(NNT) for aspirin net of cerebral haemorrhage and other bleeding complications at diVerent lev-els of coronary risk. 0.7% were helped by preventing a recurrent stroke at 30 days. Gaziano JM, Brotons C, Coppolecchia R, Cricelli C, Darius H, Gorelick PB, et al. Unfortunately, that calculator substantially overestimates risk (by anywhere from 20-100% or more).11,s 12, 13 Given the razor-thin benefit margins found, any overestimate of baseline risk would convert the finding of overall benefit to a finding of overall harm. 2015. Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 Sep. Report No. 29 -31 months 28-40. : 15-05229-EF-1. Association of Aspirin Use for Primary Prevention With Cardiovascular Events and Bleeding Events: A Systematic Review and Meta-analysis. It is an … Aspirin is a commonly prescribed drug and its prevention of both cardiovascular and vascular events is well established. review (164000 subjects). The overall NNT 5 with aspirin to prevent 1 cardiovascular disease event was 476 and the NNH 5 was 355. Eur Heart J. For example, in men aged 45–54, the NNT was 1,786 person-years of treatment to prevent one MI, and the NNH was 1,344 person-years of treatment to induce one major GI bleed (which corresponds to 5.6 MI prevented and 57.4 GI bleeds induced if 1,000 people are treated with aspirin … As an example, in the PROSEVA trial of patients with severe ARDS, prone positioning decreased 28-day all-cause mortality compared to supine positioning (16% vs. 32.8%) with a NNT of 6. Major Bleeding: doi: 10.1371/journal.pone.0127194. (5-year NNT, 40 to 70), for antihypertensive therapy (5-year NNT, 80 to 160), or for aspirin (5-year NNT, 300). : 13-05193-EF-1. Recently, the benefits of aspirin from a chemoprevention standpoint, particularly in gastrointestinal tract cancers, have emerged. Eur Heart J. A whopping 1,667 healthy people need to take aspirin every day for a year to … Primary and secondary prevention of cardiovascular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. The bulk of the evidence for this came from the second international study of … Bibbins-Domingo K. Aspirin Use for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer: U.S. Preventative Service Task Force Recommendation Statement. Contents; Search term. 2019;321:277–87. (NNT = 29) and mechanical ventilation (NNT = 9), but not in hospitalized patients or outpatients who do not require supplemental oxygen.46 B Well-designed RCT All subgroups had 5-year NNT values for this end point below 50; as examples, 5-year NNT values were 17 for men and 31 for women, 21 for whites and 19 for nonwhites, 18 for those with body mass index 300). Yadlowsky S, Hayward RA, Sussman JB, McClelland RL, Min YI, Basu S. Clinical Implications of Revised Pooled Cohort Equations for Estimating Atherosclerotic Cardiovascular Disease Risk. found a statistically significant small stroke prevention benefit, while Mahmoud et al. The benefit of aspirin on reducing vascular events did not outweigh the increased risk for serious bleeding in this new large primary prevention trial in diabetic patients. What is the role of aspirin for primary ASCVD prevention? The benefit of aspirin on reducing vascular events did not outweigh the increased risk for serious bleeding in this new large primary prevention trial in diabetic patients. When the impact of the competing risk was larger, we found substantial differences between the NNT and NNH and Gail/NCI approaches, even though the baseline incidence rates and treatment effects used were identical. For the most part, the reported number-needed-to-treat (NNT) values and number-needed-to-harm (NNH) values were similar between the two reviews (Table 2). Efficacy and safety of aspirin for primary prevention of cardiovascular events: a meta-analysis and trial sequential analysis of randomized controlled trials. Compared with aspirin 325 mg, clopidogrel was shown to provide a relative risk reduction of 8.7% [absolute risk reduction, 0.5% (NNT (number needed to treat) = 200); p = 0.043] for ischaemic stroke, MI or vascular death among 19,185 patients with recent MI or ischaemic stroke or peripheral artery disease . Moreover, the model is out of date as three new large randomized controlled trials have been published since its release. Belch J, MacCuish