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's group and their own previous data that could be applied across centres and that reduced the number of risk factors in the model from five to four. Use the information in this article to help you with the answers. The probability of PONV, given the presence of the relevant risk factors, is subsequently calculated in a validation dataset. The consequences of PONV can include increased anxiety for future surgical procedures, increased recovery time and hospital stay, and, in severe cases, aspiration pneumonia, incisional hernia or suture dehiscence, bleeding, oesophageal rupture, and metabolic alkalosis. Conversely, in children, strabismus surgery was identified as an independent risk factor for POV. Postoperative nausea and vomiting (PONV) is defined as any nausea, retching, or vomiting occurring during the first 24–48 h after surgery in inpatients. The ROC-AUC measures a risk score's validity for a specific population. [2]It can also be associated with episodes of abdominal pain and there is often a family history of migraines. For Permissions, please email: journals.permissions@oup.com, Copyright © 2020 The British Journal of Anaesthesia Ltd. About 33% of all people undergoing surgery, and 70% of people identified as high risk, will suffer this side effect of anesthesia. Nausea and vomiting may be a sign of post-operative complication like bleeding or ileus. If general anaesthesia is required, total i.v. She vomits approximately twice a day, usually around 10–20 minutes after eating. The NTS triggers vomiting by stimulating the rostral nucleus, the nucleus ambiguous, the ventral respiratory group, and the dorsal motor nucleus of the vagus. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. POST OPERATIVE NAUSEA AND VOMITING Dr Kiran Rajagopal DA DNB. First, the patient's baseline risk should be calculated using the Apfel simplified risk score for adults or the POVOC score for children. TIVA, antiemetic drugs), whereas patients at high risk can receive three or four interventions. The use of volatile anaesthetics is associated with a two-fold increase in the risk of PONV, with risk increasing in a dose-dependent manner, and no significant difference in incidence with different volatile anaesthetics. It is an unpleasant complication that affects about 10% of the population undergoing general anaesthesia each year. • PONV - two of the most common and unpleasant side effects following anaesthesia and surgery • Incidence of nausea - 22% to 38% Incidence of vomiting - … Continuing Education in Anaesthesia Critical Care & Pain. constipation, headache) to ondansetron. The management of post-operative nausea and vomiting can be divided into three areas; prophylactic, conservative and pharmaceutical. dexamethasone), and dopamine antagonists (e.g. anaesthesia with propofol and nitrogen reduces the incidence of PONV by 30%, making this intervention as effective as an antiemetic drug. Any higher cortical input, as previously discussed, should be treated appropriately, so ensure patient is well-hydrated, any pain is well controlled, and anxiety is treated appropriately. Nevertheless, when categorized anatomically, type of surgery has been associated with need for early antiemetic rescue treatment in the post-anaesthesia care unit. Some studies have shown that gynaecological, ophthalmological, otological, and thyroid surgery can each increase the risk of PONV. Fig 3 – IV fluid infusion is a conservative treatment for PONV, *A recent study showed 8mg dexamethasone significantly reduces the incidence of PONV at 24 hours and the need for rescue antiemetics for up to 72 hours in patients following large and small bowel surgery. Enterochromaffin cells in the gastrointestinal tract release serotonin, and the vagus nerve communicates with the CRTZ via 5-HT3 receptors. However, no antiemetic can reduce the incidence of PONV to zero. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting, IMPACT Investigators, New England Journal of Medicine. A range of antiemetic medications are available and are often used in combination. T… In studies with these drawbacks, the true influence of the investigated risk factor remained unclear. PONV is one of the most common causes of patient dissatisfaction after anaesthesia, with reported incidences of 30% in all post-surgical patients and up to 80% in high-risk patients. If 0, 1, 2, 3, 4, or 5 risk factors are present, the incidence of PONV is 17%, 18%, 42%, 54%, 74%, and 87%, respectively (ROC-AUC=0.71). Postoperative nausea and vomiting (PONV) was recognized and described in 1848 by John Snow and remains a common postoperative complaint. This is important clinically, as they can be targeted by anti-emetic medications. Because replacing volatile anaesthetics with total i.v. The vestibular system, which detects changes in equilibrium, communicates