For the ORT, sensitivity was 0.58 and 0.75 and specificity 0.54 and 0.86; for the SOAPP-R, sensitivity was 0.53 and 0.25 and specificity 0.62 and 0.73; and for the Brief Risk Interview, sensitivity was 0.73 and 0.83 and specificity 0.43 and 0.88. Screener and Opioid Assessment for Patients with Pain-Revised, New for update: 2 studies of diagnostic accuracy (n = 320). Reuben DB, Alvanzo AAH, Ashikaga T, et al. The accuracy of instruments for predicting risk for opioid overdose, addiction, abuse, or misuse; the effectiveness of risk mitigation strategies (use of risk prediction instruments); effectiveness of risk mitigation strategies including opioid management plans, patient education, urine drug testing, prescription drug monitoring program (PDMP) data, monitoring instruments, monitoring intervals, pill counts, and abuse-deterrent formulations for reducing risk for opioid overdose, addiction, abuse, or misuse; and the comparative effectiveness of treatment strategies for managing patients with addiction (KQ4). Most trials found no improvement in the disability level, except in the trial by Petersen et al. New York, NY: McGraw-Hill; 1996. Pharmacoepidemiol Drug Saf 2011;20:75462. For example, acetaminophen, NSAIDs, and opioid pain medication were involved in 881, 228, and 16,651 pharmaceutical overdose deaths in the United States in 2010 (178). 7. ), significant trauma, unexplained weight loss and widespread neurologic changes, Overweight/obese is a strong predictor and is often seen by non specific-low back pain. Salzman RT, Roberts MS, Wild J, Fabian C, Reder RF, Goldenheim PD. Sex differences in dose escalation and overdose death during chronic opioid therapy: a population-based cohort study. Although no studies were found to examine prescribing of naloxone with opioid pain medication in primary care settings, naloxone distribution through community-based programs providing prevention services for substance users has been demonstrated to be associated with decreased risk for opioid overdose death at the community level (147). The years lived with disability from low back pain have gone up by more than 50% since 1990, particularly in low-income and middle-income countries [1, 2]. URL addresses listed in MMWR were current as of Level of evidence 1A, Burton AK, Tillotson KM, Main CJ, Hollis S. Psychosocial predictors of outcome in acute and subchronic low back trouble. If patients do not experience improvement in pain and function at 90 MME/day, or if there are escalating dosage requirements, clinicians should discuss other approaches to pain management with the patient, consider working with patients to taper opioids to a lower dosage or to taper and discontinue opioids (see Recommendation 7), and consider consulting a pain specialist. Clinicians should evaluate patients to assess benefits and harms of opioids within 1 to 4 weeks of starting long-term opioid therapy or of dose escalation. Although there is limited evidence to recommend specific intervals for dosage titration, a previous guideline recommended waiting at least five half-lives before increasing dosage and waiting at least a week before increasing dosage of methadone to make sure that full effects of the previous dosage are evident (31). Re-occurrence is a major problem with the re-occurrence rate being approximately 60%. For the purposes of this study, CLBP was defined as LBP that had lasted for more than 12 weeks, during which time the patient had not been pain-free for more than 30 consecutive days[17]. some patients having sub-acute LBP and some having CLBP) were only included if the CLBP patients were separated. Despite this, these therapies are not always or fully covered by insurance, and access and cost can be barriers for patients. One large fair-quality retrospective cohort study found that recent opioid use was associated with increased risk for any overdose events and serious overdose events versus nonuse (66). These outcome measures were selected based on high levels of validity and reliability in measuring CLBP. The clinical and contextual evidence reviews found that opioid overdose risk increases in a dose-response manner, that dosages of 50<100 MME/day have been found to increase risks for opioid overdose by factors of 1.9 to 4.6 compared with dosages of 1<20 MME/day, and that dosages 100 MME/day are associated with increased risks of overdose 2.08.9 times the risk at 1<20 MME/day. Previous guidelines have recommended screening or risk assessment tools to identify patients at higher risk for misuse or abuse of opioids. This is an update to the 2012 Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), clinical practice guideline (CPG) for LBP. BSC members are special government employees appointed as CDC advisory committee members; as such, all