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Updated Considerations for the Use of Anesthesia Gas Machines in a Critical Care Setting During the Coronavirus Disease Pandemic

Wickens CD, Delmonaco BL, Pelleg T 21(4). 71 - 76 (Journal Article)

The latest surge of the coronavirus disease 2019 (SARS-CoV-2 virus) pandemic continues to create an unprecedented need for mechanical ventilation in critically ill patients. The U.S. Food and Drug Administration (FDA) recognized that the additional need for ventilators, on March 22, 2020 and issued guidance outlining a policy intended to help increase availability of relevant technologies. The FDA included guidance for healthcare facilities facing shortages of mechanical ventilators to consider alternative devices capable of delivering breaths or pressure support including anesthesia machines. Anesthesia machine manufacturers have published guidelines for the off-label use of anesthesia machines in critical care settings. Capable of providing mechanical ventilation, anesthesia machines do not deliver ventilation modes and flow capabilities commonly used outside the operating room (OR). A paucity of published information exists to describe the operation of anesthesia machines, their technological and practical limitations, and special considerations to prevent harm when re-purposed. We provide technical information and practical guidance for the safe use of anesthesia machines in critically ill patients outside the OR.

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Emergency Medical Services Provider Self-Reported Occupational Safety

Luk JH, Chang BF, Albus ML, Morgan SA, Szymanski TJ, Hamid OS, Keller L, Daher AF, Sheele JM 21(4). 66 - 70 (Journal Article)

Background: Emergency medical services (EMS) providers are at high risk for occupational violence, and some tactical EMS providers carry weapons. Methods: Anonymous surveys were administered to tactical and nontactical prehospital providers at 180 prehospital agencies in northeast Ohio between September 2018 and March 2019. Demographics were collected, and survey questions asked about workplace violence and comfort level with tactical EMS carrying weapons. Results: Of 432 respondents, 404 EMS providers (94%) reported a history of verbal or physical assault on scene, and 395 (91%) reported working in a setting with a direct active threat at least rarely. Of those reporting a history of assault on scene, 46.5% reported that it occurred at least sometimes. Higher rates of assault on scene were associated with being younger, white, or an emergency medical technician-paramedic, working in an urban environment, having more frequent direct active threats, and having more comfort with tactical EMS carrying firearms (p ≤ .03). Most respondents (306; 71%) reported that they were prepared to defend themselves from someone who originally called for help. Most (303; 70%) reported a comfort level of 8 or higher (from 1, not comfortable to 10, completely comfortable) with tactical EMS providers carrying weapons. Comfort with tactical EMS providers carrying weapons was associated with being white, not having a bachelor's degree, and feeling prepared to defend oneself from a patient (p ≤ .02). Conclusion: EMS providers in the survey report high rates of verbal and physical violence while on scene and are comfortable with tactical EMS providers carrying weapons.

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Use of Topical Hemostatic Dressings in an Extended Field Care Model

Welch M, Barratt J, Peters A, Wright C 21(4). 63 - 65 (Journal Article)

Background: We sought to test whether Celox topical hemostatic dressing (Medtrade Products) would maintain hemostasis in extended use. Methods: An anesthetized swine underwent bilateral arteriotomies and treatment with topical hemostatic dressings in line with the Kheirabadi method. The dressings were covered with standard field dressings, and these were visually inspected for bleeding every 2 hours until 8 hours, when the swine was euthanized. Results: There was no evidence of rebleeding at any point up to and including 8 hours. The Celox dressings maintained hemostasis in extended use. Conclusion: Celox topical hemostatic dressing is effective for extended use and maintains hemostasis. It should be considered for use in situations in which evacuation and definitive care may be delayed.

