Erroneous laboratory results

Elias Peter pheski69 at GMAIL.COM
Sun May 29 17:42:18 UTC 2016


I suspect that we agree more than we disagree. The internet magnifies that.

I agree:
There is lots of value in this study. 
It has to be read carefully and more than once.
Most clinicians have a poor understanding about the costs involved in laboratory testing. I suspect that clinicians tend to underestimate the cost of many individual tests and overestimate the overall cost of testing. (Institutions contribute to this by not putting the cost on the page/form where tests are ordered. We have asked for that for years in our institution, but can’t even actually generate conversation about it.)
Clinicians would like to order the correct test and ONLY the correct test - and our systems are not just not designed to help, they are designed to make that nearly impossible.
We are just entering an era where complex (and probably expensive) testing will move from novelty to useful to necessary if we want to practice highly individualized genetically and epigenetically informed patient-specific safe and high quality medicine. (If we think it is hard to know what test to order now, just wait a decade.OMG.)

I don’t agree that every patient with chest pain should have a troponin. If you mean, every patient where cardiac chest pains a consideration, yes, I would agree. The 14 year old with pleuritic chest pain, cough, fever and an infiltrate? The 22 year old non-smoker with no family history who has had four days of chest pain after falling off a horse? The 62 year old with no known cardiac disease and no risk factors (other than age and male) who has chest pain in the area of their classic zoster?  In the first two, a (+) troponin is almost surely a false (+). In the third, well, how do we balance the ‘obvious’ cause of the pain against the possibility that they have two ongoing processes?

I also don’t agree that 70% of decisions ***in primary care*** are leveraged by or need to be informed by lab testing. In primary care, one of the biggest challenges is separating the medically (biologically) based illness from problems of living and feeling. In these settings, where the prevalence of *relevant* disease is so low, laboratory testing does not help and often hurts. I would estimate that easily 3 out of 4 patients I see with fatigue or insomnia or back pain or knee pain or indigestion or skin lesions or dizziness should not have lab testing at their initial evaluation. 

Most importantly, I agree absolutely with the need to find ways to help clinicians better select and use the right test at the right time.  It would seem to me that we should be much further down this path than we are, given how many other algorithms are actively making suggestions to people who are not intentionally feeding information to the algorithm or depending for life-death decisions on the outcome. Amazon and Facebook are doing more than any EHR I have ever seen.

Let’s not focus so much on the differences in our perspectives driven by my primary care experience and your laboratory experience that we do not get around to talking about how to make things better.

I’d like a system that allows me to enter data (and harvests it from the prior data in the record) and gives me information about things I need to consider, along with options about testing, including sensitivity, specificity, interferences, cost. I don’t want this to slow me down with the patient with 24 hours of a runny nose and sore throat, no fever, and normal exam. But I want to be able to invoke it when they are getting worse 5 days later. And there are probably times when it should intrude itself on me regardless of whether or not I think it is necessary, not unlike the noise my car makes if I forget to buckle my seat belt.

