Expalining Procedures: Barium Enema, CT Scan, Bronchoscopy, Colonoscopy etc. for Medical Student OSCE
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General scheme:
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Introduce, identify, explain, consent
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Establish purpose of meeting
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Ask if pt has had procedure before
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Discover what pt already knows
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Explain procedure in simple terms
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Explain why procedure is needed
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Pre-procedural preparation mentioned (e.g. bowel emptying with laxatives)
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Instruct not to eat beforehand
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Mild sedative (as part of day care) mentioned
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Check for allergies (e.g. iodine – radioiodide scan), pregnancy
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More on how procedure occurs (e.g. air blown in, moving position)
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Possibility of biopsy mentioned
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After care mentioned. Pt can go home
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Do not drive – bring friend
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Do not operate heavy machinery / sign legal documents
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Mention follow up
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Check patient’s understanding. Address concerns and respond sensitively
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Give patient opportunity to ask questions. Thank patient
Barium enema
To look for problems in colon e.g. polyps, inflammation, narrowing of colon, tumours, diverticulitis… liquid containing barium to show gut outline on x-rays.
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What happens – lie on couch in gown. Small tube inserted into anus a few centimetres, barium liquid passed in. To help liquid to spread along colon to caecum, you may be asked to move into different positions on back, sides etc. some air may be passed down the enema tube, to expand the colon and push the barium along – may feel a little uncomfortable, like trapped wind. Drug may be injected to relax colon wall muscles.
Then several x-rays taken, pt in different positions. Low dose x-rays used – total amount of radiation thought to be safe. Tube then removed and you can go to toilet. 15-20 mins total.
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Preparation – to clear out faeces – strong laxatives given before with instructions. Diet advice will be given to cover a day before test. Normal medication continued except iron tablets.
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Ask – IDDM, to arrange for best timing of stopping eating and then having test. Pregnancy.
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Afterwards – go home as soon as finished. May have stomach cramps from trapped air – may want to stay near lavatory for hour or so. Eat normally straight away. Barium may make faeces pale for a day or so.
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Side effects / risks – some feel a little sick / have stomach cramps for a few hours. Barium may cause constipation, so drink a lot, eat plenty of fruit, but see your doctor if you pass no faeces in 3 days. Injection to relax muscles in colon – do not drive for an hour due to blurred vision. Rare complications – perforation, allergic reaction to muscle relaxant. X-rays – several pictures taken, but total amount of radiation for each test quite small, though to be safe.
Barium meal
Barium liquid often fruit flavoured so OK to drink. Swallow (stand in front of X-ray, pictures as you swallow of oesophagus, showing stricture, hiatus hernia, tumour, reflux from stomach, disorders of swallowing); meal (lie on couch - stomach + duodenum – ulcers, polyps, tumours); follow-through (small intestine – x-ray every 30 min, until barium has reached colon)
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What happens – radiologist may ask you to swallow some bicarbonate powder and citric acid before the barium: fizz up to inflate stomach; you may have to resist urge to burp – clearer x-ray pictures. May have to turn over onto stomach / other positions of various pictures. Drug to relax stomach and gut muscles. Barium swallow ~ 10 min, rest longer.
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Preparation – don’t eat for several hours, but sips of water up to 2 hours before
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Ask – DM to arrange timing for fasting and test. Pregnancy.
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Afterwards – vision. Eat normally.
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Side effects / complications – may feel a little sick for a few hours. Constipation due to barium. Possible allergy to muscle relaxant.
Bronchoscopy
Procedure in which doctor looks at large airways. Device used = fibre-optic endoscope, about as thick as a pencil. Passed through nose, down back of throat. Usually as outpatient / day case.
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Local anaesthetic + sedative into back of hand. Monitor – heart rate + O2 – does not hurt, checks if extra oxygen needed.
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What happens: scope inserted into a nostril, and guided down. Sometimes through mouth instead. Lining of trachea and main bronchi – main airways – inspected. Viewed on TV. May make you cough. May take painless biopsies to send to lab. 20 – 30 min procedure, but whole appointment will be at least 2 hours, including preparation / waiting for sedative to work, and recovery.
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Preparation – should get instructions, normally including – not eat / drink for several hours (small sips water up to 2 hours before); current medicine: discuss with doctor, usually continue
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Afterwards – sedative: 24hrs don’t drive, operate machinery, drink alcohol; someone to accompany back home and stay with you 24 hours, until normal activities may be resumed
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Side effects / complications: most without problem. Maybe: sore nose / throat for a day or so; slightly increased risk of chest / throat infection; may cough up a little blood following biopsy; rarely: damage to lung and collapse of lung
Colonoscopy
Operator looks at colon – part of gut after small intestine. Colonoscope – thin, flexible telescope about as thick as little finger, passed through anus to caecum, has light, camera and side channel e.g. for biopsy instrument. Not painful, may be a little uncomfortable, especially on first passing the colonoscope into the rectum. Routine, commonly done. Various conditions may be detected; result is often normal, ruling out certain possible causes of the symptoms.
