In the Operating Theatre, the plastic apron I put on goes all the way down to the floor.
"I am too short," I say to the nurse.
"You are like an African, not an American," she says. "You are small. But not so tiny. Anyway, you are wide."
Sunday, November 15, 2009
Friday, November 13, 2009
Relief
Since my last post, things got worse. After I saw the woman with preeclampsia, the Medical Officer for Maternity Ward saw her, and disagreed with me. He told the nurses that the baby was too small and would die, and because the woman had not yet had a seizure, she should not be delivered.
For the non-obstetricians out there, this is crazy talk. At 31 weeks, the infant does have a chance at survival, albeit lower in Uganda than in the US. And regardless, the mother is at high risk of death. Waiting for her to seize is not an option - once she seizes, her survival is unlikely here.
The Medical Officer had ordered two antihypertensives for her, and no magnesium.
I am stunned when I hear this. The nurses have no choice but to follow his orders. I start to doubt myself - maybe I don't understand a low resource setting, maybe priorities are different here, maybe I'm wrong. I go and speak with several of the Ugandan Medical Officers in our study, all of whom agree with me. They are shocked and horrified at the doctor's management plan, and are just as certain as I was that this woman will die soon if we don't do something. But what to do? The Medical Officer had made his decision, and there is no one left in the hospital to overrule him at that hour.
I sleep poorly, thinking of the woman. The next morning, I am relieved to find her alive. She still reports headache, scotomata, epigastric pain, and a total lack of fetal movement. I brought the ultrasound with me to see if the baby was alive - to my relief, it was, and with even less amniotic fluid now. I try to comfort her and her family, but they are very concerned about her headache and the obvious swelling in her feet, hands and face. Rightly so.
The other woman - the one with the ruptured membranes that I was inducing with misoprostol - is still pregnant, too. She had a lot of pain with the medication, but had not delivered. I examine her, and her cervix is still closed. What to do? This could take many doses, and the misoprostol is too expensive. She and her family are begging me for an alternative. I know I can do a D&E easily, but with what instruments?
I pull a nurse aside and ask her to take me the the Operating Theatre to look at the instruments. To my excellent luck, I run into Dr. W, an excellent family physician from Kampala who also works in Tororo, and whom I know and trust. I tell him about the woman with preeclampsia, and halfway through my story, he is already exclaiming that she must be delivered Now Now. He announces that I have his support, that the hospital knows and supports me, and that this patient will die if I don't deliver her. He tells the anesthetist that we must do this cesar right away.
The nurse helps me organize and consent the patient, who also wants a tubal ligation (she had 6 children already). The cesar is challenging. The lack of instruments is not a surprise - I had seen it in Mbarara, and as long as I have something that clamps, something that cuts, and something that ties, I am fine. I am a little confused by the sutures - some things have different names, one suture seems like it will be Vicryl but isn't, it is hard to find the right size suture for anything - but I deal with it. There is, of course, no stool for me to stand on, and the bed can't go any lower. As soon as I open the uterus, I find placenta where I don't expect it, trying to come out before baby. I have a very hard time getting the baby out - she hadn't been laboring, the head is floating, the scrub tech has no idea how to give fundal pressure, and the placenta is in the way. It takes so long that I use profanity once, but only once. And then I get the baby out. He is pale, small and has a weak cry, and I pass him off to the nurse. Looking at the placenta, I realize it looks about 50% abrupted. Later, I go to see him, and he is doing ok. He is pale but warm under the lights, and I encourage the midwives and the family to do kangaroo care.
After that cesar, I have to do the D&E. I look at the instruments in the OR that were prepared for me. They are as follows:
Half of a speculum
2 Regular-sized ring forceps
1 Small ring forceps
1 Curved allis clamp
4 Dilators - all the same (small) size, labeled "6"
1 Tiny sharp curette (about the size of an endometrial biopsy pipelle)
1 IUD hook (what for, I don't know)
I have no tenaculum, no real speculum, no suction, no MVA, no large curette, no large forceps, and no ultrasound.
The dilators go into the cervix easily (being all the same size, I only need 1), but I still can't even get my pinky finger into the os. By no small miracle, I manage to get the procedure done. It takes over an hour, the allis clamp shreds her anterior cervix and I think I grossed out the nurse, but I manage to do it safely and completely. Go go gadget family planning training.
