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1.
Teach Learn Med ; 35(1): 73-82, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-35023796

RESUMO

PROBLEM: Leading inpatient teams is a foundational clinical responsibility of resident physicians and leadership is a core competency for inpatient physicians, yet few training programs have formal leadership curricula to realize this clinical skill. INTERVENTION: We implemented a 4-module curriculum for PGY1 internal medicine residents. The program focused on the managerial skills necessary for daily clinical leadership, followed by clinical coaching. Interns were first introduced to foundational concepts and then given the opportunity to apply those concepts to real-world practice followed by clinical coaching. CONTEXT: Using direct-observations and a previously published checklist for rounds leadership, this study sought to evaluate the workplace behavior change for novice residents leading inpatient teams for the first time. We conducted a prospective cohort study (March 2016 and August 2018) of internal medicine residents at a large tertiary academic medical center in Boston, MA. Trained faculty raters performed direct observations of clinical rounding experiences using the checklist and compared the findings to historical and internal controls. Questionnaires were distributed pre- and post- curriculum to assess satisfaction and readiness to lead a team. IMPACT: We trained 65 PGY1 residents and raters conducted 140 direct observations - 36 in the intervention group and 104 among historical controls. The unadjusted mean score in rounds leadership skills for the intervention group was 19.0 (SD = 5.1) compared to 16.2 (SD = 6.2) for historical controls. Adjusting for repeated measures, we found significant improvement in mean scores for behaviors linked to the curricular objectives (p = 0.008) but not for general behaviors not covered by the curriculum (p = 0.2). LESSONS LEARNED: A formal curriculum to train residents as leaders led to behavior change in the workplace in domains essential to rounds leadership. We also found that the curriculum was highly regarded in that all interns indicated they would recommend the curriculum to a peer. Moreover, the program may have assuaged some anxiety during the transition to junior year as 90% of interns surveyed felt more ready to start PGY2 year than historical trainings. We learned that while a robust, multi-faceted modular curriculum and clinical coaching successfully resulted in behavior change, the resources required to manage this program are significant and difficult to sustain. Future iterations could include asynchronous material and potentially peer-observation of rounds leadership to reduce the burden on faculty and program curricular time.


Assuntos
Internato e Residência , Humanos , Pacientes Internados , Estudos Prospectivos , Currículo , Educação de Pós-Graduação em Medicina/métodos , Competência Clínica
2.
J Gen Intern Med ; 36(12): 3847-3851, 2021 12.
Artigo em Inglês | MEDLINE | ID: mdl-34240283

RESUMO

BACKGROUND: Few generalists engage in basic science research or feel comfortable teaching physiology at the bedside. This may reflect a lack of understanding or confidence teaching physiologic principles. AIM: To inspire general internists to relearn and teach physiology in clinical practice. SETTING: An active biomedical research laboratory. PARTICIPANTS: We educated 67 faculty participants (4 primary care, 59 hospitalists, and 4 other specialties) from 24 medical centers, representing 17 states. PROGRAM DESCRIPTION: The 5-day course was structured around re-learning basic physiology principles and developing teaching skills. Participants engaged in hands-on experiments through 4 modules using aquatic species, each paired with a physiology content primer. Participants also developed teaching scripts based on their experiments. PROGRAM EVALUATION: Post-course surveys revealed that 97% felt confident teaching physiology at the bedside, 100% felt the course enhanced their understanding of the mechanisms of disease, and there was a significant improvement in self-reported teaching ability. DISCUSSION: An immersive, hands-on faculty development course that integrated physiology with clinical decision-making increased participants' comfort level and self-rated ability to teach and incorporate physiology in their clinical work. We believe faculty development is one potential solution to the growing chasm between clinicians and scientists in general medicine.