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What happens – outpatient / day case. Usually: sedative to relax – drowsy but does not make you sleep – not GA. Lie on side on couch; scope pushed gently; lining shown on monitor. Air passed in – bloating – operator will expect you to need to pass wind, so no need for embarrassment as this is normal. May take painless biopsies of lining, for lab microscopy, or remove polyps (small lumps of tissue hanging from inside lining). Gently pulled out. 20-30 min, but allow at least 2 hours, including waiting for sedative to work, and recovery.
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Preparation – special diet for a few days + laxatives.
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Afterwards – most ready to go after 30 min or so, longer for observation if polyp removed. Sedative – wait longer, and have person to take you home, and look after you for 24 hours until affects fully worn off, during which do not drive, operate machinery or drink alcohol. Operator writes report and sends to doctor. If operator says what they saw before you leave, may not remember due to sedative – have close friend / relative with you
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Side effects / complications – most fine, may pass small amount of blood after biopsy / polyp removal. Occasionally – damage to colon, with bleeding, infection, perforation rare. Consult with doctor if any of the following occur within 48 hours: abdo pain, fever, passing a lot of blood from anus
CT scan
Giant thick ring, contains x-ray source and detector, rotate and emit thin beams of x-rays. Pt lies on couch that slides into centre of ring. X-rays pass less through denser tissue. Computer produces cross section images of body. Newer scanners can produce 3D pictures. Can be done on any part of body, showing bones but also soft tissues (unlike normal x-rays) such as muscles, organs, large blood vessels, brain and nerves. Most commonly to determine cause of stroke, also: detect abnormalities e.g. tumours, abscesses, abnormal blood vessels; clarify anatomy pre-op; pinpoint tumour before radiotherapy
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What happens – painless. Stay as still as possible. 20-60 min. May be a little uncomfortable lying for so long. Other people not in same room – operators behind screen, to prevent repeated exposure to x-rays. Communicate via intercom, observed constantly on monitor. Mild sedative if anxious / claustrophobic.
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Preparation – remove metal objects e.g. jewellery, hair clips, clothes with metal zips / studs. May be asked not to eat or drink for a few hours.
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Contrast – to block x-rays, to show up organ / tissue better: abdo/pelvic scan (special drink, to show up stomach / bowel); pelvis (fluid put into back passage); pelvis (tampon into vagina); dye injected into bloodstream via arm vein (flushing feeling, odd taste in mouth)
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Afterwards – no after-effects, except sedative. Scan studied by radiologist, sent to requesting doctor
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Side – effects / complications – rare, x-ray dose needed generally quite low. Rarely, allergic reaction to contrast dye – treated immediately. Dye may also cause kidney damage rarely, if already kidney probs. Pregnancy – contraindication, given small risk of abnormalities in unborn child
ERCP: endoscopic retrograde cholangio-pancreatography
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Thin, flexible telescope passed through mouth, into oesophagus, down to duodenum via stomach. Contains fibre optic channels to illuminate. ? X-ray pictures of bile and pancreatic ducts; to see these, a dye that blocks x-rays is needed. Injected through papilla back into the ducts, via a plastic tube in a side channel of the endoscope.
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What happens: doctor may spray in local anaesthetic or give lozenge. Sedative into vein in back of hand or arm: makes you drowsy, but does not make you sleep. ? Couch, lie on side, asked to swallow first section of endoscope (thinner than index finger), then gently pushed further in. TV monitor to see inside; air passed in to make lining easier to see: may feel ‘full’. 30 min – hour.
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May show: narrowing (stricture), stuck gallstones, tumours pressing on ducts. Biopsy may be taken painlessly, to check for abnormal cells. If the x-ray shows a gallstone in the duct, can be grabbed by a ‘basket’, or the opening of the papilla widened. If a narrowing or blockage is seen, stent can be positioned to keep bile duct open.
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Preparation: do not eat for several hours; small sips of water ? 2 hours before. Check for medication that should be stopped.