Two mothers and one baby safe and healthy. In one day, I have gone from frustration and despair to exhilaration and relief. And I am sure there is much more to come.
For the non-obstetricians out there, this is crazy talk. At 31 weeks, the infant does have a chance at survival, albeit lower in Uganda than in the US. And regardless, the mother is at high risk of death. Waiting for her to seize is not an option - once she seizes, her survival is unlikely here.
The Medical Officer had ordered two antihypertensives for her, and no magnesium.
I am stunned when I hear this. The nurses have no choice but to follow his orders. I start to doubt myself - maybe I don't understand a low resource setting, maybe priorities are different here, maybe I'm wrong. I go and speak with several of the Ugandan Medical Officers in our study, all of whom agree with me. They are shocked and horrified at the doctor's management plan, and are just as certain as I was that this woman will die soon if we don't do something. But what to do? The Medical Officer had made his decision, and there is no one left in the hospital to overrule him at that hour.
I sleep poorly, thinking of the woman. The next morning, I am relieved to find her alive. She still reports headache, scotomata, epigastric pain, and a total lack of fetal movement. I brought the ultrasound with me to see if the baby was alive - to my relief, it was, and with even less amniotic fluid now. I try to comfort her and her family, but they are very concerned about her headache and the obvious swelling in her feet, hands and face. Rightly so.
The other woman - the one with the ruptured membranes that I was inducing with misoprostol - is still pregnant, too. She had a lot of pain with the medication, but had not delivered. I examine her, and her cervix is still closed. What to do? This could take many doses, and the misoprostol is too expensive. She and her family are begging me for an alternative. I know I can do a D&E easily, but with what instruments?
I pull a nurse aside and ask her to take me the the Operating Theatre to look at the instruments. To my excellent luck, I run into Dr. W, an excellent family physician from Kampala who also works in Tororo, and whom I know and trust. I tell him about the woman with preeclampsia, and halfway through my story, he is already exclaiming that she must be delivered Now Now. He announces that I have his support, that the hospital knows and supports me, and that this patient will die if I don't deliver her. He tells the anesthetist that we must do this cesar right away.
The nurse helps me organize and consent the patient, who also wants a tubal ligation (she had 6 children already). The cesar is challenging. The lack of instruments is not a surprise - I had seen it in Mbarara, and as long as I have something that clamps, something that cuts, and something that ties, I am fine. I am a little confused by the sutures - some things have different names, one suture seems like it will be Vicryl but isn't, it is hard to find the right size suture for anything - but I deal with it. There is, of course, no stool for me to stand on, and the bed can't go any lower. As soon as I open the uterus, I find placenta where I don't expect it, trying to come out before baby. I have a very hard time getting the baby out - she hadn't been laboring, the head is floating, the scrub tech has no idea how to give fundal pressure, and the placenta is in the way. It takes so long that I use profanity once, but only once. And then I get the baby out. He is pale, small and has a weak cry, and I pass him off to the nurse. Looking at the placenta, I realize it looks about 50% abrupted. Later, I go to see him, and he is doing ok. He is pale but warm under the lights, and I encourage the midwives and the family to do kangaroo care.
After that cesar, I have to do the D&E. I look at the instruments in the OR that were prepared for me. They are as follows:
Half of a speculum
2 Regular-sized ring forceps
1 Small ring forceps
1 Curved allis clamp
4 Dilators - all the same (small) size, labeled "6"
1 Tiny sharp curette (about the size of an endometrial biopsy pipelle)
1 IUD hook (what for, I don't know)
I have no tenaculum, no real speculum, no suction, no MVA, no large curette, no large forceps, and no ultrasound.
The dilators go into the cervix easily (being all the same size, I only need 1), but I still can't even get my pinky finger into the os. By no small miracle, I manage to get the procedure done. It takes over an hour, the allis clamp shreds her anterior cervix and I think I grossed out the nurse, but I manage to do it safely and completely. Go go gadget family planning training.
Two mothers and one baby safe and healthy. In one day, I have gone from frustration and despair to exhilaration and relief. And I am sure there is much more to come.
Thursday, November 12, 2009
Frustration
Today was all about misdiagnosis, overuse and misuse of antibiotics and delays in care. Of course all of these happen at home, but not to the same degree. Sometimes you can only sigh, roll with it, and do what you can do.