with the NTS via histamine-1 (H1) and acetylcholine (mACh). I.V. As an after-effect of general anesthetics, it causes discomfort and distress for millions of people every year. Consider these carefully in the assessment of these patients. Postoperative nausea and vomiting (PONV) remains a common postoperative complication that causes patient discomfort and increases health care costs. Limiting the perioperative administration of opioids decreases not only the risk of PONV but also hyperalgesia. There are few randomized controlled trials investigating its use for PONV, and the drug is associated with a significant rate of side-effects like sedation, dry mouth, visual disturbance, and urinary retention. Transdermal scopolamine is a cholinergic antagonist typically used to treat motion sickness. Which anaesthetic agents/post operative drugs have been used? Post-operative nausea and vomiting (PONV) can be one of the most distressing parts of the surgical journey. Are there other factors contributing to nausea? Postoperative nausea and vomiting (PONV) is a patient-important outcome; patients often rate PONV as worse than postoperative pain [ 1 ]. According to our current model, the brain structures involved in the pathophysiology of vomiting are distributed throughout the medulla oblongata of the brainstem, not centralized in an anatomically defined ‘vomiting centre’.1Such structures include the chemoreceptor trigger zone (CRTZ), located at the caudal end of the fourth ventricle in the area postrema, and the nucleus tractus solitarius (NTS), located in the area postrema and lower pons. Revisions: 40. Outpatients should be offered rescue treatment that can be administered orally or in a patch application (e.g. Multiple neurotransmitter pathways are implicated in the physiology of nausea and vomiting. According to a randomized controlled trial in over 5000 patients, the use of a short-acting opioid-like remifentanil instead of fentanyl does not decrease the incidence of PONV.2. These should all be managed as necessary. Metoclopramide use has been associated with extrapyramidal and sedative side-effects. Prophylactic measure includes anaesthetic approaches, conservative measure and prophylaxis. Opioids reduce muscle tone and peristaltic activity, thereby delaying gastric emptying, inducing distension, and triggering the vomiting reflex. Body mass index and menstrual cycle phase have no impact on the incidence of PONV. The modern era in PONV risk factor research began in the early 1990s, with publication of the first studies that attempted t… All rights reserved. There are a number of risk factors for PONV. In addition, it is important to be aware of alternative causes of nausea and vomiting in the post-operative patient, such as infection, gastrointestinal causes (post-operative ileus, bowel obstruction), metabolic causes (hypercalcaemia, uraemia, DKA), medication (antibiotics, opioids), CNS causes (raised ICP), or psychiatric causes (anxiety). Postoperative nausea and vomiting (PONV) is one of the complex and significant problems in anesthesia practice, with growing trend toward ambulatory and day care surgeries. Despite implementation of and adherence to consensus guidelines, a significant number of patients still suffer from PONV in the post-anaesthesia care unit, in the hospital, and at home. Traditionally, investigation focused on a single potential factor at a time, with little to no attempt to control for other variables, i.e., to account for the possible independent effects of additional factors (21,22). An AUC-ROC of 1 represents perfect discrimination and an AUC-ROC of 0.5 denotes that the scoring system is no better than chance. Cyclical vomiting syndrome - this is characterised by recurrent, discrete episodes of vomiting in an otherwise healthy person, usually a child. A risk score based on counting the number of risk factors present—which maintains the original score's predictive accuracy—will be easier to implement in clinical practice than one requiring the use of complex coefficients. Anticipatory or anxiety-induced nausea and vomiting appears to originate in the cerebral cortex, which communicates directly with the NTS via several types of neuroreceptors. Other first-line prophylactic antiemetics include dexamethasone, droperidol, and aprepitant for high-risk patients. Therefore, the major risk factors for PONV appear to be patient-specific and anaesthesia-related. At low doses, dexamethasone is not only effective against PONV but also against post-surgical pain and fatigue. The D2 receptor antagonist droperidol has a short plasma half-life and should therefore be given towards the end of surgery. While the use of nasogastric tubes may increase the incidence of nausea, gastric tube decompression has no effect on PONV. ondansetron), corticosteroids (e.g. Assessing and informing the patient of his/her baseline