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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

  • Professor of Medicine
  • Joint Appointment in Radiology and Radiological Science


Delphi method A technique used for the purpose of reaching an agreement on a particular issue order orlistat with amex weight loss urination, without the participants meeting or interacting directly purchase 60mg orlistat otc weight loss yoga routine. It involves sending participants a series of postal questionnaires asking them to purchase generic orlistat weight loss pills vegetarian record their views. After the frst questionnaire, participants are asked to give further views in the light of the group feedback. The judgements of the participants are aggregated, sometimes after weighting for expertise. The diagnostic odds ratio is defned as the positive likelihood ratio divided by the negative likelihood ratio. Diagnostic study A study to assess the effectiveness of a test or measurement in terms of its ability to accurately detect or exclude a specifc disease. Dipstick A diagnostic test consisting of a chemically sensitive strip which when dipped into a sample can be used to detect the presence of leucocyte esterase, nitrites, glucose or protein. Images of the bladder and kidneys are taken as the bladder is flled and during voiding. It is used to identify renal parenchymal defects, some of which are due to chronic pyelonephritic scarring. The radiation dose incurred is approximately 1 mSv, equivalent to 4 months of natural background radiation (about 40?50 chest radiographs). Dominance A term used in health economics describing when an option for treatment is both less clinically effective and more costly than an alternative option. Double-blind study A study in which neither the subject (patient) nor the observer (investigator/clinician) is aware of which treatment or intervention the subject is receiving. Economic evaluation A comparison of alternative courses of action in terms of both their costs and consequences. Effcacy the extent to which a specifc treatment or intervention, under ideally controlled conditions. Elective A term for clinical procedures that are regarded as advantageous to the patient but not urgent. Empirical Based directly on experience (observation or experiment) rather than on reasoning alone. Encopresis Repeated soiling in children 4 years or older, most often involuntarily but occasionally intentionally. Epidemiology the study of diseases within a population, covering the causes and means of prevention. Event rate the proportion of patients in a group for whom a specifed health event or outcome is observed. Evidence based the process of systematically fnding, appraising and using research fndings as the basis for clinical decisions. Evidence-based clinical practice Evidence-based clinical practice involves making decisions about the care of individual patients based on the best research evidence available rather than basing decisions on personal opinions or common practice (which may not always be evidence based). Evidence-based clinical practice therefore involves integrating individual clinical expertise and patient preferences with the best available evidence from research. Evidence table A table summarising the results of a collection of studies which, taken together, represent the evidence supporting a particular recommendation or series of recommendations in a guideline. Experimental study A research study designed to test whether a treatment or intervention has an effect on the course or outcome of a condition or disease where the conditions of testing are to some extent under the control of the investigator. Controlled clinical trial and randomised controlled trial are examples of experimental studies. May also be referred to as the generalisability of study results to non-study patients or populations. Extrapolation the application of research evidence based on studies of a specifc population to another population with similar characteristics. It is a method of group interview or discussion, commonly involving 6?12 people, focused around a particular issue or topic. Focused question A study question that clearly identifes all aspects of the topic that are to be considered while seeking an answer. Questions are normally expected to identify the patients or population involved, the treatment or intervention to be investigated, what outcomes are to be considered, and any comparisons that are to be made. Forest plot A graphical display of results from individual studies on a common scale, allowing visual comparison of results and examination of the degree of heterogeneity between studies. They show the treatment effects estimated from separate studies on the horizontal axis against a measure of sample size on the vertical axis. Generalisability the extent to which the results of a study hold true for a population of patients beyond those who participated in the research. Gold standard A method, procedure or measurement that is widely accepted as being the best available. A guideline development group may produce a ?good practice point? (rather than an evidence-based recommendation) on an important topic when there is a lack of research evidence. A, B, C) linked to a guideline recommendation, indicating the strength of the evidence supporting that recommendation. Grey literature Reports that are unpublished or have limited distribution, and are not included in bibliographic retrieval systems. A good guideline makes recommendations about treatment and care, based on the best research available, rather than opinion. It is used to assist clinician and patient decision making about appropriate health care for specifc clinical conditions.