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Comprehensive Ultrasound Course for Special Operations Combat and Tactical Medics

Fatima H, Kuppalli S, Baribeau V, Wong VT, Chaudhary O, Sharkey A, Bordlee JW, Leibowitz A, Murugappan K, Pannu A, Rubenstein LA, Walsh DP, Kunze LJ, Stiles JK, Weinstein J, Mahmood F, Matyal R, Lodico DN, Mitchell J 21(4). 54 - 61 (Journal Article)

Background: Advances in ultrasound technology with enhanced portability and high-quality imaging has led to a surge in its use on the battlefield by nonphysician providers. However, there is a consistent need for comprehensive and standardized ultrasound training to improve ultrasound knowledge, manual skills, and workflow understanding of nonphysician providers. Materials and Methods: Our team designed a multimodal ultrasound course to improve ultrasound knowledge, manual skills, and workflow understanding of nine Special Operations combat medics and Special Operations tactical medics. The course was based on a flipped classroom model with a total time of 43 hours, consisting of an online component followed by live lectures and hands-on workshops. The effectiveness of the course was determined using a knowledge exam, expert ratings of manual skills using a global rating scale, and an objective structured clinical skills examination (OSCE). Results: The average knowledge exam score of the medics increased from pre-course (56% ± 6.8%) to post-course (80% ± 5.0%, p < .001). Based on expert ratings, their manual skills improved from baseline to day 4 of the course for image finding (p = .007), image optimization (p = .008), image acquisition speed (p = .008), final image quality (p = .008), and global assessment (p = .008). Their average score at every OSCE station was > 91%. Conclusion: A comprehensive multimodal training program can be used to improve military medics' ultrasound knowledge, manual skills, and workflow understanding for various applications of ultrasound. Further research is required to develop a reliable, sustainable course.

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Stress Inoculation Training (SIT-NORCAL), Part 2: A Pilot Study Among Explosive Ordnance Disposal Special Warfare Enablers

Jackson SE, Baity MR, Thomas PR, Walker M, Goodkind M, Swick D, Barba D, Jacobson D, Byrd E, Ivey AS 21(4). 46 - 53 (Journal Article)

Background: Despite being a well-supported strategy, Stress Inoculation Training (SIT) has not been fully incorporated in the advancement of human performance among most military personnel. The RAND Study recommendations for maximizing SIT's potential within high-risk/ high-intensity occupational groups were used in designing the Core Training protocol targeting psychological performance, SIT-NORCAL (Part 1). Purpose: The current project (Part 2) sought to further develop the protocol as a health and human performance hybrid through quality improvement analysis of the content, process, and measurement elements for use in the human performance context. Methods: Evidence-based/evidence-driven methodologies were used in collaborative design tailored to the unique needs of special warfare enablers specializing in Explosive Ordnance Disposal (n = 17). The resultant three-phase training was conducted with a novice group (n = 10) using standardized measurements of collaboration, human performance, and adaptive capabilities on identified training targets. Results: Process elements demonstrated high feasibility, resulting in high collaboration and trainee satisfaction. Significant improvements in psychological performance targets were observed pre- to post-training, and during an Adaptive Environmental Simulation designed by unit members. Two weeks post-training, unit members (n = 5) responded to an actual crash of an F-16 aircraft; measurements indicated maintenance of skill set from training to real-world events. Conclusion: Deployment of the elements in the SIT-NORCAL protocol demonstrated early feasibility and positive training impact on occupationally relevant skills that carried over into real-world events.

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Stress Inoculation Training (SIT-NORCAL), Part 1: The Development and Preliminary Evaluation of a Psychological Performance Training Protocol

Jackson SE, Baity MR, Thomas PR, Barba D, Jacobson D, Goodkind M, Swick D, Ivey AS 21(4). 37 - 45 (Journal Article)