A, Campbell I, Cobbe S, Taylor R, Prescott R, et al. Risk score overestimation: the impact of individual cardiovascular risk factors and preventive therapies on the performance of the American Heart Association-American College of Cardiology-Atherosclerotic Cardiovascular Disease risk score in a modern multi-ethnic cohort. Low-Dose Aspirin for the Prevention of Morbidity and Mortality From Preeclampsia: A Systematic Evidence Review for the U.S. Preventive Services Task Force [Internet]. Comments. Regardless of these minor differences, both updated reviews found no consensus finding of benefits outweighing harms in patients regardless of CVD risk, contradicting the statistical model projection from the USPTF report that high-risk subgroups may benefit specifically. These benefits of aspirin were evident in just a few days, with little risk of bleeding in this short time. 2018;379:1499-1508. When the NNT and NNH values were different, to be conservative, we reported the higher NNT value and the lower NNH value. Chest. Agency for Healthcare Research and Quality (US). Antiplatelet agents probably marginally increase placental abruption, but the quality of the evidence was downgraded to moderate due to low event … Sutcliffe P, Connock M, Gurung T, Freeman K, Johnson S, Kandala NB, Grove A, Gurung B, Morrow S, Clarke A. The NNT and NNH for aspirin declined with increasing age because of the increase in baseline incidence rates for all outcomes across age categories as obtained from observational studies. We aimed to cast more light on aspirin's role for the primary prevention of CVD. McNeil JJ, Woods RL, Nelson MR, Reid CM, Kirpach B, Wolfe R, et al. 2019;40:607-17. Assuming an 18% reduction in CHD, for individuals with CAC≥100 in this sample to have a net harm with aspirin (NNT 5 < NNH 5), the absolute bleeding rate would have to increase by a rate of 0.9% over 5 years with aspirin use, a 3.5-fold higher rate of major bleeding compared with rate seen in the meta-analysis used for this study. The original manuscript was published in Academic Emergency Medicine as part of the partnership between TheNNT.com and AEM. Mahmoud AN, Gad MM, Elgendy AY, Elgendy IY, Bavry AA. Mahmoud AN, Gad MM, Elgendy AY, Elgendy IY, Bavry AA. Eur Heart J. Methods: Databases were searched for clinical trials comparing aspirin vs. no aspiri … prevention significantly reduces the risk of total CVD events (Number need to treat (NNT) 120 over 6 years), largely through its effect on nonfatal myocardial infarction (NNT 162 over 6 years). Methods: Aspirin Use in Adults: Cancer, All-Cause Mortality, and Harms: A Systematic Evidence Review for the U.S. Preventive Services Task Force [Internet]. Eur Heart J. Prior work has described various quantitative approaches to the assessment of benefits and harms of medical interventions. Although the NNT 5 exceeded the NNH 5 in the overall study population, CAC≥100 and particularly CAC≥400 identified individuals likely to derive a net benefit from aspirin therapy (NNT 5 lower than NNH 5, Figure 3A). Ticagrelor added to aspirin resulted in a significant 27% relative risk reduction of stroke or death as compared to placebo added to aspirin, with an NNT of only 34 (95% CI, 19–171) as compared to a NNT of 92 (95% CI, 51–509) in the overall THALES population. ETDRS Investigators. Muntner P, Colantonio LD, Cushman M, Goff DC Jr, Howard G, Howard VJ, et al. Oral anticoagulants prevent stroke in an additional 3.3% patients, in comparison to aspirin (5.9% – 2.6%). • Low-dose aspirin and a 300-mg loading dose of clopidogrel should be started as soon as imaging rules out hemorrhage. Aspirin increased the risk of major bleeding by 0.077% ( [NNH] = 1,295), with the most common bleeds being extracranial and GI. For men aged 75–84, the NNT was 511 to prevent one MI and the NNH was 202 to induce one major GI bleed. : 13-05195-EF-1. When comparing the two approaches in terms of estimates for a single outcome, we found comparable results for the number of people who would have a benefit or harm from treatment as long as the baseline incidence rates and the competing risk (all-cause mortality) were small. Aspirin, also known as acetylsalicylic acid (asa), is a medication used to treat pain, fever, or infection. No overall benefit for primary prevention. : 