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Sacral neuromodulation decreases the number of urge incontinence episodes by at least 50 percent among patients refractory to generic 60mg orlistat mastercard weight loss kickstart conservative therapies buy cheap orlistat 60 mg on line weight loss pills at gnc. Sacral neuromodulation seems to discount orlistat 60 mg visa weight loss xtreme have less of a benefit for urinary urgency (mixed results found in our review) and frequency (31 to 45 percent decrease), with benefits in frequency tapering off over time (23 percent reduction in daily voids at 5 years). Early studies using older 100 115, 124 technology had more than one adverse event per subject, on average; studies employing 112, 119 newer technology report lower rate, with events in 11 to 53 percent of subjects. Nearly 40 percent describe pain or an unpleasant stimulation, 7 to 48 percent returned to the operating room (this increased to 67 percent at five years, but includes the need to change the implantable pulse generator battery) and between 2 to 6 percent have an infection (often requiring hospitalization, intravenous antibiotics or explantation). Our review included only one study on peripheral neuromodulation, using an anal and/or vaginal probe. Benefits in frequency were unlikely to be clinically significant (decrease from 9 to 8 voids daily) and there was a high dropout rate due to pain and effects on the bowels. Other forms of peripheral neuromodulation such as posterior tibial stimulation were not reviewed. Of the drugs injected or instilled into the bladder, botulinum toxin and oxybutynin had the greatest benefit. One trial demonstrated benefit of instillation of oxybutynin compared to sterile 126 water in the reduction of voids per day (average reduction of 6. A trial we identified and the recent review by the Cochrane Collaboration found that small trials suggest benefit though researchers continue to evaluate means to decrease the risk of undesired side effects like urinary retention with botulinum toxin. Both botulinum toxin and instilled oxybutynin increase the postvoid residuals and the long term effects of higher residuals in terms of bladder infection and other risks is not known. Although evidence for these approaches is promising, the strength of the literature is inadequate to recommend any of these approaches for broader use in general practice. Older treatment modalities such as prolonged bladder distention or bladder transection are no longer commonly used due to the morbidity of these procedures. The reviewed studies also lacked rigorous methods for evaluating treatment benefit. Most of the literature addressing behavioral interventions (with or without comparison to pharmacologic intervention) was of fair or poor quality. In general, studies of behavioral approaches rarely included a true and comparable placebo arm. Although it is well recognized that there are inherent challenges to developing placebos for behavioral techniques, a reasonably strong evidence base on means of 143 doing so suggests that it is possible. Burgio and colleagues worked to mitigate this issue by maintaining similar visit schedules and through the use of bladder diaries in all groups, which was considered adequate masking for quality grading purposes. Particularly in older studies (prior to 2002), the behavioral approach often is not fully described; and inconsistency in the language used to identify different approaches requires the reader to examine the manuscripts very carefully multiple studies may have called their approach by the same name, but in fact be studying quite different interventions. To mitigate against such confusion, we have attempted in this report to always describe the intervention along with the first description of results from a given study. Prior treatment attempts are rarely documented in this work, which may make it difficult to compare treatment groups across studies. Finally, this body of literature includes very few studies that included similar combinations of intervention and comparator making it almost impossible to summarize across them. Conclusions about the effectiveness of behavioral techniques for addressing the symptoms of overactive bladder are based on a total of 29 papers (27 studies) that encompass behavioral to behavioral comparisons as well as studies of combining behavioral approaches with pharmacologic treatment, and the reverse, combining pharmacologic approaches with behavioral ones. Overall, behavioral approaches can be effective in reducing episodes of incontinence and daily voids. Multicomponent approaches are most effective, and they perform relatively equivalent to pharmacologic treatment. Generally speaking, reductions in symptoms were modest, with potential decreases in incontinence episodes of up to 1. The addition of caffeine reduction to behavioral modification reduced frequency, but made no difference in reduction of incontinence episodes. There is no evidence the behavioral approaches enhance the effectiveness of pharmacologic therapy to reduce episodes of incontinence; and like pharmacologic approaches, there is