehabilitation
Adult
Aged
Aged, 80 and over
Ambulatory Care
Angioplasty, Balloon, Coronary - mortality - rehabilitation
Coronary Artery Bypass - mortality - rehabilitation
Feasibility Studies
Female
Follow-Up Studies
Heart Valve Prosthesis Implantation - mortality - rehabilitation
Hospitalization
Hospitals, Community
Humans
Male
Middle Aged
Myocardial Infarction - mortality - rehabilitation
Ontario
Patient Readmission - statistics & numerical data
Population Surveillance - methods
Referral and Consultation
Survival Analysis
Waiting Lists
Abstract
Our purpose was to examine the feasibility of implementing an ambulatory surveillance system for monitoring patients referred to cardiac rehabilitation following cardiac hospitalizations.
This study consists of 1208 consecutive referrals to cardiac rehabilitation between October 2007 and April 2008. Patient attendance at cardiac rehabilitation, waiting times for cardiac rehabilitation, and adverse events while waiting for cardiac rehabilitation were tracked by telephone surveillance by a nurse.
Among the 1208 consecutive patients referred, only 44.7% attended cardiac rehabilitation; 36.4% of referred patients were known not to have attended any cardiac rehabilitation, while an additional 18.9% of referred patients were lost to follow-up. Among the 456 referred patients who attended the cardiac rehabilitation program, 19 (4.2%) experienced an adverse event while in the queue (13 of which were for cardiovascular hospitalizations with no deaths), with mean waiting times of 20 days and 24 days among those without and with adverse events, respectively. Among the 440 referred patients who were known not to have attended any cardiac rehabilitation program, 114 (25.9%) had adverse clinical events while in the queue; 46 of these events required cardiac hospitalization and 8 patients died.
Ambulatory surveillance for cardiac rehabilitation referrals is feasible. The high adverse event rates in the queue, particularly among patients who are referred but who do not attend cardiac rehabilitation programs, underscores the importance of ambulatory referral surveillance systems for cardiac rehabilitation following cardiac hospitalizations.
PubMed ID
22480901 View in PubMed
Less detail

Antihypertensive therapy and incidence of type 2 diabetes in an elderly cohort.

https://arctichealth.org/en/permalink/ahliterature178189
Source
Diabetes Care. 2004 Oct;27(10):2458-63
Publication Type
Article
Date
Oct-2004
Author
Raj Padwal
Muhammad Mamdani
David A Alter
Jan E Hux
Deanna M Rothwell
Karen Tu
Andreas Laupacis
Author Affiliation
Division of General Internal Medicine, University of Alberta, Edmonton, Canada. rpadwal@ualberta.ca
Source
Diabetes Care. 2004 Oct;27(10):2458-63
Date
Oct-2004
Language
English
Publication Type
Article
Keywords
Age Distribution
Aged
Aged, 80 and over
Angiotensin-Converting Enzyme Inhibitors - adverse effects - therapeutic use
Antihypertensive Agents - adverse effects - therapeutic use
Benzothiadiazines
Calcium Channel Blockers - adverse effects - therapeutic use
Cohort Studies
Diabetes Mellitus, Type 2 - chemically induced - epidemiology
Diuretics
Female
Geriatric Assessment
Humans
Hypertension - diagnosis - drug therapy
Incidence
Male
Ontario - epidemiology
Probability
Prognosis
Proportional Hazards Models
Retrospective Studies
Risk assessment
Sex Distribution
Sodium Chloride Symporter Inhibitors - adverse effects - therapeutic use
Abstract
The aim of this study was to determine whether the incidence of type 2 diabetes differed among elderly users of four major antihypertensive drug classes.
This was a retrospective, observational cohort study of previously untreated elderly patients (aged > or = 66 years) identified as new users of an antihypertensive drug class between April 1995 and March 2000. Using a Cox proportional hazards model, the primary analysis compared diabetes incidence in users of ACE inhibitors, beta-blockers, and calcium channel blockers (CCBs), with thiazide diuretics allowed as second-line therapy. In the secondary analysis, thiazide diuretics were added as a fourth study group.
In the multivariable-adjusted primary analysis (n = 76,176), neither ACE inhibitor use (hazard ratio 0.96 [95% CI 0.84-1.1]) nor beta-blocker use (0.86 [0.74-1.0]) was associated with a statistically significant difference in type 2 diabetes incidence compared with the CCB control group. In the secondary analysis (n = 100,653), compared with CCB users, type 2 diabetes incidence was not significantly different between users of ACE inhibitors (0.97 [0.83-1.1]), beta-blockers (0.84 [0.7-1.0]), or thiazide diuretics (1.0 [0.89-1.2]).
Type 2 diabetes incidence did not significantly differ among users of the major antihypertensive drug classes in this elderly, population-based administrative cohort. These results do not support the theory that different antihypertensive drug classes are relatively more or less likely to cause diabetes.
Notes
Comment In: Diabetes Care. 2005 Mar;28(3):762; author reply 762-315735235
PubMed ID
15451916 View in PubMed
Less detail