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Check: pregnancy, drug allergies, shellfish allergy (dye), iodine allergy (dye)
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Risks: most without problems. Some have mild sore throat for a day or so. Sedative ? may feel tired or sleepy for several hours. Uncommon complications: chest infection; gut infection, bleeding or perforation (consult doctor in next 48hrs if abdominal pain, fever, SOB, vomiting blood); pancreatitis. Benefit from procedure weighed against risk of complications, especially if patient generally unwell
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Afterwards: after sedative, do not drive, operate machinery or drink alcohol for 24 hours. Someone to help you home and look after your for the 24 hours needed. Normal activities after this period. Short hospital stay may be needed if gallstone removed / stent inserted
Gastroscopy
Look into upper gut – oesophagus, stomach, duodenum – with endoscope, a thin flexible telescope about as thick as a little finger. Passed through mouth and down. Scope contains light, video camera, and side channel for various instruments – e.g. for biopsies. Not painful, may be uncomfortable to swallow endoscope
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What happens – as outpatient day case. Routine, commonly done test. Local anaesthetic spray / lozenge, sedative to relax – vein in back of hand – drowsy but does not make you sleep. Lie on side on couch, plastic mouth guard between teeth. Swallow first section of endoscope. Operator watches screen for abnormalities. Air passed in so lining easier to see – ‘full’ feeling, want to belch. May painlessly take biopsies to send to lab, then gently removes scope. Usually lasts around 10 min but allow at least 2 hours for waiting for sedative to work, recovery etc.
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Preparation – not eat 4-6 hours, sips of water up to 2 hours before. Medication to stop before test
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Afterwards – normally ready to go home after ~ ½ hour rest. If sedative, need longer rest, and help to get home and look after you 24 hours, during which you should not drive, operate machinery or drink alcohol. Operator sends report to requesting doctor. Sedative may mean you do not remember what operator says they have seen, if they tell you on the spot.
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Reliability – not foolproof, may miss minority of early ulcers / cancer. Repeat may be required.
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Side effects / complications – most without problem; some have mild sore throat; mildly increased risk of chest infection. Sedative – tired + sleepy. Occasionally: may damage gut, causing bleeding, infection, rarely perforation. Consult doctor in 48hours after, if abdominal pain, fever, SOB, vomiting blood. Allergic reaction to sedative occurs rarely.
Intravenous urogram / pyelogram
X-ray procedure to assess probs in kidneys, ureters, bladder, urethra: urinary tract, does not show well on normal x-ray. Contrast dye injected, concentrates in kidneys and passed into urine in ureters. Blocks x-rays so structure clear on x-ray. Assess range of problems, e.g. kidney stones, urine infections (blockage in urinary tract), blood in urine (IVU may clarify cause, e.g. infection, inflammation, tumour), obstruction, damage.
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What happens – wear a gown, lie on couch. Contrast injected into vein in hand / arm, may sting. Series of x-ray pictures every 5-10 min, stay on couch, but may be asked to empty your bladder before final x-ray. Approx 30-60 min, though in certain circumstances may need more pictures hours later.
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Preparation – not performed if there is kidney failure, so blood test may be needed to check. To make x-ray pictures clearer, don’t eat for several hours, may be given laxatives. Consent form.
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Ask – allergies – contrast dyes such as iodine. Diabetes – metformin – stop 2 days before. Contrast with metformin may affect kidneys; discuss this and how to manage diabetes in the period with your doctor. Pregnancy.
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Afterwards – should be able to start eating, and go home straight away.
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Risks / side effects – dye injection (flushing feeling, metallic taste), rare allergic reaction to dye (itchy skin rash to breathing difficulties; there is immediate access to full resuscitation equipment), rarely – acute kidney failure
Isotope bone / lung / thyroid scan
= Radionuclide scan / radioisotope. Chemical used that emits gamma ray radioactivity, tiny amount put into body, usually injected into vein, but sometimes breathed in or swallowed. Radionuclide selected that will concentrate in the particular organ that is to be scanned. E.g. radioactive iodine is quickly taken up into the thyroid gland, so is used to scan the thyroid. Active parts of the tissue will take up more Radionuclide than less active / inactive parts. Gamma rays detected by gamma camera – similar to x-ray. Computer builds a picture; areas of target organ emitting lots of gamma rays may be shown as red spots, emitting less ? blue.
Bone scan (cancer, infection, damage); kidney scan (kidney function – can detect scars on kidney, and how well urine drains); lung perfusion scan – VQ scan (blood clots in lungs – pulmonary embolus); heart scan (blood flow to heart muscle; areas poorly perfused do not take up radionuclide very well); thyroid (areas of overactive thyroid gland – hyperthyroidism – e.g. nodules)
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What happens – either swallow or have injected into a vein a small quantity. May take several hours for radionuclide to travel to target tissue and be taken up by active cells. You may be able to go out and return later in the day while this happens. When the scan happens, pt lies on couch under gamma camera, as still as possible. Can take 20 min to expose. Sometimes only 1 picture needed, but some scans (e.g. bone / heart) need more. Whole process can take several hours.
