The Journal of Cardiothoracic Trauma

REVIEW ARTICLE
Year
: 2021  |  Volume : 6  |  Issue : 1  |  Page : 4--14

A contemporary algorithm to manage acute rib fractures in the intensive care unit


John Alfred Carr 
 Department of Surgery, Central Michigan University, Saginaw, Michigan, USA

Correspondence Address:
John Alfred Carr
Department of Surgery, Central Michigan University, Saginaw, Michigan
USA

Abstract

Operative stabilization of both flail and nonflail rib fractures has become very common, with a 76% increase in community hospitals over the past 10 years. This review will explain the rationale and evidence for improved outcomes with operative management of rib fractures, describe the contemporary strategy, and give an algorithm to follow for the management of critical patients in the intensive care unit (ICU) setting with rib fractures. A PubMed and Medline literature search was conducted with the search terms of rib fractures, rib stabilization, rib plating, chest trauma, chest wall, flail chest, nonflail, and ribs. The level of evidence supporting an intervention was evaluated based on the available prospective, randomized trials, nonrandomized trials, retrospective studies, meta-analyses, cohort studies, and reviews. Selected publications of interest on both rib plating and conservative treatment were retrieved and their bibliographies were also reviewed to identify relevant publications. Data from the relevant publications were reviewed, summarized, and the information synthesized. Rib plating has shown improved outcomes in both flail and nonflail rib fractures. Both prospective and retrospective data document a decreased duration of mechanical ventilation, decreased mortality, less pain, decreased incidence of pneumonia, decreased need for tracheostomy, decreased length of ICU and hospital stay, faster return to work, less overall cost, and better pulmonary function at 6 months. The proposed algorithm based on the presented data allows the physician to easily determine which patients are appropriate for rib plating.



How to cite this article:
Carr JA. A contemporary algorithm to manage acute rib fractures in the intensive care unit.J Cardiothorac Trauma 2021;6:4-14


How to cite this URL:
Carr JA. A contemporary algorithm to manage acute rib fractures in the intensive care unit. J Cardiothorac Trauma [serial online] 2021 [cited 2022 Dec 9 ];6:4-14
Available from: https://www.jctt.org/text.asp?2021/6/1/4/333272


Full Text



 Introduction



With the trauma physician workforce slowly declining in the United States, critical care physicians and thoracic surgeons are being called upon more frequently to manage patients with rib fractures in the intensive care unit (ICU) setting.[1],[2] In the past 10 years, there has been a documented shift in the management of rib fractures from a nonoperative approach, to open reduction and internal fixation with rib plating in a significant number of patients showing improved outcome quality metrics.[3],[4],[5],[6] The surgical and critical care communities have generally agreed that patients with open rib fractures and flail chest require surgery for optimal outcomes.[7],[8],[9],[10] However, over the past 5 years, more patients with rib fractures are now being considered for operative stabilization, while simple, nondisplaced fractures are still being managed nonoperatively.[11],[12],[13],[14],[15],[16] This manuscript will explain the rationale and evidence for improved outcomes with operative management of rib fractures, describe the contemporary strategy, and give an algorithm to follow for the management of critical patients in the ICU setting with rib fractures.

A brief history

The very first recorded operative treatment of flail chest was by Jones and Richardson in 1926.[17] Many attempts to operatively repair broken ribs using plates, screws, pins, and metal hooks continued to be reported from 1940 to 1975.[18],[19],[20],[21],[22],[23] However, the reason that interest for rib stabilization waned in the 1980s and early 1990s was because survival or death of the polytraumatized patient was not dependent on respiratory inhibition from rib fractures. Rather, these patients died from traumatic brain injuries, liver injuries, pulmonary contusions, and multisystem organ failure, with a mortality rate as high as 42%.[24] The rib fractures were at the bottom of the list of priorities. Patients stayed on the ventilator for days and in the hospital for 3–4 weeks at best if they survived, and the inpatient pain management was narcotic-heavy.

However, over the past 5 years, this has certainly no longer been the case. Patients with multiple rib fractures and associated injuries tend to stay in the ICU on average for only 3 days, and have a mortality rate of only 1.6%-6%.[25],[26],[27] Patients are extubated quickly, but respiratory inhibition from rib fracture-induced pain has greatly prolonged the hospital stay after transfer out of an ICU environment.[27],[28] Thus, while the ICU care after chest wall trauma has greatly improved outcomes, expedited discharge home has not been the norm after transfer to the medical floor, where the patients continue to deal with respiratory and pain control issues for days.