no evidence for long term effectiveness beyond the period during which the intervention is being provided in the health care setting. Women felt they were improved as measured by scales that capture bother and quality of life. Evidence for direct comparisons of treatments was based on 19 studies: 12 were fair and 7 poor. Nine of these comparisons explicitly examined outcomes for urge urinary incontinence episodes and voids per day. In this context 102 lack of statistical differences between active drugs is somewhat uninformative as trials were often powered for the comparison of the drugs individually to placebo and in many cases statistical testing of the outcomes of drug-to-drug comparison are not provided. Strict application of inclusion criteria for this review would have eliminated virtually all studies of procedures for this reason. Masking, though challenging, was approximated by insertion of leads for sacral neuromodulation without activation; however given that a test period is done to establish efficacy before implantation of the permanent device, individuals may have been aware of their status and assessment of unmasking is not provided. Variations in the behavioral approaches used and methods for teaching them, as well as differences in the duration and intensity of treatment make comparisons challenging. As a category the methods were generally strong with the continued challenge of developing attention control comparison methods and documenting testing of the degree to which individuals believed they knew their treatment status. Both oxybutynin and tolterodine in 83, 140 extended release form were superior to tolterodine in immediate release forms. Given heterogeneity of participant populations and study designs, this limited number of studies is insufficient for any drug to be considered definitively superior. For procedures, sacral neuromodulation was compared to wait list participants on medications. It is important to note that failure of prior medical management was a criteria for entry into the study; those waiting had worsening of many symptoms. No conclusions can be reached with this data and future research should address the 124 differences in risk profile of sacral neuromodulation versus medications. One study in this group reported significant reductions in incontinence episodes with a multi-component 143 intervention; no study found differences in reductions in voids per day.

It is an autosomal recessive form in which one abnormal gene is inherited from both parents discount 60mg orlistat with amex weight loss yoga. Ristocetin Cofactor Assay the Ristocetin Cofactor Assay Measures the Functional Level of von Willebrand Factor in Plasma Indications (Ristocetin Cofactor Assay): 1 effective orlistat 120 mg weight loss pills prescribed by doctors. The Ristocetin Cofactor Assay is performed by agglutinating a standardized suspension of platelets in the presence of von Willebrand Factor (provided by the patient plasma) using the antibiotic cheap orlistat line weight loss using coconut oil, Ristocetin. Although the platelets play a passive role in such agglutination, there is an absolute requirement that the Ristocetin-dependent receptor be intact. Levels of Ristocetin Cofactor activity are determined by the ability of the test plasma and Ristocetin to induce aggregation in a standardized platelet suspension. Following reconstitution, lyophilized platelets are treated with Ristocetin in the presence of dilutions of normal standardized human plasma with a known amount of Ristocetin Cofactor Activity. A standard curve is prepared, after which patient plasma is then used as a source of Ristocetin Cofactor Activity. The Ristocetin Cofactor Activity of the patient sample is interpolated from the standard curve. This loss of higher molecular weight multimers will be reflected in an abnormal distribution of multimers. Prolonged transport of samples to the laboratory or inadequate sample preparation. In type 1 von Willebrand disease, there is a mild to moderate reduction in the amount of this protein. In extremely rare instances, anti-rabbit antibodies that can lead to aberrant test results in affected individuals. Diagnosis of the hypercoagulable state associated with resistance to activated Protein C caused by the Factor V Leiden gene mutation. The sensitivity and specificity of the assay for activated protein C resistance is unaffected by plasma samples obtained from patients on warfarin. The prescribed assay procedure allows for the analysis of plasma from heparinized patients at heparin levels < 1U/mL plasma (un-fractionated and low molecular weight heparins). Although the 1:4 pre-dilution strongly decreased interference, the assay may give misleading results in patients with high titer inhibitors (lupus anticoagulants). Hence, the presence of this mutation is responsible for the vast majority of cases of activated Protein C resistance. This complex allows the cleavage and release of a fluorescein tag, which can be detected by a fluorescence plate reader. If the mutant factor V sequence is present instead of the wild type sequence then only the mutant probes form a complex