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A Call for Innovation: Reflective Practices and Clinical Curricula of US Army Special Operations Forces Medics

Rocklein K 14(4). 70 - 80 (Journal Article)

Background: Special Operations Forces (SOF) medics have written and published numerous practice reflections that intricately describe their practice environments, clinical dilemmas, and suggestions for teaching and practice. The lack of translation of SOF medics' experiential evidence to their curriculum has created a gap in evidence-based curriculum development. This study analyzed SOF medics' learning and practice patterns and compared it to the evidence in the interdisciplinary clinical literature. After framing the problem, the literature was reviewed to determine appropriate tools by which perceptions and attitudes toward reflection-centered curricula could be measured. Methods: A recognizable practice reflection was extracted from the published SOF clinical literature and presented in writing to self-identified SOF medics and medic instructors via a descriptive crossover design, to ensure possible biases were mitigated. To measure SOF medics' perceptions of reflection-based curricula, the Dundee Ready Education Environment Measure survey instrument was used, as it has validated psychometric properties and is used worldwide. Results: SOF medics' averaged scores of perceptions of their medic education indicated positive but not completely statistically significant preferences toward reflection-based curricula over traditional curriculum.

Predicting When to Administer Blood Products During Tactical Aeromedical Evacuation: Evaluation of a US Model

Le Clerc S, McLennan J, Kyle A, Mann-Salinas EA, Russell RJ 14(4). 48 - 52 (Journal Article)

The administration of blood products to battlefield casualties in the prehospital arena has contributed significantly to the survival of critically injured patients in Afghanistan over the past 5 years. Given as part of an established military "chain of survival," blood product administration has represented a step-change improvement in capability for both UK and US tactical aeromedical evacuation (TACEVAC) platforms. The authors explore current concepts, analyzing and exploring themes associated with early use of blood products (fresh frozen plasma [FFP] and red blood cells [RBCs]), and they compare and evaluate a US/UK study analyzing the differences and recommending future strategy. The subject matter expert (SME) consensus guidelines developed for use by the US Army Air Ambulance units commonly known as call sign "DUSTOFF." These TACEVAC assets in Afghanistan were validated in this retrospective study. Using statistical analysis, the authors were able to ascertain that the current DUSTOFF SME-derived guidelines offer a sensitivity of 63.04% and a specificity of 89.07%. By adjusting the indicators to include a single above-ankle amputation with a systolic blood pressure (SBP) less than 90mmHg and pulse greater than 120/min, the sensitivity could be increased to 67.39% while maintaining the specificity at 89.07%. In our data set, a single amputation above the ankle, in combination with an SBP of less than 100mmHg and a pulse of greater than 120/min, increased the sensitivity to 76% but with a slight drop in specificity to 86%. Further study of military prehospital casualty data is under way to identify additional physiological parameters that will allow simple scoring tools in the remote setting to guide the administration of prehospital blood products.

The Use of Dexamethasone in Support of High-Altitude Ground Operations and Physical Performance: Review of the Literature

O'Hara R, Serres J, Dodson W, Bruce W, Ordway J, Powell E, Wade M 14(4). 53 - 58 (Journal Article)

Objective: Military Special Operators (SOs) are exposed environmental conditions that can alter judgment and physical performance: uneven terrain, dryness of ambient air, reduction of air density, and a diminished partial pressure of oxygen. The primary purpose of this review was to determine the medical efficacy of dexamethasone as an intervention for the prevention and treatment of high-altitude illness. The secondary purpose was to determine its ability to maintain physical performance of SOs at high altitudes. Methods: A search of the literature from 1970 to 2014 was performed, locating 61 relevant articles, with 43 addressing the primary and secondary purposes of this literature review. Conclusions: The review indicates that dexamethasone is an effective prevention and treatment intervention for high-altitude illness. Commonly used dosages of either 2mg every 6 hours or 4mg every 12 hours can prevent high-altitude illnesses in adults. Currently in USSOCOM operations, there is an option to use 4mg every 6 hours (concurrently with acetazolamide 125mg bid) if ascending rapidly to or above 11,500 ft without time for acclimatization. Researchers also determined that acute exposure to high altitude, even in asymptomatic subjects, resulted in small cognitive deficits that could be reversed with dexamethasone. Dexamethasone may also help improve cognition and maximal aerobic capacity in SOs who are susceptible to high-altitude pulmonary edema.