Association between hospital cardiac management and outcomes for acute myocardial infarction patients.

https://arctichealth.org/en/permalink/ahliterature147258
Source
Med Care. 2010 Feb;48(2):157-65
Publication Type
Article
Date
Feb-2010
Author
Therese A Stukel
David A Alter
Michael J Schull
Dennis T Ko
Ping Li
Author Affiliation
Institute for Clinical Evaluative Sciences, Toronto, ON, Canada. stukel@ices.on.ca
Source
Med Care. 2010 Feb;48(2):157-65
Date
Feb-2010
Language
English
Publication Type
Article
Keywords
Adult
Aged
Aged, 80 and over
Emergency Service, Hospital
Female
Guideline Adherence
Humans
Logistic Models
Longitudinal Studies
Male
Middle Aged
Myocardial Infarction - drug therapy - mortality - therapy
Ontario - epidemiology
Outcome and Process Assessment (Health Care) - methods
Patient Readmission - statistics & numerical data
Proportional Hazards Models
Quality Indicators, Health Care
Survival Analysis
Abstract
Randomized trials have shown that medical and interventional therapies improve outcomes for acute myocardial infarction (AMI) patients. The extent to which hospital quality improvement translates into better patient outcomes is unclear.
To determine hospital cardiac management markers associated with improved outcomes. RESEARCH DESIGN, SUBJECTS: Population-based longitudinal cohort study of 98,115 adults hospitalized with first episode of AMI during 2000 to 2006 in 77 Ontario hospitals with >50 annual AMI admissions.
Rates of 30-day and 1-year mortality, readmissions for AMI or death, and major cardiac events (readmissions for AMI, angina, heart failure, or death) within 6 months, according to index hospital cardiac management markers, including appropriate initial emergency department (ED) assessment (rate of high acuity triage) high-acuity and intensity of interventional (30-day cardiac catheterization rate) and medical (discharge statin prescribing rate) therapy.
Thirty-day risk-adjusted mortality varied 2.3-fold (7.2%-16.9%) and major cardiac events rates varied 2-fold (18.2%-35.6%) across hospitals in 2006. Patients admitted to hospitals with the highest versus lowest rates of combined medical and interventional management had lower rates of 30-day mortality (adjusted relative rate [aRR] = 0.84, 95% CI, 0.78-0.91), 1-year mortality (aRR = 0.86, 0.81-0.91), AMI readmissions or death (aRR = 0.74, 0.69-0.78), and major cardiac event (aRR = 0.65, 0.61-0.68). Patients admitted to EDs with the highest rates of appropriate initial assessment had lower 30-day (aRR = 0.93, 0.88-0.98) and 1-year mortality (aRR = 0.96, 0.93-1.00).
Hospitals with higher levels of both medical and interventional management and higher quality initial ED assessment had better outcomes. Readmissions were particularly sensitive to care processes. In the face of the unwarranted variations in outcomes across hospitals, strategies that promote better ED and inpatient management of AMI patients are needed.
PubMed ID
19927014 View in PubMed
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Association of hospital spending intensity with mortality and readmission rates in Ontario hospitals.