and only this sample generates a fluorescence signal. Likewise if both mutant and wild type sequences are present (the heterozygous states), both probes generate a signal. Wild type and mutant controls are included on each run to assist in signal interpretation. Possible results and interpretation (Factor V Leiden): Patients can be negative for the Factor V Leiden mutation, heterozygous or homozygous for the mutation. The presence of Factor V Leiden is a potent risk factor for venous thrombosis, with heterozygotes and homozygotes having a 5-8-fold and 50-fold, respectively, increased risk of thrombosis. There is a substantial variation in the Factor V Leiden gene frequency according to the ethnic background of the individual. There is also an association between this mutation and an increased risk of cerebrovascular disease among young individuals. The risk of thrombosis increases 20-25 times normal when this mutation occurs in conjunction with Factor V mutation. Homocysteine this Test Measures the Concentration Of Homocysteine in A Patient Sample Indications (Homocysteine): 1. Possible results and interpretation (Homocysteine): Homocysteine is a thiol-containing amino acid produced during the metabolism of methionine that can be re methylated back to methionine by methionine synthase (cobalamin and folate are cofactors) or converted to cysteine by cystathionine-beta-synthase (pyridoxine is a cofactor), in a trans-sulfuration step. Homocysteine has numerous effects on various components of hemostasis, but the mechanism by which it promotes thrombosis is not completely clear. Hyperhomocysteinemia has been associated with a 2-3 fold increased risk of venous and arterial thrombosis. Markedly elevated levels of homocysteine (can be several hundred micromol/L or more) can be seen in patients with the autosomal recessive metabolic disorder, homocystinuria. Cause of hyperhomocysteinemia may occur as a result of inherited disorders that alter the enzyme activity in the remethylation and transulfuration pathways or by nutritional deficiencies of cobalamin (vitamin B12), folate or pyridoxine (vitamin B6). Factors affecting test results (false positives and negatives) (Homocysteine): the assay is sensitive and specific with no interfering reagent peaks. However, differences in sample handling can cause significantly different results in homocysteine measurement. The homocysteine in plasma/serum samples is stable for at least several days in room temperature, for several weeks at 4oC and for years at -20 oC. Activated Partial Thromboplastin Time (Described above in the Screening test section) F. Although the presence of these antibodies can prolong phospholipid based coagulation tests in vitro, these antibodies are associated with an increased risk of thrombosis and fetal loss in vivo. If the ratio results are within the established laboratory normal reference ratio range (? Antiphospholipid antibodies have been associated with an increased risk of venous and arterial thrombosis and fetal loss. Serum samples are incubated in microtiter plate wells coated with anticardiolipin.


  • Forney Robinson Pascoe syndrome
  • Adrenal hyperplasia
  • Bardet Biedl syndrome, type 4
  • ABCD syndrome
  • Hypoaldosteronism
  • Hemorrhagiparous thrombocytic dystrophy
  • Miculicz syndrome
  • Hepadnovirus D
  • Diffuse idiopathic skeletal hyperostosis

When menopause starts suddenly generic orlistat 60mg visa weight loss after pregnancy, the symptoms are usually more severe than natural menopause because your body hasn?t had time to discount orlistat weight loss tea get used to order orlistat once a day weight loss cleanse the gradual loss of hormones. Premature menopause may also cause bones to weaken (known as osteoporosis or osteopenia). The loss of menstruation and fertility earlier than you expected may afect your sense of identity, or make you feel older than your age or friends. Tese treatments include: surgery in which both of your ovaries are removed; hormone therapy to decrease your ovaries? production of oestrogen; and radiation therapy and chemotherapy, which may afect your ovaries? ability to produce eggs and hormones. If your uterus is removed (hysterectomy) but one of your ovaries remains, you will no longer have monthly periods or be able to carry a child, but you will continue to produce oestrogen and can still go through natural menopause at the normal stage of life. If both of your ovaries and/or your uterus are removed, your periods will stop and you will experience a surgical menopause. See also Coping with vaginal changes on pages 50?51 for tips on coping with a dry vagina caused by menopause. Overcoming specific challenges 63 Fertility issues Some cancer treatments can cause infertility (difculty conceiving a baby), which can be temporary or permanent. If fertility is important to you, talk to your doctor before treatment starts about your risk of infertility and ways to preserve your fertility. When people learn that they may be permanently infertile, they ofen feel a great sense of loss. You may be devastated that you won?t have your own children or additional children, and you may worry