Prehospital and En Route Cricothyrotomy Performed in the Combat Setting: A Prospective, Multicenter, Observational Study

Barnard EB, Ervin AT, Mabry RL, Bebarta VS 14(4). 35 - 39 (Journal Article)

Introduction: Airway compromise is the third most common cause of potentially preventable combat death. Surgical cricothyrotomy is an infrequently performed but lifesaving airway intervention. There are limited published data on prehospital cricothyrotomy in civilian or military settings. Our aim was to prospectively describe the survival rate and complications associated with cricothyrotomy performed in the military prehospital and en route setting. Methods: The Life-Saving Intervention (LSI) study is a prospective, institutional review boardapproved, multicenter trial examining LSIs performed in the prehospital combat setting. We prospectively recorded LSIs performed on patients in theater who were transported to six combat hospitals. Trained site investigators evaluated patients on arrival and recorded demographics, vital signs, and LSIs performed. LSIs were predefined and include cricothyrotomies, chest tubes, intubations, tourniquets, and other procedures. From the large dataset, we analyzed patients who had a cricothyrotomy performed. Hospital outcomes were cross-referenced from the Department of Defense Trauma Registry. Descriptive statistics or Wilcoxon test (nonparametric) were used for data comparisons; statistical significance was set at ρ < .05. The primary outcome was success of prehospital and en route cricothyrotomy. Results: Of the 1,927 patients enrolled, 34 patients had a cricothyrotomy performed (1.8%). Median age was 24 years (interquartile range [IQR]: 22.5-25 years), 97% were men. Mechanisms of injury were blast (79%), penetrating (18%), and blunt force (3%), and 83% had major head, face, or neck injuries. Median Glasgow Coma Scale score (GCS) was 3 (IQR: 3-7.5) and four patients had GCS higher than 8. Cricothyrotomy was successful in 82% of cases. Reasons for failure included left main stem intubation (n = 1), subcutaneous passage (n = 1), and unsuccessful attempt (n = 4). Five patients had a prehospital basic airway intervention. Unsuccessful endotracheal intubation preceded 15% of cricothyrotomies. Of the 24 patients who had the provider type recorded, six had a cricothyrotomy by a combat medic (pre-evacuation), and 18 by an evacuation helicopter medic. Combat-hospital outcome data were available for 26 patients, 13 (50%) of whom survived to discharge. The cricothyrotomy patients had more LSIs than noncricothyrotomy patients (four versus two LSIs per patient; ρ < .0011). Conclusion: In our prospective, multicenter study evaluating cricothyrotomy in combat, procedural success was higher than previously reported. In addition, the majority of cricothyrotomies were performed by the evacuation helicopter medic rather than the prehospital combat medic. Prehospital military medics should receive training in decision making and be provided with adjuncts to facilitate this lifesaving procedure.

Evaluation of NuStat®, a Novel Nonimpregnated Hemostatic Dressing, Compared With Combat Gauze™ in Severe Traumatic Porcine Hemorrhage Model

Hillis GR, Yi CJ, Amrani DL, Akers TW, Schwartz RB, Wedmore I, McManus JG 14(4). 41 - 47 (Journal Article)