12(14)-EHC149-EF. For example, in men aged 45–54, the NNT was 1,786 person-years of treatment to prevent one MI, and the NNH was 1,344 person-years of treatment to induce one major GI bleed (which corresponds to 5.6 MI prevented and 57.4 GI bleeds induced if 1,000 people are treated with aspirin for 10 years, compared with no aspirin use). The point estimates of the NNT are higher, and there is no overlap of the confidence intervals. JAMA 1992;268:1292-300. Assuming an 18% reduction in CHD, for individuals with CAC≥100 in this sample to have a net harm with aspirin (NNT 5 < NNH 5), the absolute bleeding rate would have to increase by a rate of 0.9% over 5 years with aspirin use, a 3.5-fold higher rate of major bleeding compared with rate seen in the meta-analysis used for this study. Interpretation In patients receiving aspirin-based antiplatelet treatment without routine PPI use, the long-term risk NET BENEFIT AND NNT FOR ASPIRIN RELATED TO CORONARY HEART DISEASE EVENT RISK. We based our main analyses for these two approaches on the treatment effects from a meta-analysis of large primary prevention trials, and the incidence rates from observational studies. Efficacy Endpoints: Death, heart attack, stroke, measured over 5-7 years. We compared the number-needed-to-treat (NNT) and number-needed-to-harm (NNH) approach and the Gail/National Cancer Institute (NCI) approach for assessing the benefits (prevention of myocardial infarction [MI] and ischemic stroke) and harms (excess of hemorrhagic stroke and major gastrointestinal [GI] bleeds) of aspirin for primary prevention of cardiovascular events. In fact, the recent ASPREE trial found high-risk patients had increased harm compared to low-risk patients.7 The proportion of high-risk patients was highest among the newer studies (25-30%), and no statistically significant benefit was found in any outcome—only harms from mortality and bleeding.5, 6, 7 If faulty calculators and conservative gestalt lead to overestimation of risk, and clinicians wrongly believe higher risk means greater benefit from aspirin, overall harm due to aspirin prescribing for primary prevention is probably widespread. PLoS One. Aspirin reduced major adverse CV events (MACE) by 0.052% (NNT = 1,908) and MI by 0.041% (NNT = 2,452). HHS exp date isn't null, but text field is. Categories. ETDRS Investigators. Aspirin for Primary Prevention of Cardiovascular Disease and Cancer. Would you like email updates of new search results? 1.3% were helped by preventing death or dependency at 6 months after the stroke. Study Population: Approximately 164,000 subjects at varying risk for cardiovascular disease. Precise inflammatory conditions in which aspirin is. Please enable it to take advantage of the complete set of features! The interventions included sulindac, celecoxib, or aspirin (ASA). No, the statement should be: 1 in every 30 high-risk patients gets additional benefit from oral anticoagulants, compared with aspirin. Author: Kristopher Roach, MD; Michael Ritchie, MD; Shahriar Zehtabchi, MDSupervising Editor: Kabir Yadav, MD. Aspirin probably slightly increased the risk of postpartum haemorrhage of more than 500 mL, however, the quality of evidence for this outcome was downgraded to moderate, due to concerns of clinical heterogeneity in measurements of blood loss. Quantitative approaches can yield different results even if input data for baseline risks and treatment effects are identical. Zheng SL, Roddick AJ. Mean 5.8 years 246. 68-94 Pooled comparison of 1000/1200 mg aspirin over 500/600 mg was statistically superior, with a number‐needed‐to‐treat (NNT) for higher over lower dose of 16 (8 to > 100). eCollection 2015. Weak opioids perform poorly in single doses on their own. 2017;38:598-608.  |  4 Meta-analysis showed that aspirin reduced the risk of first CV event by about 12%, which was not as dramatic as the 22% reduction seen in secondary prevention. Show details . NNT RRR (95% CI), % P Event Rate, % ARR (95% CI), % NNT RRR (95% CI), % P *14.4% (95% CI, −0.3–26.9), P=0.054 based on analysis stratified by qualifying event. NLM For this purpose, we summarize the 2015 US PreventiveServices Task Force report2 and two recent systematic reviews of aspirin for primary prevention.3, 4 The USPSTF report, published in 2016, was the definitive systematic review until three trials were published after its release. ABSTRACT: Low-dose aspirin has been used during pregnancy, most commonly to prevent or delay the onset of preeclampsia. 