Assuntos
Médicos Hospitalares , Medicina , Currículo , Docentes de Medicina , Humanos , Ensino
3.
J Gen Intern Med ; 35(4): 1161-1166, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31898139

RESUMO

BACKGROUND: In the context of inpatient general medicine, "rounding" refers to the process of seeing, assessing, and caring for patients as a team. The clinical leadership skills required of residents to lead rounds are essential to inpatient care and clinical education. Assessment of these skills has relevance to developing competent physicians; however, there is an absence of widely accepted tools to specifically measure this competency. OBJECTIVE: To develop and collect validity evidence for a direct observation instrument of internal medicine residents' leadership skills during daily inpatient care rounds for future formative assessment. DESIGN: Prospective observational study. PARTICIPANTS: PGY2 and PGY3 internal medicine residents. MAIN MEASURES: The authors collected inferences of validity evidence according to Kane's validity model. They performed direct observations of PGY2 and PGY3 residents by individual faculty and trained raters and measured inter-rater reliability, using the kappa statistic. Mixed linear regression models were used to compare PGY2 and PGY3 residents. Surveys captured faculty perceptions about value of the instrument. KEY RESULTS: A total of 223 observations were performed in 92 unique individuals. Twenty-four faculty used the observation instrument, of which 18 (75%) completed the post-survey, and 100% agreed that the instrument represented the resident's global leadership abilities. Inter-rater reliability was strong, with an overall kappa statistic equaling 0.82. The mean performance for PGY2 and PGY3 residents was 15.9 (SD 5.1) and 17.7 (SD 4.1), respectively. Adjusting for repeated measures, there was no statistically significant difference between groups. CONCLUSIONS: The authors reported evidence for all four stages of validity and use of the instrument in clinical practice. Their work provides a codification of best practices of rounding leadership, which directly impacts the education of trainees, care of hospitalized patients, and use for formative assessment. The instrument also has the potential to be used for summative assessment.


Assuntos
Internato e Residência , Competência Clínica , Humanos , Liderança , Estudos Prospectivos , Reprodutibilidade dos Testes
4.
Med Teach ; 42(9): 987-992, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-31663798

RESUMO

Background: Teaching subspecialty care to trainees who are not pursuing that subspecialty poses many challenges. These challenges are amplified in the teaching of oncology to non-oncologists because there are more new therapies emerging in oncology than in any other discipline, and there are few oncologic issues managed by generalists without consultation. Concurrently, there is an increasing need for generalists to manage many aspects of care for patients with cancer.Aim: To provide 12 tips for oncologists to use to educate trainees on their oncology rotations.Method: The tips provided are based upon the available literature and the authors' own experience.Results: The 12 tips presented offer specific strategies for oncologists to enhance their teaching by selection of appropriate content and enhancing delivery. Focus is placed on aspects of oncology that trainees are likely to encounter as a generalist or non-cancer subspecialist. While oncology is used as the case study, these strategies are adaptable to any subspecialty area.Conclusion: Oncologists and other subspecialists can be core medical educators.


Assuntos
Oncologia , Oncologistas , Humanos , Encaminhamento e Consulta
5.
Teach Learn Med ; 31(1): 109-118, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-29708437

RESUMO

ISSUE: Burnout in graduate medical education is pervasive and has a deleterious impact on career satisfaction, personal well-being, and patient outcomes. Interventions in residency programs have often addressed isolated contributors to burnout; however, a more comprehensive framework for conceptualizing wellness is needed. EVIDENCE: In this article the authors propose Maslow's hierarchy of human needs (physiologic, safety, love/belonging, esteem, and self-actualization) as a potential framework for addressing wellness initiatives. There are numerous contributors to burnout among physician-trainees, and programs to combat burnout must be equally multifaceted. A holistic approach, considering both the trainees personal and professional needs, is recommended. Maslow's Needs can be adapted to create such a framework in graduate medical education. The authors review current evidence to support this model. IMPLICATIONS: This work surveys current interventions to mitigate burnout and organizes them into a scaffold that can be used by residency programs interested in a complete framework to supporting wellness.