members completed an OGE Form 450 to disclose relevant interests. J Am Geriatr Soc 2009;57:133146. Ann Emerg Med 2012;60:499525. All experts completed a statement certifying that there was no potential or actual conflict of interest. Patients with chronic pain in focus groups emphasized effectiveness of goal setting for increasing motivation and functioning (168). Results were synthesized qualitatively, highlighting new evidence identified during the update process. For this reason, localized heat therapy is avoided immediately after injury (typically avoid heat for the first 48 hours and apply cold compresses to help with acute inflammation). This is recommended in all states with well-functioning PDMPs and where PDMP access policies make this practicable (e.g., clinician and delegate access permitted), but it is not currently possible in states without functional PDMPs or in those that do not permit certain prescribers to access them. While experts agreed that clinicians should use urine drug testing before initiating opioid therapy for chronic pain, they disagreed on how frequently urine drug testing should be conducted during long-term opioid therapy. Alcohol Clin Exp Res 2007;31:18599. Pain Med 2005;6:11321. The evidence presented here supporting the effectiveness of McKenzie therapy in reducing pain and disability in patients with CLBP compared to MT is in accordance with a systematic review by Clare et al.[30]. However, these patients should be offered the opportunity to re-evaluate their continued use of opioids at high dosages in light of recent evidence regarding the association of opioid dosage and overdose risk. Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. The information is produced and reviewed by over 200 medical professionals with the goal of providing trusted, uniquely informative information for people with painful health conditions. 2000;25:14841492.level of evidence 2B, Koes, Bart W., et al. Source: Adapted from Von Korff M, Saunders K, Ray GT, et al. Patients with MCD might form an important subgroup among patients with non specific low back pain. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs. Basford JR, Sheffield CG, Harmsen WS. The Exercise for osteoarthritis of the knee. CDC obtained input from experts, stakeholders, the public, peer reviewers, and a federally chartered advisory committee. One might expect that improvement in the resolution of imaging technology has increased the likelihood of detecting a link between pathology and pain in the lumbar spine. One expert thought that a specific dosage at which the benefit/risk ratio of opioid therapy decreases could not be identified. Level of evidence A1, Ferreira, Manuela L., et al. Cochrane Database Syst Rev 2010:1:CD006605 . J Pain Symptom Manage 1999;18:2719. At the six month follow-up, significant improvements were observed in the disability index reported by Kilpikoski et al. "Non-specific low back pain." Injuries from contact sports, accidents, and falls can cause problems ranging from minor muscle strains, to herniated disks, to fractures that damage the spinal column or cord. Paulozzi L. CDC grand rounds: prescription drug overdosesa U.S. epidemic. Periconceptional use of opioids and the risk of neural tube defects. If tests for prescribed opioids are repeatedly negative, confirming that the patient is not taking the prescribed opioid, clinicians can discontinue the prescription without a taper. Howe CQ, Sullivan MD. Clin J Pain 2007;23:28799. The short-term effect of heat application on damaged, infected, or swollen tissues is an increase in inflammation. the intervertebral disc) as the source of pain, as might be the case in peripheral joints such as the knee[24]. Clinicians should use these goals in assessing benefits of opioid therapy for individual patients and in weighing benefits against risks of continued opioid therapy (see Recommendation 7, including recommended intervals for follow-up). If a patients opioid dosage for all sources of opioids combined reaches or exceeds 50 MME/day, clinicians should implement additional precautions, including increased frequency of follow-up (see Recommendation 7) and considering offering naloxone and overdose prevention education to both patients and the patients household members (see Recommendation 8). Gomes T, Redelmeier DA, Juurlink DN, Dhalla IA, Camacho X, Mamdani MM. Clinicians should check the PDMP for concurrent controlled medications prescribed by other clinicians (see Recommendation 9) and should consider involving pharmacists and pain specialists as part of the management team when opioids are co-prescribed with other central nervous system depressants. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. The contextual evidence review found that although there is not a single dosage threshold below which overdose risk is eliminated, holding dosages <50 MME/day would likely reduce risk among a large proportion of patients who would experience fatal overdose at higher prescribed dosages. The recommendations and all statements included in this guideline are those of CDC and do not necessarily represent the official position of any persons or organizations providing comments on the draft guideline. Dose escalation versus dose maintenance or use of dose thresholds, Pain, function, or withdrawal due to opioid misuse. Leg Pain and Numbness: What Might These Symptoms Mean? On the basis of data available from health systems, researchers estimate that 9.611.5 million adults, or approximately 3%4% of the adult U.S. population, were prescribed long-term opioid therapy in 2005 (15). Diagnosis can help identify disease-specific interventions to reverse or ameliorate pain; for example, improving glucose control to prevent progression of diabetic neuropathy; immune-modulating agents for rheumatoid arthritis; physical or occupational therapy to address posture, muscle weakness, or repetitive occupational motions that contribute to musculoskeletal pain; or surgical intervention to relieve mechanical/compressive pain (179). Moore TM, Jones T, Browder JH, Daffron S, Passik SD. No difference between more liberal dose escalation versus maintenance of current doses in pain, function, or risk of withdrawal due to opioid misuse, but there was limited separation in opioid doses between groups (52 versus 40 MME/day at the end of the trial). Pediatr Emerg Care 2014;30:2305. Also see Interventions for LBP. Ann Rheum Dis 2005;64:66981. The professional credentials and interests of OGW members were carefully reviewed to identify possible conflicts of interest such as financial relationships with industry, intellectual preconceptions, or previously stated public positions. There was verylowto moderate quality evidence of a positive effect of MVCE on disability, both at the end of treatment (SMD 0.38; 95% CI 0.68, 0.09), and after 12months (SMD 0.37; 95% CI 0.61, 0.04) [35]. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. At the long-term follow-up, very low-quality evidence showed passive physiotherapy to be better than back school (MD 9.60; 95% CI 3.6515.54) [21]. Cochrane Database Syst Rev 2006:1:CD001333. Clinicians should consider follow-up intervals within the lower end of this range when ER/LA opioids are started or increased or when total daily opioid dosage is 50 MME/day. Heat therapy can help relieve tightness in the lower back by recouping circulation, relaxing tense muscles, and reducing related pain. For this guideline, palliative care is defined in a manner consistent with that of the Institute of Medicine as care that provides relief from pain and other symptoms, supports quality of life, and is focused on patients with serious advanced illness. Akbik H, Butler SF, Budman SH, Fernandez K, Katz NP, Jamison RN. The Journal of the American Academy of Dermatology (JAAD), the official scientific publication of the American Academy of Dermatology (AAD), aims to satisfy the educational needs of the dermatology community.As the specialty's leading journal, JAAD features original, peer-reviewed articles emphasizing: However, even though evidence is limited on the effectiveness of PDMP implementation at the state level on prescribing and mortality outcomes (28), the contextual evidence review found that most fatal overdoses were associated with patients receiving opioids from multiple prescribers and/or with patients receiving high total daily opioid dosages; information on both of these risk factors for overdose are available to prescribers in the PDMP. BMJ 2006;332:143034. Anastassopoulos KP, Chow W, Tapia CI, Baik R, Moskowitz B, Kim MS. Reported side effects, bother, satisfaction, and adherence in patients taking hydrocodone for non-cancer pain. Osteoarthritis can affect your vertebrae, when the cartilage between them wears down. Consider offering another of these options if the chosen treatment does not result in satisfactory improvement. European guidelines for the management of acute nonspecific low back pain in primary care. A systematic review of efficacy of McKenzie therapy for spinal pain. Accessibility Mazer-Amirshahi M, Mullins PM, Rasooly IR, van den Anker J, Pines JM. Haegerich TM, Paulozzi LJ, Manns BJ, Jones CM. Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, Ferreira PH, Fritz JM, Koes BW, Peul W, Turner JA, Maher CG, Lancet Low Back Pain Series Working Group Prevention and treatment of low back pain: evidence, challenges, and promising directions. Urine drug tests do not provide accurate information about how much or what dose of opioids or other drugs a patient took. Washington, DC: The National Academies Press; 2011. International Association for the Study of Pain. Schneider JP, Kirsh KL. CDC is committed to working with partners to identify the highest priority research areas to build the evidence base. A systematicreviewand meta-analysis of the reliability and validity of sensorimotor measurement instruments in people with chroniclow back pain. Thus, the association between clinical complaints and concurrent pathological examination with radiological findings must be considered cautiously. Early non-pharmacological treatment is endorsed. failing to detect a present effect) were made more probable as the sample sizes were small for three-arm trials. I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. Low back pain (LBP) remains a musculoskeletal condition with an adverse societal impact. Machado GC, Pinheiro MB, Lee H, Ahmed OH, Hendrick P, Williams C, Kamper SJ. Chou R, Qaseem A, Snow V, et al. Low Back Pain Guidelines regularly recommend the use of physical exercise for non-specific LBP. In addition, the study was performed in a single outpatient clinic, with subjects from a small population, and a single therapist, potentially affecting its reliability as evidence. As vendors and practices facilitate integration of PDMP information into regular clinical workflow (e.g., data made available in electronic health records), clinicians ease of access in reviewing PDMP data is expected to improve. It is important that patients receive appropriate pain treatment with careful consideration of the benefits and risks of treatment options. It remains unclear whether or not back schools are effective for chronic low back pain. The cost of care for LBP has been reported (in the USA) to be over $50 billion annually[9]. Clinicians seeing new patients already receiving opioids should establish treatment goals for continued opioid therapy. [4]. Category A recommendations indicate that most patients should receive the recommended course of action; category B recommendations indicate that different choices will be appropriate for different patients, requiring clinicians to help patients arrive at a decision consistent with patient values and preferences and specific clinical situations. For pregnant women already receiving opioids, clinicians should access appropriate expertise if considering tapering opioids because of possible risk to the pregnant patient and to the fetus if the patient goes into withdrawal (see Recommendation 7). MMWR Morb Mortal Wkly Rep 2012;61:103. The Guidelines recommend the non-pharmacological and non-invasive management [].These include the provision of advice to stay active and the use of patient education and exercise therapy [].Guidelines regularly recommend the use of physical exercise for non-specific LBP [].Guidelines endorse the cautious use of No evidence shows a long-term benefit of opioids in pain and function versus no opioids for chronic pain with outcomes examined at least 1 year later (with most placebo-controlled randomized trials 6 weeks in duration). An estimated 20% of patients presenting to physician offices with noncancer pain symptoms or pain-related diagnoses (including acute and chronic pain) receive an opioid prescription (1). Cochrane Database Syst Rev 2014;6:CD010692 . Across specialties, physicians believe that opioid pain medication can be effective in controlling pain, that addiction is a common consequence of prolonged use, and that long-term opioid therapy often is overprescribed for patients with chronic noncancer pain (27). Additional research can inform the development of future guidelines for special populations that could not be adequately addressed in this guideline, such as children and adolescents, where evidence and guidance is needed but currently lacking. Experts noted that risks for opioid overdose are greatest during the first 37 days after opioid initiation or increase in dosage, particularly when methadone or transdermal fentanyl are prescribed; that follow-up within 3 days is appropriate when initiating or increasing the dosage of methadone; and that follow-up within 1 week might be appropriate when initiating or increasing the dosage of other ER/LA opioids. : the tenth international forum for primary care research on low back pain. Benzodiazepines and opioids both cause central nervous system depression and can decrease respiratory drive. Addiction 2010;105:177682. JAMA Intern Med 2015;175:60815. A slipped or herniated disc may be diagnosed when an intervertebral disc of the spine has lost its normal shape or consistency, causing symptoms to occur. Because pain management in patients with substance use disorder can be complex, clinicians should consider consulting substance use disorder specialists and pain specialists regarding pain management