about the impact of this on your relationship or future relationships. Even if your family is complete or you weren?t planning to have children, you may experience strong emotions. As well as talking with your partner, it may help to talk with a counsellor, sex therapist, oncologist, urologist or oncology nurse. If female reproductive organs are affected Surgery that removes part or all of the reproductive organs, such as the ovaries, fallopian tubes, uterus and cervix will cause your periods to stop and you will be unable to have children naturally. Depending on the type of chemotherapy drugs used and the dose, periods may become irregular but ofen return afer treatment ends. If sperm production is affected Surgery for bladder, prostate or testicular cancer may damage the nerves for getting and keeping an erection this may be temporary, 64 Cancer Council but some men may not get strong erections again. Chemotherapy may reduce or stop sperm production and afect the ability of sperm to move. If you have radiation therapy in the pelvic or groin area, you may have temporary or permanent fertility problems afer treatment. Radiation therapy to the brain may damage the pituitary gland, which afects the production of sperm and afects sex drive. You may need to > See our Fertility and use barrier contraception, Cancer booklet. Overcoming specific challenges 65 Key points about specifc challenges Talk openly Communicating openly with your partner may help you overcome any sexual problems caused by cancer treatment. Take time to get used to the changes and explore how your sexual response has changed. Physical issues Physical changes may make some of your usual sexual practices and positions uncomfortable or painful. Try to have an open mind about exploring some new ways of giving and receiving sexual pleasure. If you think you may want to have children in the future, talk to your doctor before treatment begins. Try to look afer yourself give yourself some time out and share your worries or concerns with somebody neutral, such as a counsellor or your doctor. Worrying about cancer and the way it may afect your life can interfere with your desire for sex, yet your partner may be craving physical contact. On the other hand, it may be that your partner seems to have lost interest in sex, and you may feel guilty or uncomfortable for even bringing up the topic for fear of placing pressure or appearing unsupportive. Over time, you both might get used to a relationship without intimacy or sex, assuming that this is the new way of living or ?new normal. If you and your partner have never talked much about sex before or you fnd it difcult to discuss your diferent needs without both becoming defensive, consider asking for help. A counsellor, sex therapist or psychologist can suggest ways to approach such conversations. They can help you talk about your sexual concerns and how the physical needs in the relationship can be met. Concerns for partners 67 Try other forms of intimacy If your partner is not ready for sexual contact, touching, holding, hugging and massaging can help you feel close with your partner and show you love them and fnd them physically attractive. Physical contact that doesn?t lead to sex can still be comforting and ofen helps to take the pressure of both of you. Stroking their scars may show your partner that you have accepted the changes to their body. If you are fnding the changes hard, try talking sensitively to your partner or to a counsellor. Ian Acknowledge your feelings You may have had to face the possibility that your partner could die. As they have recovered, you may expect to feel relieved but instead feel emotionally low and drained of energy. Acknowledge that you and your partner have been through a difcult and confronting experience and allow yourselves time to adjust. Look after yourself Relationships are ofen challenged through a cancer experience. Try talking openly about changes to the relationship and how you can readjust your life around them. If your partner possible for your partner is having internal radiation to transmit cancer through therapy, you may need to take intimate activities such as some precautions, such as kissing or intercourse.


Paraphimosis can often be effectively treated People with catheters should also be supported by manual manipulation of the swollen foreskin to buy orlistat with amex weight loss pills fda approved understand best practice on the indications for tissue purchase discount orlistat line weight loss diets. This involves compressing the glans the need and use of antibiotics as part of broader and moving the foreskin back to 120 mg orlistat free shipping weight loss 20 lbs its normal antimicrobial stewardship programmes in health position, perhaps with the aid of a lubricant, and care settings. If this fails, the tight oedematous band National Occupational Standards of tissue can be relieved surgically with a dorsal slit or circumcision. The erosion is usually secondary to catheter tension on the distal urethra at the meatus. The way the catheter is secured should be alternated to prevent prolonged tension or pressure at an individual