I saw a woman on labor ward yesterday who had been diagnosed with "pelvic infection" at 15 weeks gestation. This didn't make sense, because pelvic infections (like PID) are extremely rare in pregnancy. When I spoke to her (using a nurse who spoke Japadhola), I found that she was tender only over her bladder (but not her uterus) and had pain with urination and urinary frequency - so it was more likely a urinary tract infection. (At home, I would get a urinalysis and a urine culture. Here, no such luck.) She had been prescribed Ampicillin, Metronidazole, and Ceftriaxone (they tend to throw loads of antibiotics at everyone here, regardless of diagnosis). Nothing had yet been given (also typical), so I told them to give only the Ampicillin. Today, she was feeling much better.
There was another 15-week pregnant woman on the ward, who was diagnosed with a urinary tract infection. When I spoke to her, though, this sounded incorrect. She had been having pain and bleeding for almost a month, had been seen multiple times and been given antibiotics multiple times (see antibiotic overuse, above) but hadn't gotten better. She was understandably frustrated. An ultrasound 3 weeks ago had been normal. Concerned about the source of the bleeding, I wondered about vaginal or cervical lesions, or potentially spontaneous abortion in progress. I asked the nurse for a speculum to be prepared (this usually takes at least an hour). I never got one yesterday, so I came back today.
The same woman was still there, and still having bleeding. I had brought two of the study's medical officers to practice ultrasound (she needed one anyway), and we started to scan. Immediately I noticed that the entire fetus was collected in the lower uterine segment, and there was no fluid whatsoever. On interviewing her further, the "blood" that she had been seeing come out was very watery. Her membranes had ruptured over a week ago, probably, and the pain she was feeling was slow cramping, preparing to abort, most likely. I explained the situation to her. She was upset, of course, but wanted resolution. I had the husband go and buy some misoprostol at the pharmacy. (Later he told me that 2 pills cost him USh 20,000 - about $10. That means that a medicine that costs pennies at home costs $5 here.) She started the first dose, and almost immediately the cramping increased. I think she will deliver after 1 or 2 doses. I hope so, because I'm not sure the family can afford any more.
Another woman we did an ultrasound on said she was 3 months pregnant, but when we did the ultrasound, we found nothing in her uterus, just some small blood collected near the lower uterine segment. Discussion with the nurse revealed that the patient had had heavy bleeding the night before, and had likely miscarried.
During that ultrasound, the nurse asked me to see another patient who had just come in with pre-eclampsia. Her blood pressure was 180/120, her urine protein was 4+ (very high), she was having a severe frontal headache, scotomata (seeing spots), and epigastric pain. She looked ill uncomofortable, and glassy-eyed, although was conscious and responsive. The nurse had already given her some sublingual nifedipine, and when we repeated the blood pressure it was 110/70, but she still had all of the symptoms. I asked the nurses to bring some magnesium, which 2 hours later, she still hasn't received. I also asked for gloves to do a pelvic exam, which took 15 minutes to find. Her cervix is unfavorable.
No labs have yet been done, and the nurses don't think that the hospital lab can do liver function tests. (They have never heard of creatinine, so don't know if it can be done).
Our ultrasound reveals a 31-week fetus with oligohydramnios.
Clearly, this woman needs to be delivered, but there are several problems
1. There is no anesthetist in the hospital
2. She has no labs done, and her clinical picture is highly concerning for HELLP syndrome. If we do a cesarean and she is coagulopathic, she could die. Then again, if we don't deliver her, she could die.
3. We could induce her labor (she has had 5 previous vaginal deliveries), but with no fluid and severe pre-eclampsia, who knows if the baby would tolerate it and if she would survive the long induction process? There is no ability whatsoever to do an emergent cesarean - it takes hours to get a patient to theatre.
4. She is preterm. In the US, we wouldn't worry much about a 31-week fetus in this situation, but here, survival is more limited. The absolute minimum survival here is 28 weeks, but even then it's precarious, and 31 weeks certainly is not guaranteed. But the mother could easily die of her preeclampsia - and soon - so she must be delivered.
I stop by the lab to see if they can, in fact, do liver function tests, but the lab is empty and locked (for lunch?). There is a young man in a wheelchair looking very ill, grunting and gasping. His family is waiting with him outside the lab. Who knows if he will get seen in time.