Peter



> On 2016.05.29, at 1:21 PM, Mario Plebani <mario.plebani at unipd.it> wrote:
> 
> 
> Dear Peter,
> 
> again, I agree and disagree with you.
> The study presents some limitations but if you rad it carefully, there
> are some interesting messages. First and foremost, clinicians
> overestimate the costs of laboratory tests but, even more important,
> they would like to request only test that are useful for the decision
> making.
> From this viewpoint, there is the need to improve the appropriateness
> of test request and interpretation but also to recognize that the new
> generation of laboratory tests, including genomics, strongly influence
> the decision making and patient pathways. Think about cardiac
> troponin. In this case 100% of patients with chest pain should be
> tested. any generalization in medicine is wrong but the paper I sent
> you it's useful to answer the request of some more evidence-based
> evidence of the 70% claim.
> The most intriguing question is how we should improve the appropriate
> request and utilization of laboratory information to provide valuable
> clinical information and reduce the risk of patient harm. And we must
> work on this.
> Thanks
> Kind regards
> M Plebani, MD
> 
> 
> Elias Peter <pheski69 at gmail.com> ha scritto:
> 
>> My primary concern was not the cost statistic, as that is relatively
>> easy to obtain and verify. My concern was (and remains) the claim
>> that 70% of clinical decision making is dependent on laboratory
>> testing.
>> 
>> The study you provided is interesting but I don’t think it answers
>> this question. It is limited to oncologists and cardiologists, so it
>> is not a representative sample and cannot be generalized to medical
>> care as a whole. And it is an interview, asking clinicians, in
>> effect, how often did the lab testing they arranged have an impact
>> on decision making. One would expect this to generate a high number,
>> as it would be unlikely that a large percentage of narrow-scope
>> specialists who practice in relatively laboratory intensive fields
>> would respond to an interview question by saying that most of the
>> lab they do has no impact on care.
>> 
>> Peter Elias
>> 
>> 
>>> On 2016.05.28, at 3:30 AM, Mario Plebani <mario.plebani at unipd.it> wrote:
>>> 
>>> Dear Elias
>>> 
>>> while I agree with most of your sentences, I have to disagree with
>>> the story of the 70% claim. There is a recently published paper
>>> (attached) confirming that in oncology and cardiology (in the US
>>> and Germany) about 65% of clinical decisions are based on
>>> laboratory tests and that the costs compared with the total
>>> spending for healthcare is about 2.4% in the US and lower (1.6%) in
>>> Germany.
>>> There is an overestimation of laboratory costs and an
>>> underappreciation of the value of the laboratory information if
>>> tests are appropriately requested and interpreted. This is a matter
>>> of quality and patient safety, for sure. And this is particularly
>>> true in an era of "omics" and personalised medicine if we really
>>> would like to have early diagnoses, identification of risk factors
>>> and not a reactive medicine.
>>> We are working to improve the appropriate utilization of the
>>> laboratory information and to reduce diagnostic errors.
>>> Regards
>>> Mario Plebani, MD
>>> 
>>> Da: Elias Peter [mailto:pheski69 at GMAIL.COM]
>>> Inviato: venerdě 27 maggio 2016 23.43
>>> A: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>> Oggetto: Re: [IMPROVEDX] Erroneous laboratory results
>>> 
>>> Regarding the relative roles of history, exam and extra testing,
>>> context matters. A lot.
>>> 
>>> For the majority of patients in a primary care office presenting