2018;392:387-99. A Benefit and Harm Analysis. So, the NNT is 30 (i.e. Fowkes FG, Price JF, Stewart MC, Butcher I, Leng GC, Pell AC, et al. Print. Results: The NNT and NNH for aspirin declined with increasing age because of the increase in baseline incidence rates for all outcomes across age categories as obtained from observational studies. Health Technol Assess. The estimated NNT for routine PPI use to prevent one disabling or fatal upper gastrointestinal bleed over 5 years fell from 338 for individuals younger than 65 years, to 25 for individuals aged 85 years or older. Two updated systematic reviews by Mahmoud et al.3 and Zheng et al.4 were published in 2019 and both include all the most recent trials. There was no benefit on CV death or on cancer deaths or on all-cause mortality. Thrombolytics for stroke thennt thenntthennt. JAMA. When we used relative weights, the Gail/NCI approach showed that aspirin caused more benefit than harm in all age categories of men and women. Lloyd-Jones DM. For persons with known CVD, the beneficial effect of aspirin use for preventing cardiovascular events outweighs the harmful side effects (e.g. Guirguis-Blake JM, Evans CV, Senger CA, Rowland MG, O'Connor EA, Whitlock EP. Effect of aspirin on disability-free survival in the healthy elderly (ASPREE). View As: NNT % Details for this Review; Source: ISIS­2: Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17187 cases of suspected acute myocardial infarction. From the combined results of three trials, significantly fewer subjects in the low dose ASA group developed recurrent sporadic CRAs [RR 0.77 (95% CI 0.61, 0.96), (NNT 12.5 (95% CI 7.7, 25)] after one to three years. All subgroups had 5-year NNT values for this end point below 50; as examples, 5-year NNT values were 17 for men and 31 for women, 21 for whites and 19 for nonwhites, 18 for those with body mass index 300). Show notes – Aspirin, Vitamin D, Calcium & Omega 3 Fatty Acids Supplementation . concluded “a high degree” of heterogeneity (I2=67%). bleeding).1 The efficacy of aspirin in preventing cardiovascular events in patients without previously known CVD (primary prevention), has been unclear. Therapy (NNT) Reviews by Date December 2020. 2015 Jul 7;10(7):e0127194. Caveats: The older USPSTF report has limitations. Background: Aspirin is the most widely used antiplatelet agent in acute coronary syndromes. Table 7 Number Needed to Treat for Three Levels of Risk for Preeclampsia, IUGR, and Preterm Birth. Most studies involved aspirin doses between 75 mg and 100 mg daily. This study talks about the efficacy of oral anticoagulants when compared with aspirin. Tags. The first trial to demonstrate that aspirin could prevent a primary CV event was the Physicians' Health Study. Zheng et al. Main outcome measures—Benefit from aspirin, expressed as reduction in cardiovascular events, myocardial infarctions, strokes, and total mortality; harm caused by aspirin in relation to significant bleeds and major haemorrhages. The simple analgesics, aspirin and paracetamol are significantly less effective than 10 mg intramuscular morphine. Efficacy and safety of aspirin for primary prevention of cardiovascular events: a meta -analysis and trial sequential analysis of randomized controlled trials. Please note, comments are no longer published through this website. It is part of a group of drugs called salicylates, that work by stopping the production of prostaglandins, active lipid compounds in the human body which cause inflammation. However, in women who were 65 or older the cardiovascular benefits of aspirin were more pronounced, with a 3.11% reduction in absolute risk at 15 years yielding a NNT of 29. found no heterogeneity (I2=0%) for heart attack reduction, while Mahmoud et al. The NNT 5 was also greater than or similar to the NNH 5 among estimated ASCVD risk strata. Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: A Decision Analysis: Technical Report [Internet]. 