Background: Uncontrolled hemorrhage remains one of the most challenging problems facing emergency medical professionals and a leading cause of traumatic death in both battlefield and civilian environments. Survival is determined by the ability to rapidly control hemorrhage. Several commercially available topical adjunct agents have been shown to be effective in controlling hemorrhage, and one, Combat Gauze™ (CG), is used regularly on the battlefield and for civilian applications. However, recent literature reviews have concluded that no ideal topical agent exists for all injuries and scenarios. The authors compared a novel nonimpregnated dressing composed of cellulose and silica, NuStat® (NS), to CG in a lethal hemorrhagic groin injury. These dressings were selected for their commercial availability and design intended for control of massive hemorrhage. Methods: A complex penetrating femoral artery groin injury was made using a 5.5mm vascular punch followed by 45 seconds of uncontrolled hemorrhage in 15 swine. The hemostatic dressings were randomized using a random sequence generator and then assigned to the animals. Three minutes of manual pressure was applied with each agent after the free bleed. Hextend™ bolus (500mL) was subsequently rapidly infused using a standard pressure bag along with the addition of maintenance fluids to maintain blood pressure. Hemodynamic parameters were recorded every 10 minutes and additionally at critical time points defined in the protocol. Primary end points included immediate hemostasis upon release of manual pressure (T0), hemostasis at 60 minutes, and rebleeding during the 60-minute observation period. Results: NS was statistically superior to CG in a 5.5mm traumatic hemorrhage model at T0 for immediate hemostasis (ρ = .0475), duration of application time (ρ = .0093), use of resuscitative fluids (ρ = .0042) and additional blood loss after application (ρ = .0385). NS and CG were statistically equivalent for hemostasis at 60 minutes, rebleeding during the study, and the additional secondary metrics, although the trend indicated that in a larger sample size, NS could prove statistical superiority in selected categories. Conclusions: In this porcine model of uncontrolled hemorrhage, NS improved immediate hemorrhage control, stability, and use of fluid in a 60-minute severe porcine hemorrhage model. In this study, NS demonstrated equivalence to CG at achieving long-term hemostasis and the prevention of rebleed after application. NS was shown to be an efficacious choice for hemorrhage control in combat and civilian emergency medical service environments.

Prehospital Analgesia With Ketamine for Combat Wounds: A Case Series

Fisher AD, Rippee B, Shehan H, Conklin C, Mabry RL 14(4). 11 - 17 (Journal Article)

Background: No data have been published on the use of ketamine at the point of injury in combat. Objective: To provide adequate pain management for severely injured Rangers, ketamine was chosen for its analgesic and dissociative properties. Ketamine was first used in the 75th Ranger Regiment in 2005 but fell out of favor because medical providers had limited experience with its use. In 2009, with new providers and change in medic training at the battalion level, the Regiment implemented a protocol using doses of ketamine that exceed the current Tactical Combat Casualty Care recommendations. Methods: Medical after-action reports were reviewed for all Ranger casualties who received ketamine at the point of injury for combat wounds from January 2009 to October 2014. Patients and medics were also interviewed. Results: Unit medical protocols authorize ketamine for tourniquet pain, amputations, long-bone fractures, and pain refractory to other agents. Nine of the 11 patients were US Forces; two were local nationals (one female, one male). The average initial dose given intramuscularly was 183mg, about 2 to 3mg/kg and intravenously 65mg, about 1mg/kg. The patients also received an opioid, a benzodiazepine, or both. There was one episode of apnea that was corrected quickly with stimulus. Eight of the 11 patients required the application of at least one tourniquet; four patients needed between two and four tourniquets to control hemorrhage. Pain was assessed with a subjective 1-10 scale. Before ketamine, the pain was rated as 9-10, with one patient claiming a pain level of 8. Of the US Forces, seven of the nine had no pain after receiving ketamine and two had a pain level of four. Two of the eight had posttraumatic stress disorder. Conclusions: In this small, retrospective sample of combat casualties, ketamine appeared to be a safe and effective battlefield analgesic.

Tourniquet Pressures: Strap Width and Tensioning System Widths

Wall PL, Coughlin O, Rometti MR, Birkholz S, Gildemaster Y, Grulke L, Sahr SM, Buising CM 14(4). 19 - 29 (Journal Article)