Assuntos
Educação de Pós-Graduação em Medicina , Internato e Residência , Motivação , Satisfação Pessoal , Teoria Psicológica , Estudantes de Medicina/psicologia , Esgotamento Profissional , Humanos
6.
Med Teach ; 39(9): 914-919, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28504023

RESUMO

BACKGROUND: A significant proportion of human communication is nonverbal. Although the fields of business and psychology have significant literature on effectively using body language in a variety of situations, there is limited literature on effective body language for medical educators. AIM: To provide 12 tips to highlight effective body language strategies and techniques for medical educators. METHOD: The tips provided are based on our experiences and reflections as clinician-educators and the available literature. RESULTS: The 12 tips presented offer specific strategies to engage learners, balance learner participation, and bring energy and passion to teaching. CONCLUSIONS: Medical educators seeking to maximize their effectiveness would benefit from an understanding of how body language affects a learning environment and how body language techniques can be used to engage audiences, maintain attention, control challenging learners, and convey passion for a topic. Understanding and using body language effectively is an important instructional skill.


Assuntos
Comunicação , Cinésica , Comunicação não Verbal , Ensino/organização & administração , Docentes de Medicina , Humanos , Aprendizagem
9.
Am J Med ; 137(7): 658-665, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38499135

RESUMO

BACKGROUND: Adults presenting with a neutrophil-predominant leukocytosis (white cell count >50,000/µL) often necessitate urgent medical management. These patients are diagnosed with either acute presentations of chronic myeloid malignancies or leukemoid reactions, yet accurate models to distinguish between these entities do not exist. We used demographic and lab data to build a machine learning model capable of discriminating between these diagnoses. METHODS: The medical record at a tertiary care medical center was queried to identify adults with instances of white counts greater than 50,000/µL and >50% neutrophils from 2000 to 2021. For each patient, a full set of demographic and lab values were extracted at the time of their first presentation with a white count >50,000/µL. We generated a series of models in which the parameters most predictive of myeloid malignancies were identified, and a supervised machine learning approach was applied to the dataset. RESULTS: Our best model-using a support vector machine algorithm-produced a sensitivity of 96% and a specificity of 95.9% (area under the curve = 0.982) for identifying myeloid malignancies. We also identified a clinically meaningful and significant disparity in outcomes based on diagnosis-a 6-fold increase in 12-month mortality in those diagnosed with leukemoid reactions. CONCLUSIONS: These findings need to be validated but fill an unmet need for timely and accurate diagnosis in the setting of profound, neutrophil-predominant leukocytosis and support the use of predictive models as a means to improve patient outcomes.


Assuntos
Algoritmos , Reação Leucemoide , Transtornos Mieloproliferativos , Humanos , Reação Leucemoide/diagnóstico , Masculino , Feminino , Pessoa de Meia-Idade , Transtornos Mieloproliferativos/diagnóstico , Diagnóstico Diferencial , Idoso , Contagem de Leucócitos , Adulto , Leucocitose , Aprendizado de Máquina , Neutrófilos , Sensibilidade e Especificidade , Máquina de Vetores de Suporte , Estudos Retrospectivos
10.
J Hosp Med ; 19(4): 259-266, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-38472645

RESUMO

BACKGROUND: In-hospital consultation is essential for patient care. We previously proposed a framework of seven specific consultation types to classify consult requests to improve communication, workflow, and provider satisfaction. METHODS: This multimethods study's aim was to evaluate the applicability of the consult classification framework to real internal medicine (IM) consults. We sought validity evidence using Kane's validity model with focus groups and classifying consult requests from five IM specialties. Participants attended five 1 h semi-structured focus groups that were recorded, transcribed, and coded for thematic saturation. For each specialty, three specialists and three hospitalists categorized 100 (total 500) random anonymized consult requests. The primary outcome was concordance in the classification of consult requests, defined as the sum of partial concordance and perfect concordance, where respectively 4-5/6 and 6/6 participants classified a consult in the same category. We used χ2 tests to compare concordance rates across specialties and between specialists and hospitalists. RESULTS: Five major themes were identified in the qualitative analysis of the focus groups: (1) consult question, (2) interpersonal interactions, (3) value, (4) miscommunication, (5) consult framework application, barriers, and iterative development. In the quantitative analysis, the overall concordance rate was 88.8% (95% confidence interval [CI]: 85.7-91.4), and perfect concordance was 46.6% (95% CI: 42.2-51.1). Concordance differed significantly between hospitalists and specialists overall (p = .01), with a higher proportion of hospitalists having perfect concordance compared to specialists (67.2% vs. 57.8%, p = .002). CONCLUSIONS: The consult classification framework was found to be applicable to consults from five different IM specialties, and could improve communication and education.