https://arctichealth.org/en/permalink/ahliterature126185
Source
JAMA. 2012 Mar 14;307(10):1037-45
Publication Type
Article
Date
Mar-14-2012
Author
Therese A Stukel
Elliott S Fisher
David A Alter
Astrid Guttmann
Dennis T Ko
Kinwah Fung
Walter P Wodchis
Nancy N Baxter
Craig C Earle
Douglas S Lee
Author Affiliation
Institute for Clinical Evaluative Sciences, G106-2075 Bayview Ave, Toronto, ON M4N 3M5, Canada. stukel@ices.on.ca
Source
JAMA. 2012 Mar 14;307(10):1037-45
Date
Mar-14-2012
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Aged, 80 and over
Colonic Neoplasms - mortality - therapy
Economics, Hospital
Female
Health Expenditures - statistics & numerical data
Heart Failure - mortality - therapy
Hip Fractures - mortality - therapy
Hospital Costs - statistics & numerical data
Humans
Longitudinal Studies
Male
Middle Aged
Myocardial Infarction - mortality - therapy
Ontario - epidemiology
Patient Readmission - statistics & numerical data
Quality of Health Care
Treatment Outcome
Young Adult
Abstract
The extent to which better spending produces higher-quality care and better patient outcomes in a universal health care system with selective access to medical technology is unknown.
To assess whether acute care patients admitted to higher-spending hospitals have lower mortality and readmissions.
The study population comprised adults (>18 years) in Ontario, Canada, with a first admission for acute myocardial infarction (AMI) (n = 179,139), congestive heart failure (CHF) (n = 92,377), hip fracture (n = 90,046), or colon cancer (n = 26,195) during 1998-2008, with follow-up to 1 year. The exposure measure was the index hospital's end-of-life expenditure index for hospital, physician, and emergency department services.
The primary outcomes were 30-day and 1-year mortality and readmissions and major cardiac events (readmissions for AMI, angina, CHF, or death) for AMI and CHF.
Patients' baseline health status was similar across hospital expenditure groups. Patients admitted to hospitals in the highest- vs lowest-spending intensity terciles had lower rates of all adverse outcomes. In the highest- vs lowest-spending hospitals, respectively, the age- and sex-adjusted 30-day mortality rate was 12.7% vs 12.8% for AMI, 10.2% vs 12.4% for CHF, 7.7% vs 9.7% for hip fracture, and 3.3% vs 3.9% for CHF; fully adjusted relative 30-day mortality rates were 0.93 (95% CI, 0.89-0.98) for AMI, 0.81 (95% CI, 0.76-0.86) for CHF, 0.74 (95% CI, 0.68-0.80) for hip fracture, and 0.78 (95% CI, 0.66-0.91) for colon cancer. Results for 1-year mortality, readmissions, and major cardiac events were similar. Higher-spending hospitals had higher nursing staff ratios, and their patients received more inpatient medical specialist visits, interventional (AMI cohort) and medical (AMI and CHF cohorts) cardiac therapies, preoperative specialty care (colon cancer cohort), and postdischarge collaborative care with a cardiologist and primary care physician (AMI and CHF cohorts).
Among Ontario hospitals, higher spending intensity was associated with lower mortality, readmissions, and cardiac event rates.
Notes
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Comment In: JAMA. 2012 Mar 14;307(10):1082-322416105
PubMed ID
22416099 View in PubMed
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Cardiologists' charting varied by risk factor, and was often discordant with patient report.