Background: Pressure distribution over tourniquet width is a determinant of pressure needed for arterial occlusion. Different width tensioning systems could result in arterial occlusion pressure differences among nonelastic strap designs of equal width. Methods: Ratcheting Medical Tourniquets™ (RMTs; m2® inc., http://www.ratcheting with a 1.9cm-wide (Tactical RMT) or 2.3cmwide (Mass Casualty RMT) ladder were directly compared (16 recipients, 16 thighs and 16 upper arms for each tourniquet ® 2). Then, RMTs were retrospectively compared with the windlass Combat Application Tourniquet (C-A-T ["CAT"], with a 2.5cm-wide internal tensioning strap. Pressure was measured with an air-filled No. 1 neonatal blood pressure cuff under each 3.8cm-wide tourniquet. Results: RMT circumferential pressure distribution was not uniform. Tactical RMT pressures were not higher, and there were no differences between the RMTs in the effectiveness, ease of use ("97% easy"), or discomfort. However, a difference did occur regarding tooth skipping of the pawl during ratchet advancement: it occurred in 1 of 64 Tactical RMT applications versus 27 of 64 Mass Casualty RMT applications. CAT and RMT occlusion pressures were frequently over 300mmHg. RMT arm occlusion pressures (175-397mmHg), however, were lower than RMT thigh occlusion pressures (197-562mmHg). RMT effectiveness was better with 99% reached occlusion and 1% lost occlusion over 1 minute versus the CAT with 95% reached occlusion and 28% lost occlusion over 1 minute. RMT muscle tension changes (up to 232mmHg) and pressure losses over 1 minute (24 ± 11mmHg arm under strap to 40 ± 12mmHg thigh under ladder) suggest more occlusion losses may have occurred if tourniquet duration was extended. Conclusions: The narrower tensioning system Tactical RMT has better performance characteristics than the Mass Casualty RMT. The 3.8cmwide RMTs have some pressure and effectiveness similarities and differences compared with the CAT. Clinically significant pressure changes occur under nonelastic strap tourniquets with muscle tension changes and over time periods as short as 1 minute. An examination of pressure and occlusion changes beyond 1 minute would be of interest.

Imaging Comparison of Pelvic Ring Disruption and Injury Reduction With Use of the Junctional Emergency Treatment Tool for Preinjury and Postinjury Pelvic Dimensions: A Cadaveric Study With Computed Tomography

Gary JL, Kumaravel M, Gates K, Burgess AR, Routt ML, Welch T, Podbielski JM, Beeler AM, Holcomb JB 14(4). 30 - 34 (Journal Article)

Objective: Complex dismounted blast injuries from (improvised) explosive devices have caused amputations of the lower extremities associated with open injuries to the pelvic ring, resulting in life-threatening hemorrhage from disruption of blood vessels near the pelvic ring. Provisional stabilization of the skeletal pelvis by circumferential pelvic compression provides stability for intrapelvic clots and reduces the volume of the pelvis, thereby limiting the amount of hemorrhage. The Junctional Emergency Treatment Tool™ (JETT™; North American Rescue Products, http://www.narescue .com) is a junctional hemorrhage control device developed to treat pelvic and lower extremity injuries sustained in high-energy trauma on the battlefield and in the civilian environment. Our purpose was to evaluate the compressive function of the JETT in the reduction of pelvic ring injuries in a cadaveric model. Methods: Radiographic comparison of pre (intact) and post pelvic ring disruption and injury was compared with radiographic measurements post reduction with the JETT device in two cadavers. The device's ability to reduce pelvic disruption and injury in a human cadaver model was assessed through measurements of the anteroposterior (AP) and transverse diameters obtained at the inlet and outlet of the pelvis. Results: Computed tomography (CT) scans demonstrated that JETT application effectively induced circumferential soft tissue compression that was evoked near anatomic reduction of the sacroiliac joint and symphysis pubis. Conclusions: The JETT is capable of effectively reducing an AP compression type III injury (APC III) pelvic ring disruption and injury by approximating the inlet and outlet dimensions toward predisruption measurements. Such a degree of reduction suggests that the JETT device may be suitable in the acute setting for provisional pelvic stabilization.

Management of Anaphylaxis in an Austere or Operational Environment

Ellis BC, Brown SG 14(4). 1 - 5 (Case Reports)

We present a case report of a Special Operations Soldier who developed anaphylaxis as a consequence of a bee sting, resulting in compromise of the operation. We review the current literature as it relates to the pathophysiology of the disease process, its diagnosis, and its management. An evidence-based field treatment algorithm is suggested.

Tactical Hemorrhage Control Case Studies Using a Point-of-Care Mechanical Direct Pressure Device

Kirkpatrick AW, McKee JL 14(4). 7 - 10 (Journal Article)

In 2012, a new hemorrhage control device entered the market, and by May 2013, the iTClamp™ 50 had acquired US Food and Drug Administration approval. The authors describe the use of the iTClamp 50 and present two case studies in which the iTClamp 50 was successfully used in the military environment to control potentially fatal hemorrhage.