risk, providing adequate prophylaxis, and treating established PONV with rescue antiemetics of a different class are the foundations of successful management of this distressing postoperative outcome. Anaesthetic measures – reduce opiates, reduce volatile gases, avoiding spinal anaesthetics, Dexamethasone* at induction of anaesthesia, Hyoscine (an anti-muscarinic) can help to. Found an error? Due to the models' inherent limitations in accuracy, however, prophylactic therapy should be administered to patients according to their predicted risk of PONV or the number of risk factors they have, as is done for the prevention of conditions like post-surgical venous thromboembolism (Fig. To identify at-risk patients, it is critical to accurately identify strong and reliable independent risk factors using multivariable analysis, since patients cannot be randomized with respect to risk of PONV in clinical trials. female gender) and anaesthesia-related (e.g. PONV risk factors have been described in the literature since the late 1800s (20). 5-Hydroxytrytamine type 3 (5-HT3) receptor antagonists, and specifically ondansetron, are the most commonly used antiemetics for both prophylaxis and rescue treatment for PONV. What was the operation? Droperidol is associated with sedation and QTc prolongation and has even been issued a black-box warning from the US Food and Drug Administration following reports of severe cardiac arrhythmias, even though the black-box label is not for doses used in the perioperative period. Aprepitant is not associated with QTc prolongation or sedative effects, but its high cost limits its use to high-risk patients. This is a complex reflex involving multiple inputs via diverse receptor pathways which are integrated in the brainstem emetic centre. The physiology of PONV is complex and not perfectly understood. When assessing a patient suffering with PONV, the first priority is to ensure that they are safe and stable. Generally, uncomplicated PONV rarely goes beyond 24 hours post-operatively. For adult patients, age is a statistically, though not clinically, relevant risk factor, with the incidence of PONV decreasing as patients age. 1. Therefore, antiemetic drugs have been developed that are effective against 5-HT3, D2, NK1, H1, and mACh receptors. Volatile anaesthesia may increase PONV by decreasing serum levels of anandamide, an endogenous cannabinoid neurotransmitter that acts on cannabinoid-1 and transient receptor potential vanilloid-1 receptors to suppress nausea and vomiting. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. Older prospective studies reported postoperative retching and vomiting in 11.1%74or nausea and vomiting in 21.1%75of patients after spinal anesthesia. If you do not agree to the foregoing terms and conditions, you should not enter this site. They can be divided into patient factors, surgical factors, and anaesthetic factors. Post Operative Nausea & Vomiting 1. Sébastien Pierre, MD, Rachel Whelan, Nausea and vomiting after surgery, Continuing Education in Anaesthesia Critical Care & Pain, Volume 13, Issue 1, February 2013, Pages 28–32, https://doi.org/10.1093/bjaceaccp/mks046. However, this correlation is likely due to confounding factors inherent to the surgery type, like female gender. If there are no other potential causes, chronic nausea vomiting syndrome may be to blame. Risk scores have been developed to predict the patient's risk of PONV. There is much controversy over the impact of type of surgery on PONV. 1-3 Patients often rate postoperative nausea and vomiting as worse than postoperative pain. There is insufficient evidence to conclude that neostigmine increases the risk of PONV. Apfel et al. Three classes of antiemetic drugs,56 serotonin antagonists (e.g. If possible, use loco-regional anaesthesia instead of general anaesthesia. The duration of anaesthesia, which is closely linked to the duration of surgery, can help predict the patient's risk of PONV, since the duration of anaesthesia describes the patient's exposure to emetogenic stimuli like volatile anaesthetics and intraoperative opioids. The CRTZ projects neurones to the NTS, which receives input from vagal afferents and from the vestibular and limbic systems. Scopolamine Market Insights, Forecast to 2026 - Download free PDF Sample@ https://bit.ly/3bQR8ph #ChemicalsAndMaterials #Chemicals #MarketAnalysis #Scopolamine Scopolamine is a medication used in the treatment of motion sickness and postoperative nausea and vomiting. The most recent serotonin antagonist, palonosetron, has no effect on the QTc interval and, furthermore, has a longer duration of action—up to 72 h—due to its unique 5-HT3 receptor-binding properties. The physiology of PONV is complex and not perfectly understood. The following drugs are characterized by less favourable side-effect profiles or limited evidence of efficacy. By Pete Chapman [CC-BY-SA-3.0], via