>>> with a new issue, a properly done history and exam coupled with the
>>> diagnostic device between our ears and allowed to work for
>>> sufficient time will provide the diagnosis in an overwhelming
>>> majority of cases. (Based both on 40 years personal experience and
>>> a fair amount of literature.)
>>> 
>>> Further testing (lab, radiology, following the natural history by
>>> seeing the patient back and repeating the initial process after a
>>> suitable wait) are very useful to:
>>> 
>>> Confirm a suspected diagnosis, especially important if the
>>> diagnosis is going to lead to treatment that could do harm if the
>>> diagnosis is wrong.
>>> Evaluate the extent of the diagnosis (anemia with a hemoglobin of 6
>>> and MCV of 68 is different from anemia with a hemoglobin of 9 and a
>>> normal MCV).
>>> Differentiate among several possible diagnoses that could explain
>>> the presentation.
>>> Investigate why a treatment based on a diagnosis has not had the
>>> expected result.
>>> Reassure the patient or clinician.
>>> Satisfy an external process (“What do you mean you started the
>>> patient on a BP medicine for newly diagnosed hypertension without
>>> checking an LDL and calcium?”)
>>> 
>>> In primary care, however, additional testing at the initial visit
>>> often reflects less admirable triggers:
>>> 
>>> No clue what’s going on. Let’s go fishing. (How many red herrings
>>> can we catch along with the target fish?)
>>> Too little time to do a good history and exam.
>>> Too little training to do a good history and exam.
>>> Too little experience to trust one’s history and exam.
>>> The reasonable possibility that there is a time-sensitive and life
>>> threatening issue that will only be identified by further testing.
>>> (Feared far more often than justified.)
>>> 
>>> That’s in primary care and with a known patient presenting with a
>>> new problem.  If I am on call for my local hospital and the ED
>>> calls me to evaluate/admit a patient I do not know with severe
>>> abdominal pain. that is a totally different story. If I am treating
>>> a patient with a medicine that affects potassium or renal function
>>> or can depress platelet production or Vitamin K metabolism,
>>> laboratory studies can be essential and skipping them is like
>>> driving with one’s eyes closed.
>>> 
>>> With regard to the claim that 70% of medical decisions are based on
>>> laboratory studies which represent 5% of costs, I believe that is
>>> an example of a ‘zombie’ statistic that has been refuted but
>>> refuses to die. A couple years ago in preparation for a talk, I
>>> tried to find the origin. I think it comes from this paper by
>>> Forsman in 1996 (http://www.clinchem.org/content/42/5/813.full.pdf
>>> <http://www.clinchem.org/content/42/5/813.full.pdf>) where it is
>>> stated but not referenced beyond saying that at Mayo they knew that
>>> 5% of their costs at Mayo (which are arguably not broadly
>>> representative) were lab related and that 70% of ‘critical
>>> decisions’ (admissions, discharges, drug therapy) were ‘leveraged
>>> by’ lab results.  If someone has newer documentation about this, I
>>> would love to hear.
>>> 
>>> One of the problems, and this is what I understood Jason Maude to
>>> be referencing, is that laboratory testing -= because it is
>>> concrete and easy to measure/monitor - is talked and written about,
>>> used as a metric, specified in recipes far more often than the
>>> cognitive processes which should occur prior to obtaining the
>>> laboratory study, in order to be able to use the laboratory study
>>> result.
>>> 
>>> Just my take. YMMV.
>>> 
>>> Peter Elias, MD
>>> 
>>> 
>>> 
>>>> On 2016.05.27, at 2:14 PM, Knapp, Lucy <LKnapp at PEACEHEALTHLABS.ORG