https://arctichealth.org/en/permalink/ahliterature157753
Source
J Clin Epidemiol. 2008 Oct;61(10):1073-9
Publication Type
Article
Date
Oct-2008
Author
Shannon Gravely-Witte
Donna E Stewart
Neville Suskin
Lyall Higginson
David A Alter
Sherry L Grace
Author Affiliation
University Health Network Women's Health Program, 200 Elizabeth St., Toronto, Ontario, Canada. sgravely@yorku.ca
Source
J Clin Epidemiol. 2008 Oct;61(10):1073-9
Date
Oct-2008
Language
English
Publication Type
Article
Keywords
Aged
Cardiovascular Diseases - epidemiology - etiology
Clinical Competence
Diabetes Mellitus - epidemiology
Dyslipidemias - complications - epidemiology
Epidemiologic Methods
Female
Humans
Hypertension - complications - epidemiology
Male
Medical Records - standards
Middle Aged
Ontario - epidemiology
Outpatient Clinics, Hospital
Self Disclosure
Smoking - adverse effects - epidemiology
Socioeconomic Factors
Abstract
To assess the completeness of cardiac risk factor documentation by cardiologists, and agreement with patient report.
A total of 68 Ontario cardiologists and 789 of their ambulatory cardiology patients were randomly selected. Cardiac risk factor data were systematically extracted from medical charts, and a survey was mailed to participants to assess risk factor concordance.
With regard to completeness of risk factor documentation, 90.4% of charts contained a report of hypertension, 87.2% of diabetes, 80.5% of dyslipidemia, 78.6% of smoking behavior, 73.0% of other comorbidities, 48.7% of family history of heart disease, and 45.9% of body mass index or obesity. Using Cohen's k, there was a concordance of 87.7% between physician charts and patient self-report of diabetes, 69.5% for obesity, 56.8% for smoking status, 49% for hypertension, and 48.4% for family history.
Two of four major cardiac risk factors (hypertension and diabetes) were recorded in 90% of patient records; however, arguably the most important reversible risk factors for cardiac disease (dyslipidemia and smoking) were only reported 80% of the time. The results suggest that physician chart report may not be the criterion standard for quality assessment in cardiac risk factor reporting.
Notes
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PubMed ID
18411042 View in PubMed
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Clinical prognosis, pre-existing conditions and the use of reperfusion therapy for patients with ST segment elevation acute myocardial infarction.

https://arctichealth.org/en/permalink/ahliterature170648
Source
Can J Cardiol. 2006 Feb;22(2):131-9
Publication Type
Article
Date
Feb-2006
Author
Andrea B Parker
C David Naylor
Alice Chong
David A Alter
Author Affiliation
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
Source
Can J Cardiol. 2006 Feb;22(2):131-9
Date
Feb-2006
Language
English
Publication Type
Article
Keywords
Angioplasty, Balloon, Coronary - adverse effects
Cohort Studies
Evidence-Based Medicine
Fibrinolytic Agents - adverse effects
Hospital Mortality
Humans
Logistic Models
Myocardial Infarction - diagnosis - epidemiology - mortality - therapy
Myocardial Reperfusion - methods
Ontario - epidemiology
Prognosis
Prospective Studies
Risk factors
Survival Analysis
Treatment Outcome
Abstract
Some evidence-based therapies are underused in patients with a poor prognosis despite the fact that the survival gains would be highest among such patient subgroups. The extent to which this applies for acute, life-saving therapies is unknown. The impact of prognostic characteristics and pre-existing conditions on the use of reperfusion therapy among eligible patients with acute ST segment elevation myocardial infarction is examined.
Of 2829 acute myocardial infarction patients prospectively identified in 53 acute care hospitals across Ontario, 987 presented with ST segment elevation within 12 h of symptom onset and without any absolute contraindications to reperfusion therapy. The baseline prognosis for each patient was derived from a validated risk-adjustment model of 30-day mortality. Multiple logistical regression was used to examine the relationships among reperfusion therapy, prognosis and the number of pre-existing chronic conditions after adjusting for factors such as age, sex, time since symptom onset and socioeconomic status.
Of the 987 appropriate candidates, 725 (73.5%) received reperfusion therapy (70.8% fibrinolysis, 2.6% primary angioplasty). The adjusted odds ratio of reperfusion therapy fell 4% with each 1% increase in baseline risk of death (adjusted OR 0.96, 95% CI 0.92 to 1.00, P=0.04) and fell 18% with each additional pre-existing condition (adjusted OR 0.82, 95% CI 0.76 to 0.90, P
Notes
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PubMed ID
16485048 View in PubMed
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Community factors, hospital characteristics and inter-regional outcome variations following acute myocardial infarction in Canada.

