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Quick Medical Diagnosis & Treatment 2020

Pulmonary Embolism

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AMA Citation
Pulmonary Embolism. In: Papadakis MA, McPhee SJ, Bernstein J. Papadakis M.A., McPhee S.J., Bernstein J Eds. Maxine A. Papadakis, et al.eds. Quick Medical Diagnosis & Treatment 2020 New York, NY: McGraw-Hill; . http://accessmedicine.mhmedical.com/content.aspx?bookid=2750&sectionid=231379041. Accessed May 30, 2020.

MLA Citation
. "Pulmonary Embolism." Quick Medical Diagnosis & Treatment 2020 Papadakis MA, McPhee SJ, Bernstein J. Papadakis M.A., McPhee S.J., Bernstein J Eds. Maxine A. Papadakis, et al. New York, NY: McGraw-Hill, , http://accessmedicine.mhmedical.com/content.aspx?bookid=2750&sectionid=231379041.

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For further information, see CMDT Part 9-25: Pulmonary Venous Thromboembolism

Key Features

Essentials of Diagnosis

Predisposition to venous thrombosis, usually of the lower extremities
Usually dyspnea, chest pain, hemoptysis, or syncope
Tachypnea and a widened alveolar–arterial PO₂ difference
Elevated rapid D-dimer and characteristic defects on CT pulmonary arteriography, ventilation-perfusion lung scan, or pulmonary angiogram

General Considerations

Third most common cause of death in hospitalized patients
Most cases are not recognized antemortem: < 10% with fatal emboli receive specific treatment
Pulmonary thromboembolism (PE) and deep venous thrombosis (DVT) are manifestations of the same disease, with the same risk factors
- Immobility (bed rest, stroke, obesity)
- Hyperviscosity (polycythemia)
- Increased central venous pressures (low cardiac output, pregnancy)
- Vessel damage (prior DVT, orthopedic surgery, trauma)
- Hypercoagulable states, either acquired or inherited
Pulmonary thromboemboli most often originate in deep veins of the lower extremities
PE develops in 50–60% of patients with proximal lower extremity DVT; 50% of these events are asymptomatic
Hypoxemia results from vascular obstruction leading to dead space ventilation, right-to-left shunting, and decreased cardiac output
Other types of pulmonary emboli
- Fat embolism
- Air embolism
- Amniotic fluid embolism
- Septic embolism (eg, endocarditis)
- Tumor embolism (eg, renal cell carcinoma)
- Foreign body embolism (eg, talc in injection drug use)
- Parasite egg embolism (schistosomiasis)

Clinical Findings

Symptoms and Signs

See Table 9–18
Clinical findings depend on the size of the embolus and the patient's preexisting cardiopulmonary status
Dyspnea occurs in 75–85% and chest pain in 65–75% of patients
Tachypnea is the only sign reliably found in more than 50% of patients
97% of patients in the PIOPED study had at least one of the following
- Dyspnea
- Tachypnea
- Chest pain with breathing

Table 9–18.Frequency of specific symptoms and signs in patients at risk for pulmonary thromboembolism.

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Table 9–18. Frequency of specific symptoms and signs in patients at risk for pulmonary thromboembolism.

	UPET¹ PE+ (n = 327)	PIOPED I² PE+ (n = 117)	PIOPED I² PE– (n = 248)
Symptoms
Dyspnea	84%	73%	72%
Respirophasic chest pain	74%	66%	59%
Cough	53%	37%	36%
Leg pain	NR	26%	24%
Hemoptysis	30%	13%	8%
Palpitations	NR	10%	18%
Wheezing	NR	9%	11%
Anginal pain	14%	4%	6%
Signs
Respiratory rate ≥ 16 UPET, ≥ 20 PIOPED I	92%	70%	68%
Crackles (rales)	58%	51%	40%³
Heart rate ≥ 100/min	44%	30%	24%
Fourth heart sound (S₄)	NR	24%	13%³
Accentuated pulmonary component of second heart sound (S₂P)	53%	23%	13%³
T ≥ 37.5°C UPET, ≥ 38.5°C PIOPED	43%	7%	12%
Homans sign	NR	4%	2%
Pleural friction rub	NR	3%	2%
Third heart sound (S₃)	NR	3%	4%
Cyanosis	19%	1%	2%

¹Data from the Urokinase-Streptokinase Pulmonary Embolism Trial (UPET), as reported in Bell WR et al. The clinical features of submassive and massive pulmonary emboli. Am J Med. 1977 Mar;62(3):355–60.