site. Catheter maintenance solutions, bladder washouts and irrigation Bladder irrigation, instillation and washouts. When considering the use of washouts/ Catheter maintenance maintenance solutions, there must be evidence solutions of an individualised assessment and the clinical indication for use must be recorded. These are sterile prefilled prescription-only products, they should only be used when all other options have been considered. Evidence Bladder irrigation suggests smaller volumes, instilled sequentially, are more effective than large volume single this is a continuous irrigation of the bladder via a administrations. This method of the use is based on an individual assessment and irrigation is normally used for short periods only several considerations must be made before use. Use once weekly, up to a maximum of twice daily (depending on severity of symptoms). Use once a week, up to a maximum of twice a day (depending on severity of symptoms). Instil for 5 to 10 minutes in the bladder (5 to 10 minutes prior to removal of a catheter). Anti-microbial catheter inflation solution Clinical evidence suggests that many catheter encrustations are caused by Proteus mirabilis. Using Triclosan in the catheter balloon inflation solution has been shown to improve the patency of the catheter and improve the patient experience. The clinical evidence is limited, but expert opinion recommends this should be immediately (if the patient is stable and comfortable) or within 48 to 72 hours of starting antibiotic treatment European Association of Urology. There is a lack of evidence on the role of catheters at end of life/palliative care. The relaxation of the urethral sphincters of the bladder, causing urinary incontinence, can indicate approaching death. However, if a full distended bladder or urinary retention is suspected, then prompt action of urethral catheterisation is needed before the patient becomes agitated or distressed. It is important to note that retention can be a peripheral side effect of opioid medication. An evidence-based approach to the prevention of catheter-associated urinary tract infections, Bardsley A (2017) How to remove an indwelling Urologic Nursing 34(5): 238?245. Journal of Evidence-Based Healthcare 14(4): Davey G (2015) Troubleshooting indwelling 188?189. Prinjha S and Chapple A (2014) Patients? McCoy C, Paredes M, Allen S, Blackey J, Nielsen experiences of living with an indwelling urinary C, Paluzzi A, Jonas B and Radovich P (2017) catheter, British Journal of Neuroscience Catheter-Associated Urinary Tract Infections Nursing 10(2): 62. British catheter-associated urinary tract infections in Journal of Nursing 25(9): S4?S13. Yates A (2017) Urinary catheters 6: removing an indwelling urinary catheter, Nursing Times Townsend T and Anderson P (2015) Decreasing [online] 113(6): 33?35. Holroyd S (2017) A new solution for indwelling Holroyd S (2017) A new solution for indwelling catheter encrustation and blockage, Journal of catheter encrustation and blockage, Journal of Community Nursing 31(1): 48,50?52. International Journal of Urological Nursing Sandle T (2013) Using an antimicrobial skin 9(3): 138?142. Spinks J (2013) Urinary incontinence and the Catheter gels importance of catheter fixation, Journal of Farrington N, Fader M and Richardson A (2013) Community Nursing 27(5): 24?29. Managing urinary incontinence at the end of Wilson M (2016) Urinary catheter securement life: an examination of the evidence that informs and fixation in residential care homes, Nursing practice, International Journal of Palliative and Residential Care 18(9): 476?479. Yates A (2013) the importance of fixation and Farrington N, Fader M, Richardson A, Prieto J, securing devices in supporting indwelling Bush H (2014) Indwelling urinary catheter use catheters, British Journal of Community at the end of life: a retrospective audit, British Nursing 18(12)588?90. Yates A (2015) An essential part of catheter Farrington N, Fader M, Richardson A, Sartain management, Nursing and Residential Care S (2015) Exploring the role of practical nursing 17(2): 75?76. Steggall M and Jones K (2015) Anaesthetic or lubricating gels for urethral catheterisation? Urinalysis and dipsticks Williams C (2017) Making a choice of catheterisation Bardsley A (2015) How to perform a urinalysis, gel and the role of chlorhexidine, British Journal of Nursing Standard 30(2): 34?6 Community Nursing 22(7): 346?351. Test papers to dipsticks in 72 years, Journal of Professional Standards of Practice for nurses, Renal Nursing 6(2): 99. Catheters and sepsis Royal College of Nursing (2016) Female Genital Eley R (2015) Cardboard versus sterile containers: Mutilation. Royal College of Nursing (2018) Older People Melzer M and Welch C (2017) Does the presence in Care Homes: Sex, Sexuality and Intimate of a urinary catheter predict severe sepsis in Relationships, available at Journal of Hospital professional-development/publications/pub Infection 95(4): 376?382. Geng V, Cobussen-Boekhorst H, Farrell J, Gea-Sanchez M, Pearce I, Schwennesen T, Vahr S, Vandewinkel C (2012) Catheterisation.


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