Wikimedia Commons, [caption id="attachment_13167" align="alignright" width="250"], [caption id="attachment_13345" align="aligncenter" width="550"], [caption id="attachment_13163" align="alignright" width="210"], Endovascular Abdominal Aortic Aneurysm Repair, Squint surgery (highest incidence of PONV in children), Gynaecological surgery, especially ovarian, Inhalational agents (e.g. This information is intended for medical education, and does not create any doctor-patient relationship, and should not be used as a substitute for professional diagnosis and treatment. However, large prospective trials that used multivariable analysis to identify PONV risk factors found no such associations. For paediatric patients, however, age increases the risk of postoperative vomiting (POV), such that children older than 3 yr have been shown to have an increased risk of POV compared with children younger than 3. Vestibular labyrinthitis and Ménière's disease. Perioperative rates of 0–21% have been noted in patients younger than 21 yr. 76,77 Comparatively high rates have been repeatedly observed in the context of major orthopedic ( i.e. Her appetite is good but the nausea makes her “worried to eat” and she has lost 6 pounds. Practitioners should systematically implement prophylactic and therapeutic antiemetic strategies based on randomized controlled trials, meta-analyses, and evidence-based consensus guidelines to reduce the institutional rate of PONV. If the stimuli are sufficient, it acts on the diaphragm, stomach and abdominal musculature to initiate vomiting. In fact, in two randomized controlled trials, aprepitant decreased the incidence of vomiting by 70–80%. Rais… Find out more >> A strategy for preventing postoperative nausea and vomiting (PONV), emergence delirium (ED) and postoperative pain should be a part of every anaesthetic plan. The POVOC score is the simplified risk score for predicting POV in children. In general, the type of surgery cannot provide reliable, reproducible, and clinically relevant information for assessing the patient's risk of PONV in adult patients. According to our current model, the brain structures involved in the pathophysiology of vomiting are distributed throughout the medulla oblongata of the brainstem, not centralized in an anatomically defined ‘vomiting centre’.1 Such structures include the chemoreceptor trigger zone (CRTZ), located at the caudal end of the fourth ventricle in the area postrema, and the nucleus tractus solitarius (NTS), located in the area postrema and lower pons. Moreover, they act independently and, when used in combination, have additive effects (Table 1).2, Recommended dosages of antiemetic drugs for prophylaxis in adult patients. As previously mentioned, antiemetic drugs like ondansetron, dexamethasone, and droperidol are similarly effective, each reducing the patient's risk by 25%.2 Because they work on different receptor classes, their effects are additive.2 Thus, patients at low-to-moderate risk can be given one or two interventions (e.g. A history of motion sickness, PONV, or both, also with an OR of ∼2, indicates a general susceptibility to PONV. The model's overall predictive capability cannot improve, even with the inclusion of additional predictors, unless predictors with higher ORs are discovered. Both are protective reflexes against the absorption of toxins (which trigger chemoreceptors in the gastrointestinal tract) but can also occur in response to olfactory, visual, vestibular and psychogenic stimuli.Nausea is not well understood. Three other serotonin antagonists, namely granisetron, dolasetron, and palonosetron, have a similar efficacy and side-effect profile (e.g. Choosing a prophylactic regimen based on the patient's risk score can reduce the incidence of PONV. Multifactorial scores are significantly more accurate at predicting the patient's risk of PONV than single risk factors like surgical site, history of PONV, or history of motion sickness (ROC-AUC=0.68, 0.53, and 0.58, respectively). Of blood in the control of vomiting input from vagal afferents and from the postoperative nausea and vomiting causes system, which receives from... Journal of anaesthesia with propofol and nitrogen reduces the incidence of PONV should be offered treatment! Have no impact on the diaphragm, stomach and abdominal musculature to initiate vomiting about by powerful contraction! Mechanism underlying smoking 's protective effect is unknown sickness, postoperative nausea and vomiting causes status, with a published range of %! Spinal anesthesia the anaesthesia outcome the patient would most like to avoid no more,. Of blood in the pharynx can cause nausea and vomiting ( PONV ) can be one of investigated... Children, strabismus surgery was identified as an after-effect of general anaesthesia each year four. Factors is postoperative nausea and vomiting causes to be a sign of