>>>> <mailto:LKnapp at PEACEHEALTHLABS.ORG>> wrote:
>>>> 
>>>> As a medical technologist with close to 40 years’ experience I am
>>>> so offended by this poorly educated comment I don’t even know how
>>>> to respond. I do agree that history and physical are extremely
>>>> important, but objective data and the ability to correctly use the
>>>> data – both in ordering tests and interpreting results is just as
>>>> important. Recent studies (sorry, I can’t quote a source, but I’m
>>>> sure anyone with laboratory experience will agree) have shown as
>>>> much as 70% of medical decisions are based on diagnostic testing
>>>> and at the same time the cost of that testing is 3% of the total
>>>> medical costs in the US.
>>>> 
>>>> Personal experience – History and physical diagnosed a painful
>>>> uterine “fibroid’ in 2012. I had a hysterectomy using
>>>> morcellation; no danger of cancer, obviously. Pathology testing of
>>>> the removed tissue showed Leiomyosarcoma – unstageable because of
>>>> the morcellation, but undoubtedly spread by morcellation. I’m
>>>> currently trying to deal with recurrence. Additional pathology
>>>> testing for estrogen receptors has provided me an additional “gun”
>>>> in the fight.
>>>> 
>>>> Please – don’t dismiss what you don’t understand.
>>>> 
>>>> Lucy
>>>> 
>>>> Lucy Knapp, MT(ASCP)   |  Technical Specialist, Chemistry  |  Laboratory
>>>> PeaceHealth <http://www.peacehealth.org/>  |  400 NE Mother Joseph
>>>> Place  |  Vancouver, WA 98664
>>>> office 360-514-2732  |  fax 360-514-1646
>>>> 
>>>> 
>>>> From: Jason Maude [mailto:jason.maude at ISABELHEALTHCARE.COM
>>>> <mailto:jason.maude at ISABELHEALTHCARE.COM>]
>>>> Sent: Friday, May 27, 2016 2:55 AM
>>>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>>> <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>>>> Subject: Re: [IMPROVEDX] Erroneous laboratory results
>>>> This message originated outside of PeaceHealth's email system and
>>>> contains web links. Use caution when clicking on links. VERIFY THE
>>>> SENDER before opening attachments, clicking links or providing
>>>> information.
>>>> How is it the profession has ended up placing such reliance on an
>>>> aspect which is shown to contribute so little and cost so much?
>>>> 
>>>> This study backs up the old adage that 80% of the diagnosis is
>>>> given by the history and physical with relatively little
>>>> contributed by tests
>>>> http://archinte.jamanetwork.com/article.aspx?articleid=1106285
>>>> <https://mail2.peacehealth.org/enduser/classify_url.html?url=SRKJG9+bKBsCsym7kQNOcDkS6NcPUsik/R0n2BFbRkRPfGwyYd2lLfnMCg+upqON3/dK89OabI4jSAPKTwURVA==>
>>>> 
>>>> To paraphrase Churchill, never in an industry has so much been
>>>> shown to contribute so little for so much expense!
>>>> 
>>>> Regards
>>>> Jason Maude
>>>> 
>>>> 
>>>> From: Tom Benzoni <benzonit at GMAIL.COM <mailto:benzonit at GMAIL.COM>>
>>>> Reply-To: Society to Improve Diagnosis in Medicine
>>>> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>>> <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Tom Benzoni
>>>> <benzonit at GMAIL.COM <mailto:benzonit at GMAIL.COM>>
>>>> Date: Wednesday, 25 May 2016 17:08
>>>> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>>> <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>"
>>>> <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>>>> <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
>>>> Subject: Re: [IMPROVEDX] Erroneous laboratory results
>>>> 
>>>> I'm a "thin" lab tester and 90% of what I order I don't need.
>>>> My junior confreres order easily double my volume.
>>>> Same outcomes narrowly defined; fully defined, worse outcomes.