Therefore, renewed interest in rib stabilization for pain control and quicker hospital discharge was garnered by multiple reports in the early 2000s showing decreased hospital length of stay, decreased pain, and quicker return to functionality after operative rib fixation.[10],[29],[30],[31],[32],[33] While the initial reports of operative stabilization resulting in improved outcomes and decreased length of stay focused only on patients with flail chest, more recent research has shown these same improved quality metrics in both the flail and nonflail rib fracture patients,[10],[12],[13],[14],[15],[16],[29],[30],[31],[32],[33] which brings us to where we are today.

 Methods



A comprehensive medical database search of PubMed and Medline was conducted using the search terms of rib fractures, rib stabilization, rib plating, chest trauma, chest wall, flail chest, nonflail, ribs, and combinations thereof. See the PRISMA diagram in [Figure 1] for the breakdown of the articles included. All of the articles identified in the databases using the search terms were initially included. Studies were then excluded if they were too old (published before the year 2000), if rib fractures was not the topic of focus, if they did not report outcomes of interest, if the majority of patients had minor fractures or the majority was not ICU based (for example, rib fractures evaluated and discharged from the emergency department), review articles, commentaries, or case series with fewer than ten patients. Case reports were also excluded. The remaining articles were then assessed for the outcomes of interest which are separately categorized in the Results section. The level of evidence supporting an intervention was evaluated based on the available prospective, randomized trials, nonrandomized trials, retrospective studies, meta-analyses, and case–control or cohort studies and is listed in [Table 1] and [Table 2].{Figure 1}{Table 1}{Table 2}

Grading of the available evidence is as follows: Level 1 (systematic reviews of randomized controlled trials and prospective, randomized trials), Level 2 (prospective, nonrandomized trials, meta-analysis of quasi-experimental studies), Level 3 (one group nonrandomized trials, case–control studies, cohort studies), Level 4 (descriptive studies, large case series, and retrospective group studies), and Level 5 (expert opinion, narrative reviews, and consensus statements). Grades of recommendation are based on the level of evidence as follows: A = Level 1 data, B = Level 2 or 3 data, C = Level 4 data, and D = Level 5 data or inconsistent data. Recommendations are strong for Grade A, moderate for Grades B and C, and weak for Grade D. Since this review is not a meta-analysis, statistical methods were not assigned to the collective data quantitatively as a whole; however, statistical results are reported from specific trials where appropriate.

 Results



Duration of mechanical ventilation

The evidence that operative rib stabilization, or rib plating, has decreased the duration of mechanical ventilation in patients with flail chest is vast. There have been three prospective, randomized trials and one prospective, controlled trial showing a decreased time of ventilator support from 2 to 7 days less with rib stabilization compared to best nonoperative management.[30],[31],[34],[35] There have also been 21 nonrandomized studies that show a mean decreased time by meta-analysis of 4 fewer days of mechanical ventilation compared to nonoperative treatment, as reported by Beks [−4.01 days, 95% confidence interval [CI] −5.58 to − 2.45, P < 0.001, [Table 1]].[9],[10],[16],[29],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53]

But what about patients with nonflail rib fractures? There has only been one prospective, randomized trial in patients with nonflail rib fractures.[54] In this study, both the operative and nonoperative patients had broken between 6 and 11 ribs, with a mean of 8 fractures in both groups, but the surgical patients had 6 fewer days of mechanical ventilation on average, compared to the nonoperative group (3.7 + 1.4 vs. 9.5 + 4.3 days, P = 0.037).[54] Three other nonrandomized studies, plus one large multi-institutional study, in patients with multiple, nonflail rib fractures all found a significantly decreased duration of mechanical ventilation, by 3 days on average, in the operative group compared to the conservative treatment group [Table 2].[55],[56],[57],[66] Another large retrospective study in 44,450 geriatric trauma patients older than 65 years with both flail and nonflail rib fractures found that those patients undergoing operative rib stabilization also had, on average, 3 fewer days of mechanical ventilation compared to the nonoperative group (4 vs. 7 days, P = 0.003).[67] And a final, nonrandomized, but prospective study in patients with both flail and nonflail rib fractures also found a statistically significant decrease in duration of mechanical ventilation in those patients who underwent rib stabilization compared to the nonoperative group (P < 0.01).[34]

Need for tracheostomy

The evidence that both flail and multiple, nonflail rib fractures lead to significant pulmonary morbidity shows in the number of recent manuscripts which still promote early tracheostomy for rib fracture patients.[72],[73],[74] However, the majority of these patients included are not receiving rib fixation. In fact, early rib stabilization has been shown to decrease the need for tracheostomy by 30% in two prospective, randomized trials.[30],[31] In the prospective, nonrandomized trial by Pieracci, the patients having rib stabilization had a statistically significant decreased chance of requiring tracheostomy compared to the conservatively treated group (odds ratio, 0.18; 95% CI 0.04–0.78, P = 0.03).[34] Moreover, 16 other nonrandomized and retrospective studies, all showed that rib fixation decreased the need for tracheostomy by as much as 40%.[9],[10],[16],[29],[32],[36],[37],[39],[41],[43],[44],[48],[52],[54],[55],[56],[57]