²Data from patients enrolled in the PIOPED I study, as reported in Stein PD et al. Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no preexisting cardiac or pulmonary disease. Chest. 1991 Sep; 100(3):598–603.

³P < 0.05 comparing patients in the PIOPED I study.

PE+, confirmed diagnosis of pulmonary embolism; PE–, diagnosis of pulmonary embolism ruled out; NR, not reported.

Differential Diagnosis

Myocardial infarction
Pneumonia
Pericarditis
Heart failure
Pleuritis (pleurisy)
Pneumothorax
Pericardial tamponade

Diagnosis

Most North American centers use Wells' clinical prediction rule (Table 9–19) or something similar to guide a rapid D-dimer and CT-PA-based diagnostic algorithm. This approach is highly effective when applied correctly.
- In the rigorous Christopher Study, the incidence of venous thromboembolism was only 1.3% and fatal PE occurred in just 0.5% of persons monitored for 3 months off anticoagulation therapy using this approach.
- The incidence of PE following a negative integrated clinical, D-dimer and CT-PA evaluation that excludes PE is comparable to that seen following the traditional gold standard of a negative pulmonary angiography.
Concern over false positive D-dimer measurements in low-risk patients that prompt unnecessary CT-PA has led researchers to develop the Pulmonary Embolism Rule-Out Criteria (PERC, Table 9–20).
- In a prospective analysis of 8138 ED patients at risk for PE, researchers identified 20% (1666) who had both a low (< 20%) pre-test probability of PE and met all 8 PERC criteria. This group had a 1.0% incidence of PE, with one fatality.
- Patients with a Modified Wells Score ≤ 4 who meet all 8 PERC criteria do not need to undergo D-dimer testing and may be monitored clinically.

Table 9–19.Clinical prediction rule for pulmonary embolism (PE).

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Table 9–19. Clinical prediction rule for pulmonary embolism (PE).

Variable	Points
Clinical symptoms and signs of deep venous thrombosis (DVT) (leg swelling and pain with palpation of deep veins)	3.0
Alternative diagnosis less likely than PE	3.0
Heart rate > 100 beats/min	1.5
Immobilization for more than 3 days or surgery in previous 4 weeks	1.5
Previous PE or DVT	1.5
Hemoptysis	1.0
Cancer (with treatment within past 6 months or palliative care)	1.0
Three-tiered clinical probability assessment (Wells criteria)	Score
High	> 6.0
Moderate	2.0 to 6.0
Low	< 2.0
Dichotomous clinical probability assessment (Modified Wells criteria)	Score
PE likely	> 4.0
PE unlikely	< or = 4.0

Data from Wells PS et al. Derivation of a simple clinical model to categorize patients’ probability of pulmonary embolism: increasing the models’ utility with the SimpliRED D-dimer. Thromb Haemost. 2000 Mar;83(3):416–20.

Table 9–20.Pulmonary embolism rule-out criteria (PERC) for low-risk patients.

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Table 9–20. Pulmonary embolism rule-out criteria (PERC) for low-risk patients.

For patients with a Modified Wells Score ≤ 4¹ who meet ALL of the following criteria, PE is excluded, follow off anticoagulation, and search for alternative diagnoses.

Age < 50 years
Heart rate < 100 bpm
Oxyhemoglobin saturation on room air ≥ 95%
No prior history of venous thromboembolism
No recent (within 4 weeks) trauma or surgery requiring hospitalization
No presenting hemoptysis
No estrogen therapy
No unilateral leg swelling

¹See Table 9–19.