>>>> (I don't order d-dimer on patients without at least moderate
>>>> likelihood PEs or DVT. My junior guys do so routinely and so do
>>>> many more CTA and U/S. We have the same rate of final diagnoses.
>>>> But I (likely) have fewer renal failures (we don't see followup)
>>>> and fewer bankruptcies.
>>>> 
>>>> Take, for example, ABGs. They are rarely needed; the same data is
>>>> available venously and from already done tests (BMP/MGA/SMA7),
>>>> pulse ox and EtCO2, yet I see 40% of our ICU tests are ABG.
>>>> CBC with diff when most folks can't interpret the diff but don't
>>>> know they can't. CBC without diff when you only need the Hgb.
>>>> EKG in my shop is an excellent predictor that you do NOT have ACS.
>>>> All LPs go to IR.
>>>> 
>>>> I could go on.
>>>> 
>>>> So overtesting is huge.
>>>> 
>>>> tom benzoni
>>>> 
>>>> On Wed, May 25, 2016 at 10:20 AM, Cameron Powell
>>>> <cameron at physiciancognition.com
>>>> <mailto:cameron at physiciancognition.com>> wrote:
>>>>> Perhaps some of you have already seen this study on under- and
>>>>> over-testing.
>>>>> 
>>>>> “First we found that the rate of overuse, meaning [medical
>>>>> laboratory] tests that we performed that shouldn’t have been
>>>>> performed, average around 20%. That means out of every 10 tests
>>>>> ordered about two tests on average should not have been ordered.
>>>>> 
>>>>> “Even more surprising was the rate of underuse [of medical
>>>>> laboratory tests]. This is the rate of tests that should have
>>>>> been ordered in a given time but weren’t ordered. That rate was
>>>>> over 40%. So, for every three tests performed, an additional two
>>>>> tests should have been ordered.”
>>>>> 
>>>>> http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0078962
>>>>> <https://mail2.peacehealth.org/enduser/classify_url.html?url=BxZ18kZyS6/KbPy/1ujgfTFrANiURXwk9lu0BcA37sQiueOJlTGHIQYgv3MPwM/VOughlTjYANbZQFZKLC1gNg1hOHMtXP+U9p3xGL+KxP0=>
>>>>> 
>>>>> 
>>>>> We’ve taken a run at solving suboptimal testing strategies and
>>>>> it’s going very well. We’ll keep you posted on our progress.
>>>>> 
>>>>> Cameron
>>>>> 
>>>>> 
>>>>> 
>>>>> Teaching Mode is Here! (Android
>>>>> <https://mail2.peacehealth.org/enduser/classify_url.html?url=imGsfm3ZNesqbP1TCmWOGASQo7k4WxSSgHzcyCv3fKrrXbqRp0dPI35H4ZTlUWueZrBN45CXLydjYw7283X2CXPd451/aS/cjQxRlQ1TzAs=> | IOS
>>>>> <https://itunes.apple.com/us/app/xebra-pro/id1051676634>),
>>>>> 
>>>>> 
>>>>> Cameron Powell  |  CEO, Physician Cognition, Inc.
>>>>>  ———————————————————————
>>>>>  (:  503 502 5030 <tel:503%20502%205030>
>>>>>  -:  Cameron at PhysicianCognition.com
>>>>> <mailto:Cameron at physiciancognition.com>
>>>>>  ::   PhysicianCognition.com
>>>>> <https://mail2.peacehealth.org/enduser/classify_url.html?url=tm0RsqSiffd2djt32oSygEjmXlBSS9AH1yTF0M6A4is=>
>>>>> Watch Xebra Pro in action!
>>>>> <https://mail2.peacehealth.org/enduser/classify_url.html?url=dkoKAD9Dgsrkfu6keZWIk2rCFSQC15Sv3/wq3KfpsLU=>
>>>>>  Follow On:
>>>>>  Twitter - Company
>>>>> <https://mail2.peacehealth.org/enduser/classify_url.html?url=kaTpWu4oiE4MJvNQ9aqcAEQi7FOH/yGbbn5qfkCY2R5exBWDlCHrDCqGevrkBshi>
>>>>>  Twitter - Personal
>>>>> <https://mail2.peacehealth.org/enduser/classify_url.html?url=uvw+mZhHWusDE4LfQvtkOd3b9LocPFu6zxp3JF3fTH9lQ2o+CM0KywgCvsQYUXKp>
>>>>> Facebook
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>>>>> 
>>>>> <image001.png>
>>>>> 
>>>>>> On May 20, 2016, at 12:40 PM, DR WILLIAM CORCORAN
>>>>>> <williamcorcoran at SBCGLOBAL.NET
>>>>>> <mailto:williamcorcoran at sbcglobal.net>> wrote:
>>>>>> 
>>>>>> What do you think of the YouTube video and the comments posted?
>>>>>> 
>>>>>> WSJ journalist John Carreyrou shares year-long Theranos
>>>>>> investigation & breaks latest, stunning news