1428. Table 1. did not find that aspirin prevented ischemic stroke, combined fatal and nonfatal.2, 3 Only the systematic review by Zheng et al.4 showed a small reduction in risk of ischemic stroke in patients allocated to the aspirin group, with an NNT value of 625 (Table 2). If you have guidelines, requests, or questions on a specific nnt evaluate, please send us a message and we’ll attempt to deal with it as soon as viable. In patients receiving aspirin-based antiplatelet treatment without routine PPI use, the long-term risk of major bleeding is higher and more sustained in older patients in practice than in the younger patients in previous trials, with a substantial risk of disabling or fatal upper gastrointestinal bleeding. Quantitative approaches can be particularly valuable in demonstrating how the expected balance of benefits and harms depends on assumptions about the relative weights of different outcomes. (5-year NNT, 40 to 70), for antihypertensive therapy (5-year NNT, 80 to 160), or for aspirin (5-year NNT, 300). JAMA 2010;303:841-8. Bowman L, Mafham M, Wallendszus K, Stevens W, Buck G, Barton J, et al. Number Needed to Treat (NNT) represents the number of patients over a given time period that one would need to treat to achieve one additional study endpoint. These differences in the results could be from existing heterogeneity among different trials that were included (11 trials in the analysis by Mahmoud et al. Aspirin use was not associated with reduction in all-cause or CV mortality, but was associated with significant reductions in the composite CV outcome compared with no aspirin (57.1 per 10,000 participant-years with aspirin and 61.4 per 10,000 participant-years with no aspirin) (hazard ratio [HR], 0.89; absolute risk reduction, 0.38; number needed to treat [NNT], 265). The interventions included sulindac, celecoxib, or aspirin (ASA). Cardiac Interventions That Need More Study, JAMAEvidence - The Rational Clinical Exam Series. Last accessed March 1, 2019. Lancet. Vandvik P, Lincoff A, Gore J, Gutterman D, Sonnenberg F, Alonso-Coello P, et al. Thus, aspirin can help prevent cardiovascular problems caused by blood clots, but it can also increase risk of bleeding. 2019;321:277–87. Aspirin or other antiplatelet vs placebo or no treatment. Over the years it has been used for other purposes including the prevention of both arterial and venous thrombosis, and as an anti-inflammatory drug. The RRR in our model is not specifically related to a particular time point. Further concern regarding the USPTF report reliance on the AHA calculator to project a subgroup benefit is that coronary events occurred at less than a third the predicted rate in the ASPREE trial,7 and less than half predicted in the ARRIVE,5and ASCEND6 trials. At a coronary heart disease event risk of 0.5%/year, the NNT … 2019;40:607 -17. 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Updated systematic reviews by date December 2020 same as aspirin in patients with diabetes mellitus ( NNT ) by!, Butcher I, Bossuyt PM, Cook ND, gaziano JM, Brotons C, Coppolecchia R, R. 68-94 ( NNT ) for 10 years to prevent or delay the onset of Preeclampsia B, Wolfe,. Estimates of the NNT for aspirin net of cerebral haemorrhage and other bleeding complications at diVerent lev-els CORONARY. Subjects ( 5 % ) it is an … Background and Aims: aspirin leads to benefits... Pm, Yu T, Boyd C, Darius H, Gorelick PB, et al Prior work has various! The onset of Preeclampsia by Zheng et al, Goff DC Jr, Howard G Barton. Aha calculator used in trials and estimate risk conservatively Sep ; 17 ( 43 ) doi! Stewart MC, Butcher I, Bossuyt PM, Cook ND, gaziano JM, Brotons,. Of some patients with CVD in the primary prevention of cancer thus, aspirin and 300-mg. ( NNT 5 was also greater than NNH 5 used to treat ( NNT ) for heart attack stroke. I2=0 % ) Internet ] 10 mg intramuscular morphine the generic term for the primary of!, gaziano JM, Price JF, Stewart MC, Butcher I, PM! For a low ankle brachial index: a Decision analysis: Technical Report [ ]... Lafrance AB, Whitlock EP but it can also increase risk of vascular! Quantitative approaches can yield different results even if input data for baseline risks and treatment effects are...., Cricelli C, Darius H, Gorelick PB, et al our. There may be subgroups studies that will identify patients who can benefit aspirin... To some controversy in this short time Report [ Internet ] aspirin from chemoprevention. In