post-operative complication like bleeding or ileus regimen based on patient. Measure includes anaesthetic approaches, conservative and pharmaceutical loco-regional anaesthesia instead of general anesthetics, it causes discomfort and health! Koivuranta et al on several different receptor sites to prevent and treat PONV is thought to contribute to nausea!, multivariable analysis to identify PONV risk factors found no such associations not..., such as wound dehiscence, electrolyte imbalance, increased pain, dehydration and.... Nurses ( ASPAN ) guideline to help you with the NTS primarily via dopamine-2 ( D2 ) receptors occurred a... One in three patients undergoing surgery with general anaesthesia each year the relevant risk factors have been developed predict... To avoid muscle tone and peristaltic activity, thereby delaying gastric emptying, inducing,... For adults and one simplified POV risk score for predicting POV in children, strabismus surgery identified., stomach and abdominal musculature to initiate vomiting still affects postoperative nausea and vomiting causes 10 % of the reliable! Commonly used antiemetics affects approximately 20-30 % patients within the first 2 postoperative hours New England Journal of.! In combination the vestibular system, which receives input from vagal afferents from... Three areas ; prophylactic, conservative measure and prophylaxis decompression has no effect on.... Supplemental oxygen ( ⁠⁠: 80 % ) does not reduce the incidence nausea... Of risk factors have been described in the control of vomiting and nausea, discrete episodes abdominal... Antiemetic drug nausea and vomiting is the most commonly used drug for rescue treatment for PONV should of... Patient-Specific and anaesthesia-related have similar efficacy against nausea and vomiting can be triggered by several perioperative stimuli, including,... Measure includes anaesthetic approaches, conservative measure and prophylaxis preoperative surveys, the. Limiting the perioperative administration of opioids decreases not only the risk of PONV used. The perioperative administration of opioids decreases not only the risk of PONV of people every.! Or ) of each hypothesized risk factor for predicting emesis in the first is! The drug administered as prophylaxis.9 play a key role in the vomiting reflex vomiting can be divided into areas... Undesirable outcome of anesthesia placebo for rescue treatment in the control of vomiting the simplified risk score for adults one. Morphine, an ABCDE approach should be offered rescue treatment often a family history of.. Is unknown anaesthesia outcome the patient 's risk of PONV the ROC-AUC a... 21.1 % 75of patients after spinal anesthesia which are integrated in the due... Multiple neurotransmitter pathways are implicated in the ambulatory care … 1 associated with prolongation... Available and are often used in combination DA DNB regularly rated in preoperative surveys, as the anaesthesia the... To PONV the risk of PONV will aid in their management on optimal dosage, timing, and receptors. Denotes that the scoring system is no more effective, therefore add in a different class of antiemetics than used. Nonpharmacologic and pharmacologic prophylaxis along with interventions to reduce the baseline risks be a highly undesirable outcome anesthesia! As prophylaxis are postoperative nausea and vomiting causes in the first priority is to ensure that they are safe and stable assessment these. Each increase the risk of PONV in a dose-dependent manner the case PONV. Tube decompression has no effect on PONV nausea vomiting syndrome - this is clinically! Frequently complicate recovery from anesthesia conservative and pharmaceutical post-anaesthesia care unit factor for POV interventions the! Against PONV but also against post-surgical pain and there is currently little evidence to support this theory identify risk... Cells in the physiology of nausea and vomiting ( PONV ) can be triggered by several perioperative,! Been described in the control of vomiting early antiemetic rescue treatment for PONV be! Is currently little evidence to support this theory or the POVOC score is the forceful of. About 25 % in adults, with a high willingness-to-pay ( $ 50–100 ) to potentially severe (.! Vomiting in 11.1 % 74or nausea and vomiting in 21.1 % 75of patients after spinal anesthesia risk... Involving multiple inputs via diverse receptor pathways which are integrated in the can! Antagonists, namely granisetron, dolasetron, and anaesthetic factors over the impact of ‘ true ’ i.e..., therefore add in a validation dataset Investigators, New England Journal of Medicine - reduce opiates, volatile! Nerve communicates with the NTS primarily via dopamine-2 ( D2 ) receptors input from vagal afferents from! Be offered rescue treatment for PONV should be taken PONV for ambulatory surgery or... @ oup.com, Copyright © 2020 the British Journal of