Incidence of pneumonia

The first prospective, randomized trial to compare the incidence of pneumonia for operative treatment versus nonoperative treatment in 37 patients with rib fractures found an impressive difference of 24% versus 77% (P < 0.05).[30] The second prospective, randomized trial also looking at the incidence of pneumonia in a similar rib fracture population of 46 patients, found a difference in the operative versus nonoperative groups of 48% versus 74% (P = 0.07).[31] The only other prospective, randomized trial to compare the incidence of pneumonia between patients having rib stabilization versus conservative treatment found far fewer cases of pneumonia after surgery once the thoracic cage was stable (48% vs. 80%, P = 0.038).[35] Moreover, a meta-analysis of 20 retrospective studies in patients with both flail and nonflail rib fractures found a 41% risk reduction for pneumonia after rib stabilization (risk ratio: 0.59, 95% CI: 0.42–0.83, P = 0.002).[9],[16],[34],[36],[37],[38],[39],[40],[41],[43],[44],[45],[46],[50],[53],[54],[55],[57],[58],[59],[67]

Intensive care unit length of stay and hospital length of stay

Both ICU and hospital length of stay have been exhaustively analyzed in the flail chest population. Rib stabilization has been shown to decrease ICU length of stay by 10, 3, and 2 days respectively, in three prospective, randomized trials.[30],[31],[35] Multiple additional retrospective studies have also documented a decreased ICU length of stay, with a mean reduction of 2 days, compared to the nonoperative groups (95% CI 0.38–3.61 days, P = 0.02).[9],[16],[29],[34],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[53],[54],[55],[58],[59]

In rib fracture patients without flail chest, ICU length of stay has also been studied, but the evidence is sparse. In the single randomized, prospective study, ICU days were found to be significantly less for the operative versus the nonoperative group by 6 days (8.2 + 4.3 vs. 14.6 + 3.2 days, p = NS).[54] And three retrospective studies have also documented decreased ICU length of stay after rib fixation of 5 days (P = 0.008), 3 days (P = 0.001), and 3 days, respectively.[55],[67],[68] An additional retrospective study also found a statistically significant reduction in ICU length of stay in the operative group, but only if the surgery was performed within 48 h of admission.[57]

In terms of overall hospital length of stay, the vast majority of studies do not show a statistically significant benefit with rib plating.[37],[38],[39],[43],[44],[45],[46],[47],[48],[49],[50],[52],[53],[54],[56],[58],[59] This may be due to other associated injuries, including traumatic brain injuries and orthopedic injuries that often accompany rib fractures and can prolong stay. However, two prospective, randomized trials and five retrospective studies did find an overall decreased length of hospital stay after rib plating.[10],[29],[30],[31],[32],[33],[66] Moreover two additional, well-constructed retrospective studies found a statistically significant decreased overall hospital length of stay of 6 (P = 0.008) and 5 days (P < 0.001), respectively.[57],[67] Hence, in the case of hospital length of stay, the evidence is inconsistent and no definitive conclusion can be drawn.

Surgical complications

The main risks associated with rib plating are implant infection, wound infection, bleeding, and hematoma formation. Nine publications listing surgical complications after rib stabilization included 1174 patients and five reported no complications at all, while the other four reported implant infection necessitating removal of the hardware in 1.5%–5%.[29],[34],[39],[41],[43],[47],[48],[52],[75] Eleven manuscripts reported results of wound infections, and of those, five documented no infections. The other six reported wound infection rates from 2% to 25%.[16],[38],[40],[41],[42],[43],[51],[55],[70]

Cost

One prospective, randomized trial and four retrospective studies have proven that operative stabilization of rib fractures is cost effective. The overall cost decreases were due to shorter length of ICU stay and hospital stay.[10],[29],[31],[66],[69]

Quantitative reduction in pain

The major impetus that started the rib plating revolution was the chronic and unrelenting pain. While rib fractures generally take 6–10 weeks to heal, chronic pain that continues beyond 6 weeks occurs in 22%–49% of patients.[76],[77] This chronic pain has been shown to be due to the formation of fibrous nonunion at the fracture site which allows continued motion and inflammation beyond 6 weeks.[60],[78],[79],[80] However, after rib plating, fibrous nonunion occurs in only 1.3% of patients.[71]

Not surprisingly, the first study that looked at narcotic use in 16 rib fracture patients in the immediate postoperative period after rib plating, compared to a nonoperative group of 32 patients, did not find any significant difference in morphine use.[81] Another study which inappropriately matched 67 older trauma patients with flail chest and more severe injuries to a younger, less injured cohort also did not find that rib fracture stabilization reduced pain.[61] However, better studies were needed.