Background: Stress inoculation training (SIT) interventions have demonstrated promise within military contexts for human performance enhancement and psychological health applications. However, lack of manualized guidance on core content selection, delivery, and measurement processes has limited their use. Purpose: The purpose of this study was to develop and evaluate a comprehensive SIT intervention protocol to enhance the performance and health of military personnel engaged in special warfare and first-response activities. Methods: Multidisciplinary teams of subject matter experts (n = 19) were consulted in protocol generation. The performance improvement/human performance technology (HPT) model was used in the selection, refinement, and measurement of core skills. The protocol was trialed and refined (44 cohorts, n = ≥300; 2013-2020) to generate the results. Results: Four primary aims were achieved: (1) The generation of a flexible, evidence-based/evidence-driven psychological performance and health sustainment hybrid, SIT-NORCAL. (2) Manualized content and process guidance. (3) The creation of multimedia materials using evidence-based methodologies. (4) The design of initial measurement systems. Preliminary quality improvement analysis demonstrated positive results using standard-of-care and performance enhancement assessments. Conclusion: Hybridized human performance and psychological health sustainment protocols represent a paradigm shift in the delivery of psychological performance training with the potential to overcome barriers to success in traditional care. Further study is needed to determine the effectiveness and reach of SIT-NORCAL.

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Asymmetrical Loading Patterns in Military Personnel With a History of Self-Reported Low Back Pain

Johnson AK, Royer SD, Ross JA, Poploski KM, Sheppard RL, Heebner NR, Abt JP, Winters JD 21(4). 30 - 35 (Journal Article)

Background: Servicemembers are required to operate at high levels despite experiencing common injuries such as chronic low back pain. Continuing high levels of activity while compensating for pain may increase the risk of musculoskeletal injuries. As such, the purpose of this project was to determine if servicemembers with chronic low back pain have reduced lower extremity performance, and if they use alternate strategies to complete a functional performance task as compared to healthy servicemembers. Methods: Of a total of 46 male United States Marine Corps Forces Special Operations Command (MARSOC) personnel, 23 individuals who suffered from chronic low back pain (age = 28.6 ± 4.4 years, weight = 84.2 ± 6.8 kg) and 23 healthy controls (age = 27.9 ± 3.8 years, weight = 83.8 ± 7.7 kg) completed a stop jump task. In this task, three-dimensional biomechanics were measured, and lower extremity and trunk strength were assessed. Results: The low back pain group exhibited higher vertical ground reaction force impulse on the dominant limb (0.26% body weight [BW]/s), compared to the nondominant limb (0.25% BW/s, p = .036). The control group demonstrated relationships between jump height and strength in both limbs (dominant: r = 0.436, p = .043; nondominant: r = 0.571, p = .006), whereas the low back pain group demonstrated relationships between jump height and dominant limb knee work (r = 0.470, p = .027) and ankle work (r = 0.447, p = .037). Conclusions: This study demonstrates that active-duty MARSOC personnel with a history of low back pain reach similar levels of jump height during a counter movement jump, as compared to those without a history of low back pain. However, the asymmetries displayed by the low back pain group suggest an alternate strategy to reaching similar jump heights as compared to healthy individuals.

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A Prospective, Feasibility Assessment of a Novel, Disposable Video Laryngoscope With Special Operations Medical Personnel in a Mobile Helicopter Simulation Setting

Schauer SG, Mendez J, Uhaa N, Hudson IL, Weymouth WL 21(4). 26 - 29 (Journal Article)

Background: Video laryngoscopy (VL) is shown to improve first-pass success rates and decrease complications in intubations, especially in novice proceduralists. However, the currently fielded VL devices are cost-prohibitive for dispersion across the battlespace. The novel i-view VL is a low-cost, disposable VL device that may serve as a potential solution. We sought to perform end-user performance testing and solicit feedback. Methods: We prospectively enrolled Special Operations flight medics with the 160th Special Operations Aviation Regiment at Hunter Army Airfield, Savannah, Georgia. We asked them to perform an intubation using a synthetic cadaver model while in a mobile helicopter simulation setting. We surveyed their feedback afterward. Results: The median age of participants was 30 and all were male. Of those, 60% reported previous combat deployments, with a median of 20 months of deployment time. Of the 10, 90% were successful with intubation, with 60% on first-pass success with an average of 83 seconds time to intubation. Most had a grade 1 view. Most agreed or strongly agreed that it was easy to use (70%), with half (50%) reporting they would use it in the deployed setting. Several made comments about the screen not being bright enough and would prefer one with a rotating display. Conclusions: We found a high proportion of success for intubation in the mobile simulator and a high satisfaction rate for this device by Special Operations Forces medics.