>>>>>> <https://mail2.peacehealth.org/enduser/classify_url.html?url=PXYTP0DfAoGKNy2qWUaxDadPXd0hfftNChM33MkbHcI=>
>>>>>> 
>>>>>> <https://mail2.peacehealth.org/enduser/classify_url.html?url=PXYTP0DfAoGKNy2qWUaxDadPXd0hfftNChM33MkbHcI=>
>>>>>> WSJ journalist John Carreyrou shares year-long Theranos ...
>>>>>> <https://mail2.peacehealth.org/enduser/classify_url.html?url=PXYTP0DfAoGKNy2qWUaxDadPXd0hfftNChM33MkbHcI=>
>>>>>> View on youtu.be
>>>>>> <https://mail2.peacehealth.org/enduser/classify_url.html?url=PXYTP0DfAoGKNy2qWUaxDadPXd0hfftNChM33MkbHcI=>
>>>>>> Preview by Yahoo
>>>>>> 
>>>>>> Take care,
>>>>>> 
>>>>>> Bill Corcoran
>>>>>> 
>>>>>> 
>>>>>> William  R. Corcoran, Ph.D., P.E.
>>>>>> 21 Broadleaf Circle
>>>>>> Windsor, CT 06095-1634
>>>>>> 860-285-8779 <tel:860-285-8779>
>>>>>> William.R.Corcoran at 1959.USNA.com
>>>>>> <mailto:William.R.Corcoran at 1959.usna.com>
>>>>>> <>http://www.linkedin.com/in/williamcorcoranphdpe
>>>>>> <https://mail2.peacehealth.org/enduser/classify_url.html?url=grUuPh2Y1yp5jXJzQmUTYus/AVT/0rp7IZvdELgtXB4A4KGm7s1jjip5XmzH7/aM>
>>>>>> https://www.box.com/shared/kfxg1lt9dh
>>>>>> <https://mail2.peacehealth.org/enduser/classify_url.html?url=eyYEaShs9B/PkcYiyojPU/yR/XxJlJP0hwHBPJK0K0oNzuk4e6kW5e4oJx26XJW4>
>>>>>> 
>>>>>> 
>>>>>> On Friday, May 20, 2016 11:10 AM, Dwight Oxley
>>>>>> <dwight.oxley at GMAIL.COM <mailto:dwight.oxley at gmail.com>> wrote:
>>>>>>> 
>>>>>>> The link below details how a large number of erroneous results
>>>>>>> were reported from a commercial medical laboratory. This report
>>>>>>> is just the latest in the Wall Street Journal’s coverage of the
>>>>>>> Theranos Co. Lab results account for more than 50% of the
>>>>>>> information in a medical record, thus the impact of these is
>>>>>>> enormous.
>>>>>>> 
>>>>>>> Dwight Oxley
>>>>>>> 
>>>>>>> 
>>>>>>> http://on.wsj.com/1TpKiL3
>>>>>>> <https://mail2.peacehealth.org/enduser/classify_url.html?url=iTdf6NEttgW/V5B52qqWhkdYtwG9sKVjV9kGwBzHuhU=>
>>>>>>> 
>>>>>>> 
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>>>> 
>>>> Moderator:David Meyers, Board Member, Society for Improving
>>>> Diagnosis in Medicine
>>>> 
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>>>> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX>
>>>> 
>>>> Moderator:David Meyers, Board Member, Society for Improving
>>>> Diagnosis in Medicine
>>>> 
>>>> To learn more about SIDM visit:
>>>> http://www.improvediagnosis.org/ <http://www.improvediagnosis.org/>
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>>>> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX>
>>>> 
>>>> 
>>>> Moderator:David Meyers, Board Member, Society for Improving
>>>> Diagnosis in Medicine
>>>> 
>>>> To learn more about SIDM visit:
>>>> http://www.improvediagnosis.org/ <http://www.improvediagnosis.org/>
>>>> 
>>> 
>>> 
>>> 
>>> 
>>> To unsubscribe from IMPROVEDX: click the following link:
>>> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>>> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1>
>>> 
>>> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>>> 
>>> 
>>> 
>>> Moderator:David Meyers, Board Member, Society for Improving
>>> Diagnosis in Medicine
>>> 
>>> To learn more about SIDM visit:
>>> http://www.improvediagnosis.org/
>>> 
>> 
>> 
>> 
>> 
>> 
>> 
>> 
>> Moderator: David Meyers, Board Member, Society to Improve Diagnosis
>> in Medicine
>> 
>> To unsubscribe from the IMPROVEDX list, click the following link:<br>
>> <a
>> href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1"
>> target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
>> </p>
> 
> 







Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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