Data from: Kline JA et al. Impact of a rapid rule-out protocol for pulmonary embolism on the rate of screening, missed cases, and pulmonary vascular imaging in an urban US emergency room. Ann Emerg Med. 2004 Nov;44(5):490–502.

Laboratory Tests

ECG is abnormal in 70% of patients
- Sinus tachycardia and nonspecific ST-T changes are the most common findings
Acute respiratory alkalosis, hypoxemia, and widened arterial–alveolar O₂ gradient (A–a DO₂), but these findings are not diagnostic (Table 9–18)
Using a D-dimer threshold between 300 and 500 ng/mL (300 and 500 mcg/L), a rapid ELISA has shown a sensitivity for venous thromboembolism of 95–97% and a specificity of 45%

Imaging Studies

Chest radiograph—most common findings
- Atelectasis
- Infiltrates
- Pleural effusions
- Westermark sign is focal oligemia with a prominent central pulmonary artery
- Hampton hump is a pleural-based area of increased intensity from intraparenchymal hemorrhage
Lung scanning (V/Q scan)
- A normal scan can exclude PE
- A high-probability scan is sufficient to make the diagnosis in most cases
- Indeterminate scans are common and do not further refine clinical pretest probabilities
Helical CT pulmonary angiography is supplanting V/Q scanning as the initial diagnostic study
- It requires administration of intravenous radiocontrast dye but is otherwise noninvasive
- It is very sensitive for the detection of thrombus in the proximal pulmonary arteries but less so in the segmental and subsegmental arteries
Venous thrombosis studies
- Venous ultrasonography is the test of choice in most centers
- Diagnosing DVT establishes the need for treatment and may preclude invasive testing in patients in whom there is a high suspicion for PE
In the setting of a nondiagnostic V/Q scan, negative serial DVT studies over 2 weeks predict a low risk (< 2%) of subsequent DVT over the next 6 weeks
Pulmonary angiography is the historical reference standard for the diagnosis of PE
- Invasive, but safe—minor complications in < 5%
- Indicated when there is a high clinical probability and negative noninvasive studies
MRI is a research tool for the diagnosis of PE

Treatment

Medications

See Table 14–16
Full anticoagulation with heparin should begin with the diagnostic evaluation in patients with a moderate to high clinical likelihood of PE and no contraindications
Once the diagnosis of proximal DVT or PE is established, it is critical to ensure adequate therapy
LMWHs are as effective as unfractionated heparin
- Administered in dosages determined by body weight once or twice daily without the need for coagulation monitoring
- Subcutaneous administration appears to be as effective as the intravenous route
Warfarin (vitamin K antagonist)
- Initial dose: 2.5–10 mg/day
- Usually requires 5–7 days to become therapeutic; therefore, heparin is generally continued for 5 days
- Maintenance therapy usually requires 2–15 mg/day
- Contraindicated in pregnancy; LMWHs are safe alternatives
- Interacts with many drugs
The 2016 CHEST Guideline and Expert Panel Report recommends direct oral anticoagulants (Factor Xa inhibitors and direct thrombin inhibitors) over warfarin (vitamin K antagonist) and LMWH in all patients with VTE without a cancer diagnosis and recommends LMWH for patients with cancer
Guidelines for the duration of full anticoagulation
- 3 months of anticoagulation after a first episode provoked by a surgery or a transient nonsurgical risk factor
- Extended therapy (no scheduled stop date) for unprovoked or recurrent episode with a low to moderate risk of bleeding
- Patients who continue to receive anticoagulation long-term should be reassessed for venous thrombosis at least annually
- For patients with cancer, extended therapy with LMWH is recommended regardless of bleeding risk
Thrombolytic therapy accelerates resolution of thrombi when compared with heparin, but does not improve mortality
- Carries 10-fold greater risk of intracranial hemorrhage compared with heparin (0.2–2.1%)
- Indicated in patients who are hemodynamically unstable while on heparin
Venal caval interruption (IVC filters) may be indicated when a significant contraindication to anticoagulation exists or when recurrence occurs despite adequate anticoagulation
IVC filters decrease the short-term incidence of PE, but increase the rate of recurrent DVT