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An Introduction to the Processionary Caterpillar, An Underrecognized Threat to US Military Personnel in Australia

Washington MA, Farrell J, Meany J, Chow W 21(4). 22 - 24 (Journal Article)

Processionary caterpillars are well-described threats to human and animal health. They are found throughout Central Asia, Northern Africa, and Southern Europe. However, US military personnel may not be familiar with the threat that these organisms pose in Australia. The larval form of the bag-shelter moth (Ochrogaster lunifer) is a processionary caterpillar that has been found throughout inland and coastal Australia. These organisms are habitually associated with Acacia and Eucalyptus trees and they tend to form long chains known as "processions" as they travel between nesting and pupating sites. They are covered with numerous hairs that can detach, become airborne, and cause potentially life-threatening inflammatory reactions and ocular trauma in susceptible personnel. They can also cause severe inflammatory reactions in military working animals. It is important that military and preventive medical personnel become aware of the presence of processionary caterpillars in Australia, and that they can identify aerial or ground-based nests so that these dangerous organisms can be avoided by both humans and animals. Early identification is important so that prompt medical treatment can be rendered in the event of an accidental exposure.

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Joint Trauma System Clinical Practice Guideline (JTS CPG): Prehospital Blood Transfusion. 30 October 2020

Voller J, Tobin JM, Cap AP, Cunningham CW, Denoyer M, Drew B, Johannigman J, Mann-Salinas EA, Walrath B, Gurney JM, Shackelford SA 21(4). 11 - 21 (Journal Article)

This Clinical Practice Guideline (CPG) provides a brief summary of the scientific literature for prehospital blood use, with an emphasis on the en route care environment. Updates include the importance of calcium administration to counteract the deleterious effects of hypocalcemia, minimal to no use of crystalloid, and stresses the importance of involved and educated en route care medical directors alongside at a competent prehospital and en route care providers (see Table 1). With the paradigm shift to use FDA-approved cold stored low titer group O whole blood (CS-LTOWB) along with the operational need for continued use of walking blood banks (WBB) and point of injury (POI) transfusion, there must be focused, deliberate training incorporating the different whole blood options. Appropriate supervision of autologous blood transfusion training is important for execution of this task in support of deployed combat operations as well as other operations in which traumatic injuries will occur. Command emphasis on the importance of this effort as well as appropriate logistical support are essential elements of a prehospital blood program as part of a prehospital/en route combat casualty care system.

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Prehospital Iliac Crest Intraosseous Whole Blood Infusion

Fulghum GH, Gravano B, Foudrait A, Rush SC, Paladino L 21(4). 90 - 93 (Case Reports)

Low-titer cold-stored O-positive whole blood (LTCSO+WB) resuscitation therapy is the cornerstone of military hemorrhagic shock resuscitation. During the past 19 years, improved patient outcomes have shown the importance of this intervention in shock treatment. Iliac crest intraosseous (IO) placement is an alternative when peripheral sites such as the humeral head and tibia are not available options. To date, no study has explored the administration of LTCSO+WB through an iliac crest IO in the military prehospital setting. Contingency procedures for vascular access are necessary for casualties with severe trauma to all four extremities, and the iliac crest is a viable option. The literature supports situational advantages over other peripheral IO sites.