Assuntos
Medicina Interna , Encaminhamento e Consulta , Humanos , Grupos Focais
11.
Open Forum Infect Dis ; 11(5): ofae204, 2024 May.
Artigo em Inglês | MEDLINE | ID: mdl-38746950

RESUMO

Background: To end the HIV and hepatitis C virus (HCV) epidemics, people who use drugs (PWUD) need more opportunities for testing. While inpatient hospitalizations are an essential opportunity to test people who use drugs (PWUD) for HIV and HCV, there is limited research on rates of inpatient testing for HIV and HCV among PWUD. Methods: Eleven hospital sites were included in the study. Each site created a cohort of inpatient encounters associated with injection drug use. From these cohorts, we collected data on HCV and HIV testing rates and HIV testing consent policies from 65 276 PWUD hospitalizations. Results: Hospitals had average screening rates of 40% for HIV and 32% for HCV, with widespread heterogeneity in screening rates across facilities. State consent laws and opt-out testing policies were not associated with statistically significant differences in HIV screening rates. On average, hospitals that reflexed HCV viral load testing on HCV antibody testing did not have statistically significant differences in HCV viral load testing rates. We found suboptimal testing rates during inpatient encounters for PWUD. As treatment (HIV) and cure (HCV) are necessary to end these epidemics, we need to prioritize understanding and overcoming barriers to testing.

12.
J Med Educ Curric Dev ; 10: 23821205231184362, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-37378042

RESUMO

OBJECTIVES: Improved knowledge of hepatitis C virus (HCV) screening, linkage to care, and treatment is needed among nonspecialist medical professionals to combat the HCV epidemic. The authors sought to implement and analyze the impact of an HCV curriculum for primary care professionals (PCPs) across the state of Vermont, USA. METHODS: This investigation was a retrospective analysis of uptake of a Vermont HCV educational curriculum and its impact on HCV direct-acting antiviral (DAA) prescribing rates within the state before and after the study period. The curriculum was delivered online and in-person over 2 years from 2019 to 2020. The primary outcome was health care professional performance on a pre- and post-curriculum short-term knowledge assessment exam. The secondary outcome was assessing the number of unique healthcare professionals within a single payor database prescribing DAA treatment for HCV in Vermont before and after the study intervention, from January 1, 2017 until December 1, 2021. RESULTS: There were 31 unique respondents on the pre- and post-intervention examinations, which represented 9% of known participants. Respondents included physicians (n = 15), nurse practitioners (n = 8), and nurses (n = 8). Pre- and post-intervention knowledge scores increased significantly across all provider groups, from 3.2 (SD 0.6) to 4.5 (SD 0.4) 1 to 5 scale (P = .01). The total number of unique HCV DAA therapy prescribers decreased over the study period, from 17 in 2017 to 9 in 2021. CONCLUSIONS: A Vermont statewide HCV curriculum for PCPs was successful at increasing short-term HCV-related knowledge. However, this did not obviously translate to an increase in new professionals treating HCV.