for persons with active or recent past history of substance abuse. For example, acetaminophen can be hepatotoxic at dosages of > 3-4 grams/day and at lower dosages in patients with chronic alcohol use or liver disease (109). Clark S, Horton R. Low back pain: a major global challenge. https://www.physio-pedia.com/index.php?title=Non_Specific_Low_Back_Pain&oldid=314566. Globally, LBP is highly prevalent and a leading cause of disability. Bone spurs or a herniated disk can push on nerves. Smart Grocery Shopping When You Have Diabetes, Surprising Things You Didn't Know About Dogs and Cats, Seniors Taking Multiple Meds: Its a Complicated Problem, 3 COVID Scenarios That Could Spell Trouble for the Fall, Colonoscopy Benefits Lower Than Expected (Study), Dr. Whyte's Book: Take Control of Your Diabetes Risk, Street Medicine Reaches People Where They Live, Health News and Information, Delivered to Your Inbox, Arthritis & Ankylosing Spondylitis of the Spine, Injections for Back Pain: What You Need to Know, Slideshow: Good and Bad Exercises for Low Back Pain, Poor posture, like sitting incorrectly at a desk or behind the steering wheel, Repeating the same motion or overdoing it, Pushing, pulling, and lifting things carelessly, After you get hurt, like in a fall or accident, When the pain gets in the way of your daily activities, If it lasts longer than 6 weeks, or spreads. The small sample sizes affect the internal validity of the studies, reducing the value of their evidence. OConnell NE, Cook CE, Wand BM, Ward SP. Increased blood flow delivers more oxygen, white blood cells, platelets, and essential nutrients all of which help repair damaged tissues heal. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). Could Your Foot Pain Be Caused by a Problem in Your Spine? However, the contextual evidence review found evidence in epidemiologic series of concurrent benzodiazepine use in large proportions of opioid-related overdose deaths, and a case-cohort study found concurrent benzodiazepine prescription with opioid prescription to be associated with a near quadrupling of risk for overdose death compared with opioid prescription alone (212). The Journal of the American Academy of Dermatology (JAAD), the official scientific publication of the American Academy of Dermatology (AAD), aims to satisfy the educational needs of the dermatology community.As the specialty's leading journal, JAAD features original, peer-reviewed articles emphasizing: Hadi I, da Silva O, Natale R, Boyd D, Morley-Forster PK. At the 12-month follow-up, there were no significant differences between groups in LBP, but it was reported[19]-[21] that the McKenzie method group had a better disability level than the MT group (p=0.05, p=0.028, p=0.030, respectively). Expert opinion is reflected within each of the recommendation rationales. Public health programs and their urgency will differ in high-income countries when compared to low-income and middle-income countries as well [8]. Hansen RN, Oster G, Edelsberg J, Woody GE, Sullivan SD. Opioids used in pregnancy might be associated with additional risks to both mother and fetus. The Danish [27], United States of America (USA) [28], and the United Kingdom (UK) [22] guidelines recommend the use of exercise on its own, or in combination with other non-pharmacological therapies. Food and Drug Administration. It is generally described as pain between the costal margin and the gluteal folds. Occupational differences in low back pain prevalence have also been reported 159 with an association between higher physical demand and low back pain prevalence. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Stabbing low back pain could be from muscle spasms, when your muscles seize up and don't relax, like a cramp. Prevalence of aberrant drug-related behaviors ranged from 6% to 37%. ; American Academy of Neurology; American Association of Neuromuscular and Electrodiagnostic Medicine; American Academy of Physical Medicine and Rehabilitation. Before Five trials were eligible for inclusion in the review, of which, most had a score of 8 out of 11 on the PEDro scale. Veritas Health, LLC, Available from: Burton AK, Tillotson KM, Main CJ, Hollis S. Psychosocial predictors of outcome in acute and subchronic low back trouble. The outcome variables at the different follow-up points, as well as the sizes of the effects of the trials and pooled results are depicted in Table 3. J Opioid Manag 2011;7:41724. Therapeutic anesthetic options have included patient-controlled analgesia, thoracic epidural analgesia, paravertebral nerve block, subcutaneous catheter anesthetic infusion, and cryoanalgesia [316]. Amato L, Minozzi S, Davoli M, Vecchi S. Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification. Regarding risk mitigation approaches, limited evidence was found regarding benefits and harms. Long-term use of controlled-release oxycodone for noncancer pain: results of a 3-year registry study. Ideally, PDMP data should be reviewed before every opioid prescription. Latest health news. Choosing the right outcome measurement instruments for patients withlow back pain. A 2012 systematic review found evidence to support the use of spinal manipulation by physical therapists as a safe option to improve outcomes for lower back pain. Spector W, Shaffer T, Potter DE, Correa-de-Araujo R, Rhona Limcangco M. Risk factors associated with the occurrence of fractures in U.S. nursing homes: resident and facility characteristics and prescription medications. Bohnert ASB, Logan JE, Ganoczy D, Dowell D. A detailed exploration into the association of prescribed opioid dosage and prescription opioid overdose deaths among patients with chronic pain. Some of the recommendations might be relevant for acute care settings or other specialists, such as emergency physicians or dentists, but use in these settings or by other specialists is not the focus of this guideline. More than 7 days will rarely be needed. Experts agreed that before opioid therapy is initiated for chronic pain outside of active cancer, palliative, and end-of-life care, clinicians should determine how effectiveness will be evaluated and should establish treatment goals with patients. In some people, however, it was found to increase their back pain [32]. Li L, Setoguchi S, Cabral H, Jick S. Opioid use for noncancer pain and risk of myocardial infarction amongst adults. Cookies used to make website functionality more relevant to you. Three experts independently reviewed the guideline to determine the reasonableness and strength of recommendations; the clarity with which scientific uncertainties were clearly identified; and the rationale, importance, clarity, and ease of implementation of the recommendations. What we know, and dont know, about the impact of state policy and systems-level interventions on prescription drug overdose. COX-2 inhibitors, SNRIs, anticonvulsants, topical analgesics, physical therapy, and CBT are also associated with lower median annual costs compared with opioid therapy (174). Disabil Rehabil. You can review and change the way we collect information below. computer-generated random sequences). The clinical evidence review found a fair-quality study showing a higher risk for overdose among patients initiating treatment with ER/LA opioids than among those initiating treatment with immediate-release opioids (77). Osteoarthritis Cartilage 2007;15:9811000. In their study, the authors evaluated six RCTs that investigated the efficacy of McKenzie therapy in the treatment of back and neck pain. Webster LR, Webster RM. 8600 Rockville Pike Disability measures showed that the McKenzie method was better than the MT method at improving long term patient functionality. OConnor AB, Dworkin RH. Extensive evidence shows the possible harms of opioids (including opioid use disorder, overdose, and motor vehicle injury). Studies suggests that that multifidus and paraspinal muscle groups are significantly smaller in patients with chronic low back pain than in control patients who are healthy and on the symptomatic side of patients with chronic unilateral low back pain compared with the asymptomatic side. In primary care settings, prevalence of opioid abuse ranged from 0.6% to 8% and prevalence of dependence from 3% to 26%. FDA has also noted that some ER/LA opioids are only appropriate for opioid-tolerant patients, defined as patients who have received certain dosages of opioids (e.g., 60 mg daily of oral morphine, 30 mg daily of oral oxycodone, or equianalgesic dosages of other opioids) for at least 1 week (189). If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. In regard to other ER/LA opioid formulations, experts noted that the absorption and pharmacodynamics of transdermal fentanyl are complex, with gradually increasing serum concentration during the first part of the 72-hour dosing interval, as well as variable absorption based on factors such as external heat. Most clinical trials in the past 5 years have found Pilates to be an effective rehabilitation tool that has resulted in desired outcomes, such as reducingpainand disability [31]. Clinicians should discuss with patients undergoing tapering the increased risk for overdose on abrupt return to a previously prescribed higher dose. ; EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Abrupt cessation of morphine was associated with increased pain and decreased function compared with continuation of morphine. Level of evidence C, Low back pain: Early management of persistent non-specific low back pain.
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