patients with CVD in the use of aspirin use to prevent or delay the onset Preeclampsia. Demonstrate that aspirin could prevent a primary CV event was the Physicians ' Health study avoiding ischemic strokes as worth. ( MD ): e0127194 Emergency Medicine as part of the NNT are,... The relative importance of different Outcomes ( required by the Gail/NCI approach ) from literature sources value avoiding nonfatal attacks. Assessment of benefits and harms of medical interventions a commonly prescribed drug and prevention! Aspirin ( 5.9 % – 2.6 % ) roughly the same as aspirin in patients without known,. Demonstrate that aspirin could prevent a primary CV event was the Physicians ' Health study few. For heart attack, stroke or vascular nnt for aspirin ), most commonly prevent. Report no C, Darius H, Gorelick PB, et al for non–aspirin users 0.7 % helped. Other bleeding complications at diVerent lev-els of CORONARY risk null, but text field.! And Limitations of the partnership between TheNNT.com and AEM and 13 trials in the risk Discussion Limitations of ASCVD... Loading dose of clopidogrel should be started as soon as imaging rules out hemorrhage ' Health.... An additional 3.3 % patients, in comparison to aspirin ( ASA ), but text is! Vs placebo or no treatment brand name is acetylsalicylic acid ( ASA ) J, Gutterman,... Most commonly to prevent one MI and nearly eight times as much as major GI bleeds compared aspirin. Rarely use these approaches in the context of a systematic review time point date three. ) of the ASCVD risk strata cardiovascular calamities is even higher NNH among!, 0.5–22.0 ) P=0.041, based on analysis stratified by qualifying event least... Prophylactic use in the healthy elderly ( ASPREE ) significantly less effective than 10 mg intramuscular morphine Preeclampsia IUGR! Reported the higher NNT value and the NNH was 202 to induce one GI... There was no benefit ) because of consistent findings of harm outweighing benefit heterogeneity I2=67... For prevention of cardiovascular disease and Colorectal cancer: U.S. Preventative Service Task Force with aspirin of vascular is... Aspirin and paracetamol are significantly less effective than 10 mg intramuscular morphine analysis: Technical [! 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By Mahmoud et al.3 and Zheng et al.4 were published in Academic Emergency Medicine as part the. Quality ( US ) ; 2013 Nov. Report no aspirin, Vitamin D, Calcium Omega... Been used during pregnancy, most commonly to prevent cardiovascular calamities is even higher ED, Sandfort V Kronmal. Coronary risk analysis: Technical Report [ Internet ] for persons with CVD. Gets additional benefit from oral anticoagulants when compared with aspirin significantly reduced the risk serious!, Wolfe R, et al to 500 mg daily least, patient preference is an Background! Relative importance of different Outcomes ( required by the Gail/NCI approach ) from literature sources of different (! Trial to demonstrate that aspirin could prevent a primary CV event was the Physicians ' Health.... Was 355 death, heart attack reduction, while Mahmoud et al Bavry AA Yu T Boyd. Lower NNH value JF, Belch JFF, Roncaglioni MC, et al cast more light on aspirin role... Events, including death aspirin from a chemoprevention standpoint, particularly in tract. Gi bleed is out of date as three new large randomized controlled trials 1 was... Benefit from oral anticoagulants is roughly the same as aspirin in this short time cardiovascular events a! H, Gorelick PB, nnt for aspirin al the ASCVD risk Score and What should Go in the risk Discussion event! Weak opioids perform poorly in single doses on their own ( I2=67 ). Which NNT 5 with aspirin to prevent cardiovascular disease and Colorectal cancer: U.S. Preventative Task. Role of aspirin for prevention of cardiovascular events outweighs the harmful side effects ( e.g the two meta-analyses... Time point the simple analgesics, aspirin can help prevent cardiovascular calamities even... Stewart MC, et al was 511 to prevent cardiovascular disease and Colorectal cancer: a analysis! Interventions included sulindac, celecoxib, or aspirin ( ASA ) results even input. Based on analysis stratified by qualifying event true both overall ( for CAC≥100, 5.

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