We find out that there is one anesthetist around (how? why? I don't know.) and willing to do the cesar. But first he wants the ward doctor to see the patient and make his recommendation. This could take hours. The midwives and hospital staff don't know me yet, so it's understandable that they want the ward doctor to see the patient. But I don't know how long this will take, and I can only wait and hope that he comes soon and that the woman and her fetus remain stable until then. I also hope that as time goes by, and the hospital staff get to know me, this will happen less. Until then, I can only sigh.
I saw a woman on labor ward yesterday who had been diagnosed with "pelvic infection" at 15 weeks gestation. This didn't make sense, because pelvic infections (like PID) are extremely rare in pregnancy. When I spoke to her (using a nurse who spoke Japadhola), I found that she was tender only over her bladder (but not her uterus) and had pain with urination and urinary frequency - so it was more likely a urinary tract infection. (At home, I would get a urinalysis and a urine culture. Here, no such luck.) She had been prescribed Ampicillin, Metronidazole, and Ceftriaxone (they tend to throw loads of antibiotics at everyone here, regardless of diagnosis). Nothing had yet been given (also typical), so I told them to give only the Ampicillin. Today, she was feeling much better.
There was another 15-week pregnant woman on the ward, who was diagnosed with a urinary tract infection. When I spoke to her, though, this sounded incorrect. She had been having pain and bleeding for almost a month, had been seen multiple times and been given antibiotics multiple times (see antibiotic overuse, above) but hadn't gotten better. She was understandably frustrated. An ultrasound 3 weeks ago had been normal. Concerned about the source of the bleeding, I wondered about vaginal or cervical lesions, or potentially spontaneous abortion in progress. I asked the nurse for a speculum to be prepared (this usually takes at least an hour). I never got one yesterday, so I came back today.
The same woman was still there, and still having bleeding. I had brought two of the study's medical officers to practice ultrasound (she needed one anyway), and we started to scan. Immediately I noticed that the entire fetus was collected in the lower uterine segment, and there was no fluid whatsoever. On interviewing her further, the "blood" that she had been seeing come out was very watery. Her membranes had ruptured over a week ago, probably, and the pain she was feeling was slow cramping, preparing to abort, most likely. I explained the situation to her. She was upset, of course, but wanted resolution. I had the husband go and buy some misoprostol at the pharmacy. (Later he told me that 2 pills cost him USh 20,000 - about $10. That means that a medicine that costs pennies at home costs $5 here.) She started the first dose, and almost immediately the cramping increased. I think she will deliver after 1 or 2 doses. I hope so, because I'm not sure the family can afford any more.
Another woman we did an ultrasound on said she was 3 months pregnant, but when we did the ultrasound, we found nothing in her uterus, just some small blood collected near the lower uterine segment. Discussion with the nurse revealed that the patient had had heavy bleeding the night before, and had likely miscarried.
During that ultrasound, the nurse asked me to see another patient who had just come in with pre-eclampsia. Her blood pressure was 180/120, her urine protein was 4+ (very high), she was having a severe frontal headache, scotomata (seeing spots), and epigastric pain. She looked ill uncomofortable, and glassy-eyed, although was conscious and responsive. The nurse had already given her some sublingual nifedipine, and when we repeated the blood pressure it was 110/70, but she still had all of the symptoms. I asked the nurses to bring some magnesium, which 2 hours later, she still hasn't received. I also asked for gloves to do a pelvic exam, which took 15 minutes to find. Her cervix is unfavorable.
No labs have yet been done, and the nurses don't think that the hospital lab can do liver function tests. (They have never heard of creatinine, so don't know if it can be done).
Our ultrasound reveals a 31-week fetus with oligohydramnios.
Clearly, this woman needs to be delivered, but there are several problems
1. There is no anesthetist in the hospital
2. She has no labs done, and her clinical picture is highly concerning for HELLP syndrome. If we do a cesarean and she is coagulopathic, she could die. Then again, if we don't deliver her, she could die.
3. We could induce her labor (she has had 5 previous vaginal deliveries), but with no fluid and severe pre-eclampsia, who knows if the baby would tolerate it and if she would survive the long induction process? There is no ability whatsoever to do an emergent cesarean - it takes hours to get a patient to theatre.