Special Forces Medicine in Israel

Ostfeld I, Paran H, Chen J, Barneis Y, Dreyfuss U, Kedem H, Glassberg E 14(3). 116 - 120 (Journal Article)

The Special Forces (SF) of the Israel Defense Force (IDF) have a long and pioneering history in tactical and medical aspects. Moreover, the importance of medical assistance is highly regarded in the Israeli SF community. Consequently, as current military challenges of Israel increase, the need for SF activity and for its medical support increases as well. Therefore, the authors anticipate that further development of SF medicine (SFM), as a specific branch of military medicine in Israel, will continue.

The Ongoing Evolution (Revolution) of TEMS

Carmona PA 14(3). 139 - 141 (Journal Article)

This Is Africa: An Introduction to Medical Operations on the African Continent

Givens ML, Lynch JH 14(3). 107 - 110 (Journal Article)

This article regarding Special Operations Forces (SOF) medical operations in Africa is an introduction to a follow- on series of articles that will address in more detail pertinent medical topics which pertain to operations on the African continent. Medical operations in Africa require dynamic and systematic approaches that consider the myriad challenges, yet offer flexible solutions applied as situations and environments dictate. We believe this series of articles will be of high interest to readers and provide key information that will be germane to future SOF operations.

Seroprevalence of Dengue Fever in US Army Special Operations Forces: Initial Results and the Way Ahead

Caci JB, Blaylock JM, De La Barrera R, Thomas SJ, Lyons AG 14(3). 111 - 115 (Journal Article)

The endemicity of dengue fever (DF) and, consequently, sequelae of DF are increasing worldwide. The increases are largely a result of widespread international travel and the increased range of the mosquito vectors. US Army Special Operations Command (USASOC) personnel are at an increased risk of exposure to dengue based on their frequent deployments to and presence in dengue endemic areas worldwide. Repeated deployments to different endemic areas can increase the risk for developing the more serious sequelae of dengue: dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). Information about the seroprevalence rate of dengue in USASOC personnel, in particular, is lacking and is critical to assessing the risk, tailoring preventive medicine countermeasures, leveraging field diagnostics, and maintaining mission capability. In the first part of a two-part project to assess baseline seroprevalence in USASOC units, a random, unit-stratified sample of 500 anonymous serum specimens from personnel assigned to the highest-risk units in USASOC were screened for dengue using a microneutralization assay. Of the 500 specimens screened, 56 (11.2%) of 500 had neutralizing titers (NT) (MN(50) ≥ 10) against at least one DENV serotype. Subsequent sample titration resulted in 48 (85.7%) of 56 of the samples with NT (MN(50) ≥ 10) against at least one dengue serotype for an overall dengue exposure rate of 9.6% (48 of 500). The second part of the ongoing project, started in 2012, was a multicenter, serosurveillance project using predeployment and postdeployment sera collected from USASOC personnel deployed to South and Central America, Africa, and Southeast Asia. Preliminary results show a 13.2% (55 of 414) seropositivity rate. The significance of these findings as they relate to personal risk and operational impact is discussed.

Flank Pain

Meriano T 14(3). 98 - 101 (Journal Article)

The series objective is to review various clinical conditions/ presentations, including the latest evidence on management, and to dispel common myths. In the process, core knowledge and management principles are enhanced. A clinical case will be presented. Cases will be drawn from real life but phrased in a context that is applicable to the Special Operations Forces (SOF) or tactical emergency medical support (TEMS) environment. Details will be presented in such a way that the reader can follow along and identify how they would manage the case clinically depending on their experience and environment situation. Commentary will be provided by currently serving military medical technicians. The medics and author will draw on their SOF experience to communicate relevant clinical concepts pertinent to different operational environments including SOF and TEMS. Commentary and input from active special operations medical technicians will be part of the feature.