13.
Public Health Rep ; 138(2): 265-272, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-35264027

RESUMO

OBJECTIVES: Incarcerated persons in the United States have a high burden of hepatitis C virus (HCV) infection. This study assessed the impact of a statewide effort in Vermont to treat HCV in this group. METHODS: We performed a retrospective, observational cohort study of all HCV-infected persons who were imprisoned in Vermont during the 19-month study period (December 2018-June 2020). The cascade of care comprised opt-out HCV screening, full access to direct-acting antiviral treatment (without hepatic fibrosis-based treatment restrictions), HCV specialist involvement, and medication-assisted treatment for patients with opioid use disorder. The primary outcome was sustained virologic response at 12 weeks after treatment completion (SVR12). RESULTS: The study included 217 HCV-infected patients; the median age was 35 years (range, 18-73 years), 89% were male, 76% had opioid use disorder, 67% had a psychiatric comorbidity, and 9% had cirrhosis. Of the 217 patients, 98% had a liver fibrosis assessment, 59% started direct-acting antiviral treatment, 55% completed direct-acting antiviral treatment, and 51% achieved documented SVR12. Of the 129 HCV-infected persons who started direct-acting antiviral treatment, 92% completed therapy and 86% achieved documented SVR12. Psychiatric comorbidity was not significantly associated with achieving SVR12 (odds ratio = 0.67; 95% CI, 0.27-1.65; P = .38), nor was receiving medication-assisted treatment for patients with opioid use disorder (odds ratio = 1.45; 95% CI, 0.62-2.56; P = .45). CONCLUSIONS: This study reports the highest SVR12 rate achieved in a state incarcerated population to date. HCV treatment in incarcerated populations is a practical and efficacious strategy that should serve a foundational role in HCV elimination.


Assuntos
Hepatite C Crônica , Hepatite C , Transtornos Relacionados ao Uso de Opioides , Prisioneiros , Humanos , Masculino , Adulto , Feminino , Hepacivirus , Antivirais/uso terapêutico , Estudos Retrospectivos , Vermont/epidemiologia , Hepatite C Crônica/complicações , Hepatite C/diagnóstico , Hepatite C/tratamento farmacológico , Hepatite C/epidemiologia , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/terapia , Resultado do Tratamento
14.
J Med Educ Curric Dev ; 10: 23821205231203908, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-37744421

RESUMO

OBJECTIVES: Although proficient systems-based practice is a foundational skill for physicians, how best to teach it has not been well established. An elective course for fourth-year medical students wherein participants had an immersive experience with multiple interprofessional staff was created and analyzed. The authors hypothesized that participating students and interprofessional staff would show gains in systems-based knowledge and interprofessional communication. METHODS: The course was a 2-week elective experience for fourth-year medical students at the Larner College of Medicine at the University of Vermont, Burlington, VT, USA. Participants integrated into a variety of interprofessional, non-physician, and administrative roles within the hospital system. Pre- and post-elective systems-based knowledge and interprofessional communication were assessed. Participating interprofessional staff were also surveyed on their experiences. RESULTS: From 2019 through 2022, 14 students participated in the elective, all of whom provided data. All participating students showed a quantitative improvement in systems-based knowledge and qualitatively commented on the high value of the elective in furthering their understanding of interdisciplinary care and communication. Of the 22 participating interprofessional staff surveyed, 17 responded (response rate 77%), and data showed high satisfaction with the experience and that having students learn more about their jobs improved their own job satisfaction. CONCLUSIONS: An immersive, hands-on experience with interprofessional colleagues showed dual benefits for both students and staff alike. Such an elective experience is scalable to other institutions nationally and should become a standard part of medical student curricula.

15.
J Med Educ Curric Dev ; 10: 23821205231173490, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-37163150

RESUMO

Objectives: Although some US medical schools have incorporated high-value care into their preclinical curriculum, there is no standardized approach and major curricular overhaul can be prohibitively onerous. The objectives of this study were to develop a feasible and effective high-value care curriculum, integrate it into an existing pre-clinical course, and assess student and faculty perceptions of the educational value of the curriculum. Methods: Between 2019 and 2021, University of Vermont preclinical medical students participating in the Students & Trainees Advocating for Resource Stewardship (STARS) program collaborated with the faculty director of the preclinical pathophysiology course to identify Choosing Wisely® recommendations relevant to course topics. For each recommendation, STARS students created a case-based, multiple-choice question, answer key and rationale to accompany standard course materials. At each year's course completion, participating students and faculty were invited to complete a survey to assess their perceptions of the curriculum. Results: Seventeen case-based questions were integrated into existing pathophysiology course sessions each year. Over the 3-year period, 420 students and 35 teaching faculty participated in the course, and 171 (40.7%) students and 24 (68.6%) faculty completed the post-course survey. Among student respondents, 80% agreed the curriculum increased their awareness of high-value care, 79% agreed they would be more likely to apply high-value care concepts during their medical career, and 92% agreed it was valuable to discuss Choosing Wisely® recommendations during the second year of medical school. Conclusion: A student-led initiative to incorporate high-value care content within an existing pre-clinical course was well-received by medical students, who reported increased awareness of and intention to apply high-value care principles. This model may offer a feasible and effective approach to high-value care education in the absence of an extensive formal curriculum.