4. She is preterm. In the US, we wouldn't worry much about a 31-week fetus in this situation, but here, survival is more limited. The absolute minimum survival here is 28 weeks, but even then it's precarious, and 31 weeks certainly is not guaranteed. But the mother could easily die of her preeclampsia - and soon - so she must be delivered.
I stop by the lab to see if they can, in fact, do liver function tests, but the lab is empty and locked (for lunch?). There is a young man in a wheelchair looking very ill, grunting and gasping. His family is waiting with him outside the lab. Who knows if he will get seen in time.
We find out that there is one anesthetist around (how? why? I don't know.) and willing to do the cesar. But first he wants the ward doctor to see the patient and make his recommendation. This could take hours. The midwives and hospital staff don't know me yet, so it's understandable that they want the ward doctor to see the patient. But I don't know how long this will take, and I can only wait and hope that he comes soon and that the woman and her fetus remain stable until then. I also hope that as time goes by, and the hospital staff get to know me, this will happen less. Until then, I can only sigh.
Monday, November 9, 2009
And Buries Her
I had high hopes this week to do lots of ward rounds and cesareans, but that was thwarted by a new TIA development - the lack of an anesthetist. One anesthetist has been transferred to another site, and the other one is on leave, so there is no option of doing any surgeries whatsoever. The midwives informed of me of the problem this morning.
All patients must be referred to out to St. Anthony's, a private hospital in Tororo (where, of course, they have to pay for services if they are to receive them).
Since no cesars can be done, and the cesarean patients usually take up most of the beds because they stay so long, there are almost no patients on the wards.
Instead, I decided to teach ultrasound to some of the Medical Officers working on my study. As I was teaching one Medical Officer, the midwives asked me to scan a woman who had just been beaten by her husband.
Interviewing her was difficult, because she spoke Japadhola and not a word of English. The nurse kept dashing away to deliver a baby or clean a bed, so I could only get 1 or 2 questions in at a time. I finally managed to establish that she was punched and kicked in the abdomen by her husband, and had no vaginal bleeding.
I did an ultrasound, fearing the worst, but found a healthy, kicking, happy 28-week fetus inside.
At home, we would automatically offer to admit women who had suffered domestic violence - to allow them a safe place to stay, and access to social services. Of course, there is none of that here. I was asked to do the ultrasound so they could send her home. A new midwife arrived who spoke Japadhola, and had more time to translate.
ME: Sister, can you tell her that the baby looks good?
(She does, and the patient smiles, relieved)
ME: I can see the baby moving. Does she feel it now?
(Discussion in Japadhola)
MIDWIFE: She first started feeling the baby move this morning.
ME: Started? I thought it stopped.
(Discussion in Japadhola)
MIDWIFE: Ehhhhh.... (which is a noncommittal yes)
ME: Did it start or stop today?
(Discussion in Japadhola)
MIDWIFE: The baby started moving this morning.
ME: OK...so it's moving now?
(Discussion in Japadhola)
MDIWIFE: Ehhhh......We can discharge her?
ME: Where is she going to go?
MIDWIFE: She says to her mother's house.
ME: Why did he hit her?
(Discussion in Japadhola, lasts a long time)
MIDWIFE: She says he is going to kill her.
ME: Kill her?
MIDWIFE: She says this is her first pregnancy, and they are just married, and he has already taken another woman. She says he is going to kill her.
ME: She shouldn't go back to him then.
MIDWIFE: Ehhh....But her is her husband. He probably paid two cows dowry for her. She must go back to him.
ME: Even if he kills her?
MIDWIFE: And buries her.
All patients must be referred to out to St. Anthony's, a private hospital in Tororo (where, of course, they have to pay for services if they are to receive them).
Since no cesars can be done, and the cesarean patients usually take up most of the beds because they stay so long, there are almost no patients on the wards.
Instead, I decided to teach ultrasound to some of the Medical Officers working on my study. As I was teaching one Medical Officer, the midwives asked me to scan a woman who had just been beaten by her husband.
Interviewing her was difficult, because she spoke Japadhola and not a word of English. The nurse kept dashing away to deliver a baby or clean a bed, so I could only get 1 or 2 questions in at a time. I finally managed to establish that she was punched and kicked in the abdomen by her husband, and had no vaginal bleeding.