Table 14–16.Initial anticoagulation for VTE.¹

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Table 14–16. Initial anticoagulation for VTE.¹

		Clinical Scenario
Anticoagulant	Dose/Frequency	DVT, Lower Extremity	DVT, Upper Extremity	PE	VTE, With Concomitant Severe Kidney Disease²	VTE, Cancer-Related	Comment
Unfractionated Heparin
Unfractionated heparin	80 units/kg intravenous bolus, then continuous intravenous infusion of 18 units/kg/h	×	×	×	×		Bolus may be omitted if risk of bleeding is perceived to be elevated. Maximum bolus, 10,000 units. Requires aPTT monitoring. Most patients: begin warfarin at time of initiation of heparin.
	330 units/kg subcutaneously × 1, then 250 units/kg subcutaneously every 12 hours	×					Fixed-dose; no aPTT monitoring required
LMWH and Fondaparinux
Enoxaparin³	1 mg/kg subcutaneously every 12 hours	×	×	×			Most patients: begin warfarin at time of initiation of LMWH
Dalteparin³	200 units/kg subcutaneously once daily for first month, then 150 units/kg/day	×	×	×		×	Cancer: administer LMWH for ≥ 3–6 months; reduce dose to 150 units/kg after first month of treatment
Fondaparinux	5–10 mg subcutaneously once daily; use 7.5 mg for body weight 50–100 kg; 10 mg for body weight > 100 kg	×	×	×
Direct-Acting Oral Anticoagulants (DOACs)
Rivaroxaban	15 mg orally twice daily with food for 21 days then 20 mg orally daily with food	×	×	×			Contraindicated if CrCl < 30 mL/min
Apixaban	10 mg orally twice daily for first 7 days then 5 mg twice daily	×	×	×			Contraindicated if CrCl < 25 mL/min Monotherapy without need for initial parenteral therapy
Dabigatran	5–10 days of parenteral anticoagulation, then 150 mg orally twice daily	×	×	×			Contraindicated if CrCl < 15 mL/min Initial need for parenteral therapy
Edoxaban	5–10 days of parenteral anticoagulation, then 60 mg orally once daily; 30 mg once daily recommended if CrCl is between 15 and 50 mL/min, if weight ≤ 60 kg, or if certain P-gp inhibitors are present	×	×	×			Contraindicated if CrCl < 15 mL/min or > 95 mL/min Initial need for parenteral therapy

¹Obtain baseline hemoglobin, platelet count, aPTT, PT/INR, and creatinine prior to initiation of anticoagulation.

Anticoagulation is contraindicated in the setting of active bleeding.

²Defined as creatinine clearance < 30 mL/min.

³If body weight < 50 kg, reduce dose and monitor anti-Xa levels.

CrCl, creatinine clearance; DVT, deep venous thrombosis; PE, pulmonary embolism; P-gp, P-glycoprotein; VTE, venous thromboembolic disease (includes DVT and PE).

Note: An “×” denotes appropriate use of the anticoagulant.

Surgery

Pulmonary embolectomy is an emergency procedure with a high mortality rate performed at few centers

Therapeutic Procedures

Catheter devices that fragment and extract thrombus have been used on small numbers of patients
Platelet counts should be monitored for the first 14 days of UFH due to the risk of immune-mediated thrombocytopenia

Outcome

Complications

Immune-mediated thrombocytopenia occurs in 3% of patients taking UFH
Hemorrhage is the major complication of anticoagulation with heparin: risk of any hemorrhage is 0–7%; risk of fatal hemorrhage is 0–2%
Risk of hemorrhage with warfarin therapy is 3–4% per patient year, but correlates with INR
Chronic thromboembolic pulmonary hypertension occurs in about 1% of patients; selected patients may benefit from pulmonary endarterectomy

Prevention

See Table 14–14

Table 14–14.Pharmacologic prophylaxis of VTE in selected clinical scenarios.¹

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Table 14–14. Pharmacologic prophylaxis of VTE in selected clinical scenarios.¹