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Preparation – usually very little, but for some types may be asked to drink lots of water to flush radionuclide, or empty bladder of urine before scanning begins
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Ask – pregnancy; allergy to injected material – check for iodine allergy ; theoretical possibility of overdose of injected chemical, very rare
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Risks / side effects – ‘radioactivity’ may sound alarming, but the chemicals used in radionuclide scans are considered safe and leave the body quickly in the urine. Radiation dose very small, normally not much different from having a few normal x-rays.
MRI scan
To get better pictures. Uses strong magnetic fields and radio waves to create pictures of tissues, organs and structures. Magnetic field lines up particles called protons, inside the millions of hydrogen atoms in the body. Radio waves emitted, changing the position of the protons, and when this stops they realign with the magnetic field, while emitting their own radio waves, that are picked up by the scanner. The hydrogen atoms are in water molecules, and each organ has a different water content. The strength of the returned signal from different areas is measured, and a different colour or shade is given for each strength of signal.
Why? – clear pictures of any part of body, for many reasons when less detailed tests do not give enough information. Esp. brain and spinal cord – abnormalities and tumours
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What happens. Scanner = like short tunnel, surrounded by giant circular magnet. Lie on couch, and another smaller magnet – receiving device – placed around part of body being examined, to detect the tiny radio signals emitted. Couch slides into scanner, a bit at a time so several pictures taken – each time, stay still to avoid blurring. Painless. 30-60 min depending on how many pictures. Lying still may be a little uncomfortable. Contrast dye injected into bloodstream via arm vein, in some cases. Operator in separate room, as computer needs to be away from magnetic field. Communicate via intercom, observed on monitor. Quite noisy – headphones / ear plugs; claustrophobia ? mild sedative (small children GA to stay still)
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Preparation – usually very little.
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Ask – metal: safety due to strong magnet – inform of pacemaker / hearing aid / metal (fixed e.g. hip / screws usually fine, but inform); jewellery. Pregnancy – deferred if non-urgent, thought to be safe but long-term effects on developing baby not known
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Afterwards – no after-effects, return straight away to normal activities. Report sent by radiologist to requesting doctor.
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Side effects / complications. No radiation. Sedative – 24 hours, someone to accompany home etc. Rarely – allergic reaction to contrast dye. Can be treated immediately.
Ultrasound scan
Inaudible, high frequency sound can be emitted and detected by special machines. Bounces back from denser surfaces, but travels freely through soft tissues and fluid e.g. blood. So can see heart valves (echocardiogram), monitor growth of unborn child, check for abnormalities. Diagnose problems of liver, gallbladder (e.g. gallstones), pancreas, thyroid gland, lymph nodes, ovaries, testes, kidneys, bladder and breast. E.g. tells whether abnormal lump is fluid-filled cyst or tumour. Also abnormal widening of blood vessels – aneurysms.
ECHO of heart – some abnormalities can be seen quite clearly, e.g. damaged heart valves, thickened heart muscle, some congenital heart defects, etc. Doppler: rather than heart structure, shows variations in blood flow, e.g. turbulence due to damaged valve – assess how well heart valves are working. Transoesophageal echo – swallow probe, attached to thin wire connecting it to ultrasound machine; views heart from oesophagus (gullet), to give a very detailed picture, such as before valve surgery, or test extent of infection; then gently pulled out again.
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What happens – lie on couch, operator places probe on skin, like very thick blunt pen. Lubricating jelly, for good contact. Connected by wire to machine and monitor. Pulses sent and echo back, detected by same probe. Displayed on monitor, constantly updated picture so movement of structures is shown. E.g. heart valves moving. Painless, 15-45 minute duration. Record of results as still picture or video recording.
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Specialist techniques – small probe inserted into body, still attached by wire to US machine. E.g. swallowed into gullet, for clearer images of heart (just in front of gullet); in vagina or rectum to get clearer pictures of pelvic and reproductive organs; during operation to look deeper into structures, to guide surgeon.
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Preparation – usually none needed; continue usual medication. Eat and drink normally, unless instructed otherwise: if certain parts of abdomen examined (low fibre diet for a day, to minimise gas); no food for several hours before some abdominal scans; lower bowel – enema to clear contents; full bladder before pelvic / bladder scan
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Side effects / complications – painless and safe. No radiation.
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Date: Fri, 22 Jan 2010 Time: 4:17 PM
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