I did an ultrasound, fearing the worst, but found a healthy, kicking, happy 28-week fetus inside.
At home, we would automatically offer to admit women who had suffered domestic violence - to allow them a safe place to stay, and access to social services. Of course, there is none of that here. I was asked to do the ultrasound so they could send her home. A new midwife arrived who spoke Japadhola, and had more time to translate.
ME: Sister, can you tell her that the baby looks good?
(She does, and the patient smiles, relieved)
ME: I can see the baby moving. Does she feel it now?
(Discussion in Japadhola)
MIDWIFE: She first started feeling the baby move this morning.
ME: Started? I thought it stopped.
(Discussion in Japadhola)
MIDWIFE: Ehhhhh.... (which is a noncommittal yes)
ME: Did it start or stop today?
(Discussion in Japadhola)
MIDWIFE: The baby started moving this morning.
ME: OK...so it's moving now?
(Discussion in Japadhola)
MDIWIFE: Ehhhh......We can discharge her?
ME: Where is she going to go?
MIDWIFE: She says to her mother's house.
ME: Why did he hit her?
(Discussion in Japadhola, lasts a long time)
MIDWIFE: She says he is going to kill her.
ME: Kill her?
MIDWIFE: She says this is her first pregnancy, and they are just married, and he has already taken another woman. She says he is going to kill her.
ME: She shouldn't go back to him then.
MIDWIFE: Ehhh....But her is her husband. He probably paid two cows dowry for her. She must go back to him.
ME: Even if he kills her?
MIDWIFE: And buries her.
Sunday, November 8, 2009
Welcome to My Soapbox
Inspired by the complete and total idiocy of certain American politicians, I am going to use this opportunity to imagine what our country would look like if abortion were criminalized.
Let's take the example of Uganda, where I am currently living. Abortion is illegal in Uganda, except in cases where the mother's life is at risk.
Then again, when is it not at risk? The (official) maternal mortality ratio in Uganda is 440 per 100,000 live births (in contrast, that number in the United States is 13).
A report by the Guttmacher Institute estimates that 297,000 induced abortions occur in Uganda every year, and 85,000 women are treated for complications of abortion every year. (Imagine how many have complications and are not treated.)
Half of all pregnancies in Uganda are unintended, and one in five pregnancies ends in abortion.
Unsafe abortion causes 13% of maternal deaths worldwide.
Making abortion illegal doesn't make it any less frequent. In fact, the opposite is true. Abortion rates are lowest in Western Europe (12 per 1000 women), somewhat higher in the US (21 per 1000 women), and while the worldwide average is 29 per 1000 women, the rate in Uganda is 54 per 1000 women.
While politicians grandstand about conception and life and babies from the comfort of their privileged lives, women are making risky choices and dying because someone else wanted to make that choice for them. They show up in the hospital septic, bleeding, and unconscious, with holes, sticks or cassava stems in their uteruses.
Women shouldn't die because they got pregnant. Maybe it's time to stop lamenting the morality of abortion, and start recognizing the reality of it.
Let's take the example of Uganda, where I am currently living. Abortion is illegal in Uganda, except in cases where the mother's life is at risk.
Then again, when is it not at risk? The (official) maternal mortality ratio in Uganda is 440 per 100,000 live births (in contrast, that number in the United States is 13).
A report by the Guttmacher Institute estimates that 297,000 induced abortions occur in Uganda every year, and 85,000 women are treated for complications of abortion every year. (Imagine how many have complications and are not treated.)
Half of all pregnancies in Uganda are unintended, and one in five pregnancies ends in abortion.
Unsafe abortion causes 13% of maternal deaths worldwide.
Making abortion illegal doesn't make it any less frequent. In fact, the opposite is true. Abortion rates are lowest in Western Europe (12 per 1000 women), somewhat higher in the US (21 per 1000 women), and while the worldwide average is 29 per 1000 women, the rate in Uganda is 54 per 1000 women.
While politicians grandstand about conception and life and babies from the comfort of their privileged lives, women are making risky choices and dying because someone else wanted to make that choice for them. They show up in the hospital septic, bleeding, and unconscious, with holes, sticks or cassava stems in their uteruses.
Women shouldn't die because they got pregnant. Maybe it's time to stop lamenting the morality of abortion, and start recognizing the reality of it.
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