A Multiyear Analysis of the Clinical Encounters of the ATF Tactical Medical Program

Tang N, Kubit J, Berrett OM, Levy MJ 14(3). 102 - 106 (Journal Article)

Background: The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) Tactical Medical Program provides tactical medical support for ATF's tactical Special Response Teams (SRTs) and investigative National Response Teams (NRTs) through the deployment of specially trained ATF Agent-Medics. All patient care activities are centrally coordinated through ATF Headquarters. Methods: A retrospective analysis of de-identified patient care reports (PCRs) from the ATF Tactical Medical Program from 2009 to 2012 was performed. Clinical and operational data were extracted from PCRs and were entered into a database by the research team. Descriptive and summative analyses were performed to assess patient type, law enforcement incident type, chief complaint, and interventions performed. Results: Analysis was performed on the 254 charts. Nearly half (114; 44.9%) of patients encountered during the study period were law enforcement officers. High-risk warrant service was associated with one third (85; 33.5%) of the ATF medics' clinical encounters. The most common chief complaints of patients encountered were musculoskeletal pain/injury (57; 22.4%) and wounds/lacerations (57; 22.4%), followed by heat illness (17; 6.7%). The most common intervention was wound care (61; 26.9%), followed by control of bleeding with direct pressure (43; 18.9%). The most common medications administered were ibuprofen (28; 25.2%), topical antibiotic (12; 10.8%), and acetaminophen (12;10.8%). Conclusion: This multiyear analysis represents an important contribution to the growing body of scientific literature surrounding tactical medicine. The results of this analysis demonstrate a continued need for expanded scope of practice training, as well as enhanced treatment protocols for tactical medics.

Erythema Multiforme

Sola CA, Beute TC 14(3). 90 - 92 (Journal Article)

An active duty male Soldier presents to your clinic with concerns of blister-like lesions on both hands and feet several weeks after receiving immunizations. He is diagnosed with erythema multiforme (EM), a hypersensitivity reaction that is typically self-resolving. This article reviews the etiologies, pathophysiology, course, diagnosis, and treatment of erythema multiforme.

Ebola Hemorrhagic Fever

Burnett MW 14(3). 93 - 94 (Journal Article)

Ebola hemorrhagic fever is an often-fatal disease caused by a virus of the Filoviridae family, genus Ebolavirus. Initial signs and symptoms of the disease are nonspecific, often progressing on to a severe hemorrhagic illness. Special Operations Forces Medical Providers should be aware of this disease, which occurs in sporadic outbreaks throughout Africa. Treatment at the present time is mainly supportive. Special care should be taken to prevent contact with bodily fluids of those infected, which can transmit the virus to caregivers.

Risk Factors for Injuries During Airborne Static Line Operations

Knapik JJ, Steelman R 14(3). 95 - 97 (Journal Article)

US Army airborne operations began in World War II. Continuous improvements in parachute technology, aircraft exit procedures, and ground landing techniques have reduced the number of injuries over time from 27 per 1,000 descents to about 6 per 1,000 jumps. Studies have identified a number of factors that put parachutists at higher injury risk, including high wind speeds, night jumps, combat loads, higher temperatures, lower fitness, heavier body weight, and older age. Airborne injuries can be reduced by limiting risker training (higher wind speeds, night jumps, combat load) to the minimum necessary for tactical and operational proficiency. Wearing a parachute ankle brace (PAB) will reduce ankle injuries without increasing other injuries and should be considered by all parachutists, especially those with prior ankle problems. A high level of upper body muscular endurance and aerobic fitness is not only beneficial for general health but also associated with lower injury risk during airborne training.

Laryngeal Mask Airway Exchange Using a Gum Elastic Bougie With a Rotational Twist Technique

Stancil S, Miller J, Riddle M 14(3). 74 - 77 (Journal Article)

Previous studies have sought to determine the feasibility of exchanging the laryngeal mask airway (LMA) for an endotracheal tube (ETT) over a gum elastic bougie (GEB) and found the practice to have a success rate of about 50%. It has been speculated that the poor success rate may be due to the upward angle of the bougie tip meeting resistance against the anterior laryngeal wall. The use of a 90- to 180-degree twist technique to angle the bougie tip away from the anterior tracheal wall and caudally along the trachea theoretically could improve results. We conducted a prospective cadaveric study to determine if the use of a bougie 90- to 180-degree twist technique or the use of a more flexible pediatric bougie would improve previously published success rates. Emergency medicine personnel attempted exchange of an LMA for an ETT over a GEB using a twisting technique. Despite using the twisting technique, successful exchange over a bougie remained at 50%, similar to previous studies. Using a smaller, more flexible pediatric bougie led to a successful exchange in only 28% of attempts. In this study, the adding of a twist technique or using a pediatric bougie did not result in consistent successful exchange to an ETT from an LMA.

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