Anticoagulant	Dose	Frequency	Clinical Scenario	Comment
Enoxaparin	40 mg subcutaneously	Once daily	Most medical inpatients and critical care patients	—
			Surgical patients (moderate risk for VTE)
			Abdominal/pelvic cancer surgery	Consider continuing for 4 weeks total duration after abdomino-pelvic cancer surgery
		Twice daily	Bariatric surgery	Higher doses may be required
	30 mg subcutaneously	Twice daily	Orthopedic surgery²	Give for at least 10 days. For THR, TKA, or HFS, consider continuing up to 1 month after surgery in high-risk patients
			Major trauma	Not applicable to patients with isolated lower extremity trauma
			Acute spinal cord injury	—
Dalteparin	2500 units subcutaneously	Once daily	Most medical inpatients	—
			Abdominal surgery (moderate risk for VTE)	Give for 5–10 days
	5000 units subcutaneously	Once daily	Orthopedic surgery²	First dose = 2500 units. Give for at least 10 days. For THR, TKA, or HFS, consider continuing up to 1 month after surgery in high-risk patients
			Abdominal surgery (higher risk for VTE)	Give for 5–10 days
			Medical inpatients	—
Fondaparinux	2.5 mg subcutaneously	Once daily	Orthopedic surgery²	Give for at least 10 days. For THR, TKA, or HFS, consider continuing up to 1 month after surgery in high-risk patients
Rivaroxaban	10 mg orally	Once daily	Orthopedic surgery: total hip and total knee replacement	Give for 12 days following total knee replacement; give for 35 days following total hip replacement
Apixaban	2.5 mg orally	Twice daily	Following hip or knee replacement surgery	Give for 12 days following total knee replacement; give for 35 days following total hip replacement
Dabigatran	110 mg orally first day, then 220 mg	Once daily	Following hip replacement surgery	For patients with CrCl > 30 mL/min
Betrixaban	Initial single dose of 160 mg, then 80 mg once daily with food Reduce dose for patients with severe renal impairment or taking P-gp inhibitors	Daily	Adult patients hospitalized for an acute medical illness with moderately to severely restricted mobility and other risk factors for VTE	Recommended duration of treatment is 35–42 days
Unfractionated heparin	5000 units subcutaneously	Three times daily	Higher VTE risk with low bleeding risk	Includes gynecologic surgery for malignancy and urologic surgery, medical patients with multiple risk factors for VTE
	5000 units subcutaneously	Twice daily	Hospitalized patients at intermediate risk for VTE	Includes gynecologic surgery (moderate risk)
			Patients with epidural catheters	LMWHs usually avoided due to risk of spinal hematoma
			Patients with severe kidney disease³	LMWHs contraindicated
Warfarin	(variable) oral	Once daily	Orthopedic surgery²	Titrate to goal INR = 2.5. Give for at least 10 days. For high-risk patients undergoing THR, TKA, or HFS, consider continuing up to 1 month after surgery
Aspirin	variable		Hip and knee replacement

¹All regimens administered subcutaneously, except for warfarin.

²Includes TKA, THR, and HFS.

³Defined as creatinine clearance < 30 mL/min.

CrCl, creatine clearance; HFS, hip fracture surgery; INR, international normalized ratio; LMWH, low-molecular-weight heparin; P-gp, P-glycoprotein; THR, total hip replacement; TKA, total knee arthroplasty; VTE, venous thromboembolic disease.