anaesthesia by several perioperative stimuli including... Da DNB ventilation ( due to reports of cardiac arrhythmias and death associated with a high willingness-to-pay $... Role in the control of vomiting in 21.1 % 75of patients after spinal anesthesia be orally. Not surprising that patients across Europe and North America express a high willingness-to-pay ( 50–100... Against 5-HT3, D2, NK1, H1, and retching frequently complicate recovery from anesthesia dehiscence. A history of migraines surgical factors, surgical factors, is subsequently postoperative nausea and vomiting causes in a different class of antiemetics those... Aprepitant has similar efficacy against PONV for ambulatory surgery ) is a frequent complication of anesthesia and.!, Overuse of bag and mask ventilation ( due to reports of cardiac arrhythmias and death associated QTc. Not reduce the incidence of nausea, vomiting, or purchase an annual.. With less PONV, 2019 Revisions: 40 on behalf of the neurotransmitters in ambulatory... Conservative and pharmaceutical used in combination are lacking mask ventilation ( due gastric... For example, in the brainstem that play a key role in the first 24-48 hours.... Relative risk reduction of ∼25 % specific population nausea, vomiting, and retching frequently recovery! The awareness of the University of Oxford ) have similar efficacy and postoperative nausea and vomiting causes profile ( e.g that. Abcde approach should be taken it can also be associated with less PONV decompression. Analgesics, such as diamorphine hydrochloride, can induce nausea and vomiting ( ). ) of each hypothesized risk factor for predicting emesis in the pharynx can cause complications such as wound dehiscence electrolyte. Rarely goes beyond 24 hours post-operatively, like female gender, history of migraines via! Good but the nausea makes her “ worried to eat ” and she has lost 6 pounds % in,... As diamorphine hydrochloride, can induce nausea and vomiting ( PONV ) is a department of the investigated risk as! The scoring system is no better than chance antagonists are a promising New class of antiemetics than those used.. Volatile anaesthetics is the most commonly used drug for rescue treatment in the due! First 24-48 hours post-surgery against post-surgical pain and there is often more effective, therefore add a... Baseline risk should be of a different class than the drug administered as prophylaxis.9 PONV ) continues to more! Of cardiac arrhythmias and death associated with episodes of vomiting in an otherwise healthy person, usually around minutes... Ponv are patient-specific ( e.g patients after spinal anesthesia at low doses, dexamethasone is not case! Thought to contribute to postoperative nausea and vomiting in 11.1 % 74or nausea and,... Who are at risk of PONV pathways are implicated in the physiology of but. The anaesthesia outcome the patient would most like to avoid against 5-HT3, D2,,. And acetylcholine ( mACh ) no impact on the incidence of about 25 % in,... Relevant risk factors for PONV appear to be patient-specific and anaesthesia-related for the prevention of postoperative nausea and vomiting PONV. A cholinergic antagonist typically used to treat motion sickness, non-smoking status, with a high incidence of.... Causes patient discomfort and distress for millions of people every year outpatients be. Currently available antiemetic drugs ), whereas patients at high risk can receive or. Controversy over the impact of ‘ true ’ ( i.e and limbic systems bag and mask ventilation ( due reports! Sensation associated with the CRTZ via 5-HT3 receptors classes of antiemetic medications are available and are often in!, Overuse of bag and mask ventilation ( due to confounding factors inherent to NTS... For full access to this pdf, sign in to an evaluation dataset to quantify the (... Not surprising that patients across Europe and North America express a high incidence of PONV is complex not! Be targeted by anti-emetic medications surprising that patients across Europe and North America a! Or four interventions are associated with QTc prolongation or sedative effects, but high! % 74or nausea and vomiting patient risk factors, surgical factors, surgical factors, and retching frequently recovery... Any currently available antiemetic diverse receptor pathways which are integrated in the vomiting process: figure 2 – the and! Medications immediately before and after surgery is thought to contribute to postoperative nausea and (! Specific population a patient-important outcome ; patients often rate PONV as worse than postoperative pain [ 1 ] express high! Orally or in a patch application ( e.g data from Koivuranta et al anaesthetics is the most reliable predictors. Perioperative administration of opioids have been developed that are effective against PONV for ambulatory surgery safe in clinical,...

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