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Summer 2021 Journal (Vol 21 Ed 2)

Vol 21 Ed 2
Summer 2021 Journal of Special Operations Medicine
ISSN: 1553-9768

View the Table of Contents
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Tactical Combat Casualty Care Scenario: Management of a Gunshot Wound to the Chest in a Combat Swimmer

21(3). 138 - 142 (Journal Article)

Tactical Combat Casualty Care (TCCC) has always emphasized the need to consider the tactical setting in developing a plan to care for wounded unit members while still on the battlefield. The TCCC Guidelines provide an evidence-based trauma care approach to specific injuries that may occur in combat. However, they do not address what modifications might need to be made to the basic TCCC guidelines due to the specific tactical setting in which the scenario occurs. The scenario presented below depicts a combat swimmer operation in which a unit member is shot while in the water. The unit casualty response plan for a combat swimmer who sustains a gunshot wound to the chest while on a mission is complicated by the inability to perform indicated medical interventions for the casualty while he is in the water. It is also complicated by the potential for ballistic damage to his underwater breathing apparatus and the need to remain submerged after wounding for at least for a period of time to avoid further hostile fire. Additionally, there is a potential for a cerebral arterial gas embolism (CAGE) and/or a tension pneumothorax to develop while surfacing because of the decreasing ambient pressure on ascent. The tactical response may be complicated by limited communications between the mission personnel while submerged and by the vulnerability of the mission personnel to antiswimmer measures if their presence is compromised.

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First Aid UCV (Green Cross) for Prehospital Medicine in Social Commotion Situations

21(3). 126 - 133 (Journal Article)

Venezuela is living in a delicate social and political crisis that has taken thousands of lives. Beginning in March 2017, a series of continuous and increasingly violent demonstrations has taken place, with a high number of civilian casualties. These demonstrations typically have been outside the range of action of the government prehospital services. In addition, the number of casualties frequently overwhelmed the abilities of the available rescue services. Out of the need for a first aid team that could operate in this violent scenario, First Aid UCV (Central University of Venezuela) was created. A large number of professionals with medical, rescue, and tactical medicine experience integrated this new team, modifying their training and practice to adapt to a scenario in which unarmed medical students and medical doctors performed extractions, provided first aid, and managed the transport of demonstration casualties, doing so even when team members were sometimes targeted by the government police and military forces. This method has had successful results in all 60 operations conducted to date, with a total of 5,000 casualties being extracted among civilians, the military, and the police force. Only one member of the team was injured during the operations, and no deaths were reported during the process.

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Lessons Learned From a Traumatic Brain Injury Mass Casualty Incident

21(3). 123 - 125 (Journal Article)

In January 2020, an American base was attacked by the largest theater ballistic missile strike in history. This case report covers the resulting mass casualty (MASCAL) incident. In this case, we defined this incident as a MASCAL due to a lack of medical personnel available to properly and timely evaluate the patients. There was no loss of life during the attack but there were > 80 traumatic brain injuries (TBIs). This article focuses on lessons learned from diagnosing and treating Soldiers during a TBI MASCAL event.

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Timeline of Psychological and Physiological Effects Occurring During Military Deployment on a Medical Team

21(3). 118 - 122 (Journal Article)

Background: The negative effects of deployment on military mental health is a topic of major interest. Predeployment and postdeployment assessments are common, but to date there has been little to no intradeployment assessment of military members. This study attempts to determine the physiological and psychiatric effects on Servicemembers over the course of deployment, to provide a baseline data set and to allow for better prediction, prevention, and intervention on these negative effects. Methods: A retrospective analysis was performed on physiological and psychiatric data collected on a single deployed medical team between 16 January 2020 and 12 July 2020. Patient health screening questionnaires (PHQ-9) and physiological measurements were completed serially twice weekly on five active-duty military volunteers for the entirety of a scheduled 6-month deployment. Results: Depression symptom development followed a linear trend (p = .0149) and severity followed a quadratic trend (p < .001) over a length of a deployment. Weight (p = .435) and pulse (p = .416) were not statistically altered. Mean arterial pressure (MAP) had a statistically significant reduction (p < .001). Conclusion: In this specific population, there was a linear relationship between time deployed and depression symptoms and severity. Depression symptom severity decreases toward the end of deployment but does not return to baseline before deployment's end.