Prognosis

Overall prognosis depends on the underlying disease rather than the thromboembolic event
Death from recurrent PE occurs in only 3% of cases; 6 months of anticoagulation therapy reduces the risk of recurrent thrombosis and death by 80–90%
Perfusion defects resolve in most survivors

When to Refer

All patients evaluated for or diagnosed with a PE should be evaluated by an expert (typically a pulmonologist, hematologist, or internist)

When to Admit

Patients with an acute PE should be admitted for stabilization, initiation of therapy, evaluation of cause of PE, and education

References

Anderson DR et al. Aspirin or rivaroxaban for VTE prophylaxis after hip or knee arthroplasty. N Engl J Med. 2018 Feb 22;378(8):699–707.
[PubMed: 29466159]

Appelen D et al. Compression therapy for prevention of post-thrombotic syndrome. Cochrane Database Syst Rev. 2017 Sep 26;9:CD004174.
[PubMed: 28950030]

Couturaud F et al. PADIS-PE Investigators. Six months vs extended oral anticoagulation after a first episode of pulmonary embolism: the PADIS-PE randomized clinical trial. JAMA. 2015 Jul 7;314(1):31–40.
[PubMed: 26151264]

Freund Y et al. PROPER Investigator Group. Effect of the Pulmonary Embolism Rule-Out criteria on subsequent thromboembolic events among low-risk emergency department patients: the PROPER Randomized Clinical Trial. JAMA. 2018 Feb 13;319(6):559–66.
[PubMed: 29450523]

Jin J. JAMA patient page. Treatment duration for pulmonary embolism. JAMA. 2015 Jul 7;314(1):98.
[PubMed: 26151285]

Kahale LA et al. Anticoagulation for people with cancer and central venous catheters. Cochrane Database Syst Rev. 2018 Jun 1;6:CD006468.
[PubMed: 29856471]

Kahn SR et al. Interventions for implementation of thromboprophylaxis in hospitalized patients at risk for venous thromboembolism. Cochrane Database Syst Rev. 2018 Apr 24;4:CD008201.
[PubMed: 29687454]

Kearon C et al. Antithrombotic therapy for VTE disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb;149(2):315–52.
[PubMed: 26867832]

Kline JA. Utility of a clinical prediction rule to exclude pulmonary embolism among low-risk emergency department patients: reason to PERC up. JAMA. 2018 Feb 13;319(6):551–3.
[PubMed: 29450510]

Konstantinides SV et al. Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014 Nov 14;35(43):3033–69. Erratum in: Eur Heart J. 2015 Oct 14;36(39):2666. Eur Heart J. 2015 Oct 14;36(39):2642.
[PubMed: 25173341]

Meinel FG et al. Predictive value of computed tomography in acute pulmonary embolism: systematic review and meta-analysis. Am J Med. 2015 Jul;128(7):747–59.
[PubMed: 25680885]

Othieno R et al. Home versus in-patient treatment for deep vein thrombosis. Cochrane Database Syst Rev. 2018 Jan 9;1:CD003076.
[PubMed: 29315455]

Raja AS et al. Evaluation of patients with suspected acute pulmonary embolism: best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015 Nov 3;163(9):701–11.
[PubMed: 26414967]

Righini M et al. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA. 2014 Mar 19;311(11):1117–24.
[PubMed: 24643601]

Righini M et al. Diagnosis of pulmonary embolism during pregnancy: a multicenter prospective management outcome study. Ann Intern Med. 2018 Dec 4;169(11):766–73.
[PubMed: 30357273]

van der Hulle T et al. YEARS study group. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet. 2017 Jul 15;390(10091):289–97. Erratum in: Lancet. 2017 Jul 15;390(10091):230.
[PubMed: 28549662]

Vinson DR et al. eSPEED Investigators of the KP CREST Network. Increasing safe outpatient management of emergency department patients with pulmonary embolism: a controlled pragmatic trial. Ann Intern Med. 2018 Dec 18;169(12):855–65.
[PubMed: 30422263]

Wells PS et al. Diagnosis of venous thromboembolism: 20 years of progress. Ann Intern Med. 2018 Jan 16;168(2):131–40.
[PubMed: 29310137]

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Citation

Key Features

Essentials of Diagnosis

General Considerations

Clinical Findings

Symptoms and Signs

Differential Diagnosis

Diagnosis

Laboratory Tests

Imaging Studies

Treatment

Medications

Surgery

Therapeutic Procedures

Outcome

Complications

Prevention

Prognosis

When to Refer

When to Admit

References

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