https://arctichealth.org/en/permalink/ahliterature175675
Source
Can J Cardiol. 2005 Mar;21(3):247-55
Publication Type
Article
Date
Mar-2005
Author
David A Alter
Peter C Austin
Jack V Tu
Author Affiliation
University of Toronto, Toronto, Canada. david.alter@ices.on.ca
Source
Can J Cardiol. 2005 Mar;21(3):247-55
Date
Mar-2005
Language
English
Publication Type
Article
Keywords
Adult
Aged
Angioplasty, Balloon, Coronary - statistics & numerical data
Canada - epidemiology
Coronary Artery Bypass - statistics & numerical data
Educational Status
Emigration and Immigration - statistics & numerical data
Ethnic Groups - statistics & numerical data
Female
Hospital Mortality
Hospitals - statistics & numerical data
Humans
Logistic Models
Male
Middle Aged
Multivariate Analysis
Myocardial Infarction - etiology - mortality - therapy
Outcome Assessment (Health Care) - organization & administration
Patient Readmission - statistics & numerical data
Physician's Practice Patterns - organization & administration
Quality Indicators, Health Care
Reoperation - statistics & numerical data
Residence Characteristics - statistics & numerical data
Risk Adjustment
Risk factors
Socioeconomic Factors
Abstract
While various community and hospital characteristics have been demonstrated to have an impact on individual cardiovascular outcomes, the extent to which such factors account for inter-regional and interhospital outcome variations following acute myocardial infarction (AMI) remains unknown.
To examine the impact of community and hospital factors on individual AMI outcomes and procedure use, and to determine the extent to which such characteristics account for inter-regional and interinstitutional AMI outcome and procedure variations across Canada.
Patients hospitalized with AMI between April 1, 1997, and March 31, 2000, across Canada were examined. The community and hospital characteristics studied included three indicators of socioeconomic status, two indicators of ethnicity, rural-urban status of residence, hospital academic affiliation, and the presence or absence of on-site angiography or revascularization capabilities at the admitting institution. Outcomes included in-hospital mortality, one-year cardiac readmissions and 30-day revascularization rates post-AMI. All analyses were adjusted for age, sex and age-sex interaction. The relationships between community/hospital factors and individual outcomes were examined using random-effects hierarchical logistic regression analysis, while the relationships between community/hospital characteristics and inter-regional/hospital risk-adjusted outcomes were examined using least squares regression and the coefficient of determination (r2).
After adjusting for demographic factors, a patient's neighbourhood socioeconomic status was inversely correlated with the likelihood of death and downstream cardiac readmissions (P
PubMed ID
15776114 View in PubMed
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Comparing hierarchical modeling with traditional logistic regression analysis among patients hospitalized with acute myocardial infarction: should we be analyzing cardiovascular outcomes data differently?

https://arctichealth.org/en/permalink/ahliterature187148
Source
Am Heart J. 2003 Jan;145(1):27-35
Publication Type
Article
Date
Jan-2003
Author
Peter C Austin
Jack V Tu
David A Alter
Author Affiliation
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. peter.austin@;ices.on.ca
Source
Am Heart J. 2003 Jan;145(1):27-35
Date
Jan-2003
Language
English
Publication Type
Article
Keywords
Adult
Age Distribution
Aged
Aged, 80 and over
Cohort Studies
Female
Hospitalization - statistics & numerical data
Humans
Logistic Models
Male
Middle Aged
Models, Statistical
Multivariate Analysis
Myocardial Infarction - mortality - therapy
Ontario - epidemiology
Severity of Illness Index
Sex Distribution
Survival Rate
Treatment Outcome
Abstract
Data in health research are frequently structured hierarchically. For example, data may consist of patients treated by physicians who in turn practice in hospitals. Traditional statistical techniques ignore the possible correlation of outcomes within a given practice or hospital. Furthermore, imputing characteristics measured at higher levels of the hierarchy to the patient-level artificially inflates the amount of available information on the effect of higher-level characteristics on outcomes.
Conventional logistic regression models and multilevel logistic regression models were fit to a cross-sectional cohort of patients hospitalized with a diagnosis of acute myocardial infarction. The statistical significance of the effect of patient, physician, and hospital characteristics on patient outcomes was compared between the 2 modeling strategies.
The 2 analytic strategies agreed well on the effect of patient characteristics on outcomes. According to the traditional analysis, teaching status was statistically significantly associated with 5 of the 9 outcomes, whereas the multilevel models did not find a statistically significant association between teaching status and any patient outcomes. Similarly, the traditional and multilevel models disagreed on the statistical significance of the effect of being treated at a revascularization hospital and 3 patient outcomes.
In comparing the resultant models, we see that false inferences can be drawn by ignoring the structure of the data. Conventional logistic regression tended to increase the statistical significance for the effects of variables measured at the hospital-level compared to the level of significance indicated by the multilevel model.
Notes
Comment In: Am Heart J. 2003 Jan;145(1):16-812514649
PubMed ID
12514651 View in PubMed
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