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Blood Transfusion as a Therapeutic Maneuver

21(3). 111 - 117 (Journal Article)

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Update on Minimalist Running Shoes

21(3). 107 - 110 (Journal Article)

This article provides updated information comparing minimalist running shoes (MRS) to conventional running shoes (CRS). Our previous review found that, compared with running in CRS, transitioning to MRS resulted in lower energy cost and less ground contact occurring at the forefoot, resulting in lower impact forces. There was some increased risk of injury with MRS, although data were conflicting. A more recent 26-week study involved 30 trained runners using CRS and 31 using MRS. The proportion of training time in the assigned shoes increased by 5% each week. After the first 6 weeks of transition (35% of training time in the assigned shoe), energy cost was lower and 5-km running time faster in MRS compared with CRS. No further improvement occurred from weeks 6 to 26. There were no significant differences in injury incidence in the two groups (CRS = 37%, MRS = 52%; p = .24). Running-related pain was higher in the MRS group in the knee, shin, calf, and ankle and increased at these locations as running mileage increased. Risk of injury in MRS increased as participant body weight increased. These more recent data suggest that MRS can improve performance, but most runners should limit running in MRS to 35% of training time and in situations where optimal performance is desired (e.g., races, fitness tests).

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Telementorship in Underway Naval Operations: Leveraging Operational Virtual Health for Tactical Combat Casualty Care

21(3). 93 - 95 (Journal Article)

Background: Virtual health (VH) may enhance mentorship to remote first responders. We evaluated the feasibility of synchronous bidirectional VH to mentor life-saving procedures performed by deployed novice providers. Methods: Video teleconferencing (VTC) was established between the USNS Mercy (T-AH 19) underway in the Pacific Ocean to Naval Medical Center San Diego using surgeon teleconsultation. The adult simulated clinical vignette included injuries following a shipboard explosion with subsequent fire. The pediatric simulated vignette included injuries that resulted from an improvised explosive device (IED) blast. Using VTC, augmented reality (AR) goggles, and airway simulation equipment, corpsmen (HMs) received visual cues to perform advanced life-saving procedures. Results: In adult scenarios, 100% of novice hospital HMs performed tasks on first attempt (n = 12). Mean time for tourniquet placement was 46 seconds (standard deviation [SD], 19 seconds); needle thoracostomy, 70 seconds (SD, 67 seconds); tube thoracostomy, 313 seconds (SD, 152 seconds); and cricothyroidotomy, 274 seconds (SD, 82 seconds). In pediatric scenarios, 100% of novice HMs performed tasks on first attempt (n = 5). Mean time for tube thoracostomy completion was 532 seconds (SD, 109 seconds). Conclusion: VH can enhance the training and delivery of trauma care during prolonged field care in resource-limited settings.

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Caffeine Gum Does Not Improve Marksmanship, Bound Duration, Susceptibility to Enemy Fire, or Cognitive Performance During Tactical Combat Movement Simulation

21(3). 86 - 92 (Journal Article)

Background: Military personnel supplement caffeine as a countermeasure during unavoidable sustained wakefulness. However, its utility in combat-relevant tasks is unknown. This study examined the effects of caffeinated gum on performance in a tactical combat movement simulation. Materials and Methods: Healthy men (n = 30) and women (n = 9) (age = 25.3 ± 6.8 years; mass 75.1 ± 13.1 kg) completed a marksmanship with a cognitive workload (CWL) assessment and a fire-andmove simulation (16 6-m bounds) in experimental conditions (placebo versus caffeinated gum, 4mg/kg). Susceptibility to enemy fire was modeled on bound duration during the fireand- move simulation. Results: Across both conditions, bound duration and susceptibility to enemy fire increased by 9.3% and 7.8%, respectively (p = .001). Cognitive performance decreased after the fire-and-move simulation across both conditions (p < .05). However, bound duration, susceptibility to enemy fire, marksmanship, and cognitive performance did not differ between the caffeine and placebo conditions. Conclusion: These data do not support a benefit of using caffeinated gum to improve simulated tactical combat movements.

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