16.
IDCases ; 29: e01526, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35693327

RESUMO

The authors report the case of a 45-year-old male with history of human immunodeficiency virus who presented unresponsive and with injuries to his hands after spending a night on a lakeside beach. During his hospitalization, he developed a fever with arthralgias and was initially thought to have calcium pyrophosphate dihydrate crystal deposition disease before a diagnosis of Rat Bite Fever was ultimately discovered. He was successfully treated with six-weeks of ceftriaxone. The authors discuss the epidemiology, diagnosis, treatment, and prognosis of Rat Bite Fever.

17.
IDCases ; 29: e01539, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35756699

RESUMO

The authors present the case of a bloodstream infection and sepsis due to Dietzia cinnamea in a severely malnourished patient with small bowel obstruction and pelvic abscess. The organism was identified with matrix-assisted laser desorption ionization-time-of-flight mass spectrometry. The authors discuss the characteristics, diagnosis, treatment, and emerging scope of clinical infection caused by Dietzia species.

18.
IDCases ; 30: e01615, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36119757

RESUMO

The authors report the case of a 42-year-old female with history of type I diabetes mellitus and recent episode of diabetic ketoacidosis who presented with symptoms of epistaxis, gastrointestinal upset, hyperglycemia, confusion, and a cough. She was found to have rhino-cerebral mucormycosis with associated multi-focal strokes and a left internal carotid artery pseudoaneurysm. Her infection was successfully treated with dual-antifungal therapy consisting of liposomal amphotericin B and isavuconazole, and required only minimal surgical debridement.

19.
IDCases ; 28: e01503, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35469210

RESUMO

The authors present the case of a 57-year-old male with a large polymicrobial brain abscess complicated by eruption into the intraventricular space. He was treated with parenteral ampicillin, cefepime, and metronidazole and adjuvant intraventricular vancomycin/gentamicin as well as surgical debridement. The authors discuss the diagnosis, treatment, and prognosis of brain abscesses, with a focus on prior cases with pyogenic ventriculitis and those treated with intraventricular antimicrobials.

20.
Open Forum Infect Dis ; 9(8): ofac380, 2022 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-35983262

RESUMO

Background: Patients who receive splenectomy are at risk for overwhelming postsplenectomy infection (OPSI). Guidelines recommend that adult asplenic patients receive a complement of vaccinations, education on the risks of OPSI, and on-demand antibiotics. However, prior literature suggests that a majority of patients who have had a splenectomy receive incomplete asplenic patient care and thus remain at increased risk. This study assessed the impact of standardized involvement of infectious diseases (ID) providers on asplenic patient care outcomes in patients undergoing splenectomy. Methods: A quasi-experimental study design compared a prospective cohort of patients undergoing splenectomy from August 2017 to June 2021 who received standardized ID involvement in care of the asplenic patient with a historic control cohort of patients undergoing splenectomy at the same institution from January 2010 through July 2017 who did not. There were 11 components of asplenic patient care defined as primary outcomes. Secondary outcomes included the occurrence of OPSI, death, and death from OPSI. Results: Fifty patients were included in the prospective intervention cohort and 128 in the historic control cohort. There were significant improvements in 9 of the 11 primary outcomes in the intervention arm as compared with the historic controls. Survival analysis showed no statistically significant difference in the incidence of OPSI-free survival between the groups (P = .056), though there was a trend toward improvement in the prospective intervention arm. Conclusions: Standardized involvement of an ID provider in the care of patients undergoing splenectomy improves asplenic patient care outcomes. Routine involvement of ID in this setting may be warranted.

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