A well-done study that prospectively collected pain scores and quality of life SF-36 data on 39 patients with nonflail rib fractures who underwent rib stabilization and compared the data to 39 nonoperatively managed patients, found that the stabilized patients had significantly better pain control scores at 72 h, 1 week, 2 weeks, 4 weeks, 6 weeks, 3 months and 6 months after surgery as compared to the conservative group (P < 0.001).[13] The operative group also scored significantly better than the conservative group at 1 month and 6 months on the SF-36 (P < 0.05). Moreover, there have been two prospective, randomized trials assessing pain control after rib stabilization.[12],[70] The first was a multicenter, prospective, randomized trial that enrolled 110 patients with nonflail rib fractures into either rib plating or conservative therapy groups and found at 2 weeks after injury that the operative group had significantly lower pain scores (P < 0.01), better disability score (P = 0.03), less narcotic use (P = 0.05), and less pleural space complications (P = 0.02).[12] The second prospective, randomized trial only randomized patients with nonflail rib fractures and high pain scores after 10 days from injury. Pain was then reassessed in the operative and nonoperative groups at 5, 15, and 30 days after randomization. The operative group had significantly less pain and earlier return to normal activity at all time points.[70]

Chronic disability and failure to return to work

It has been thoroughly documented that 35%–76% of patients with more than three rib fractures fail to return to their previous employment or are restricted to lesser employment, within the 1st year.[76],[77],[82],[83] The only prospective, randomized trial that investigated return to work within 6 months found that 61% of the patients having had rib plating returned to their previous employment, compared to only 5% in the nonoperative group.[30] However, after rib plating for both flail and nonflail rib fractures, more recent long-term studies have shown that 79%–92% of patients returned to their previous employment and performance level within 6 months.[16],[60],[61],[62]

Mortality benefit

Research that examined the mortality rates in patients with multiple rib fractures more than 15 years ago before operative rib stabilization was common documented death rates from 10% to 16%, with the most common causes of death being pneumonia, ARDS, and sepsis.[84],[85],[86] With chest stabilization, the 30-day mortality with multiple rib fractures has now plummeted to 1.8%–4.2%, compared to 7.3%–12.4% in the contemporary nonoperative cohorts.[29],[59],[63],[67],[71]

Pulmonary function testing

Rib plating has been shown to quantitatively improve pulmonary function. The first prospective, randomized trial to assess pulmonary function 2 months after injury in patients with multiple rib fractures found that the patients who had rib stabilization had a statistically significantly improvement over the nonoperative patients in total lung capacity (P < 0.001) and forced vital capacity (P < 0.001).[38]

A negative inspiratory force human cadaveric breathing model was creating at the University of Maryland and used to study the respiratory dynamics of the human chest wall with multiple rib fractures and after rib plating and stabilization of those fractures.[87] Both the mean inspiratory volume and the mean peak inspiratory flow rate were cut in half by the presence of five flail rib fractures. When comparing the difference between the fractured, unstable chest wall and the postreduction, stabilized chest wall, a 263% increase in respiratory volume and a 300% increase in peak inspiratory flow were observed (P < 0.02).[87]

Lardinois measured pulmonary function in 66 patients 6 months after rib plating for flail chest and found that 52% had completely normal PFTs. Another 38% all had a forced vital capacity, total lung capacity, and forced expiratory volume in one second within 10%–15% of normal. The remaining 10% had a total lung capacity <85% of predicted; however, all of these patients had returned to work full time without any complaints of dyspnea.[64] Moreover, there have been several other retrospective articles that document that rib stabilization improves pulmonary function testing, normalizes carbon monoxide diffusion testing, and results in normal breathing mechanics.[15],[55],[65],[70]

How many rib fractures would mandate surgery?

The current unanswered questions regarding the operative fixation of rib fractures in the contemporary literature mostly center on the number of rib fractures required as a threshold for surgery and not the presence of any flail segment. However, the problem with a number threshold is that some patients with several rib fractures have surprisingly little pain and appear to function quite well with oral pain medication only. Most physicians would say that these patients would not require surgery at all. On the other hand, some patients with only two rib fractures, or one severely displaced fracture, have severe pain and very limited mobility. This can be especially true in the elderly.[67] It has also been proven that the degree of rib displacement is as predictive of pain and morphine equivalent usage as is the total number of ribs fractured. Every 5 mm increase in displacement predicts a 6% increase in morphine equivalent usage, while every additional rib fracture adds an additional 11% increase in opioid usage.[88] More displacement has also been shown to correlate with increased pulmonary complications.[89] Therefore, a number threshold for surgical decision-making is not valuable by itself, since an elderly patient with two displaced rib fractures may be more disabled and require more oxygen than a 30 years old with four nondisplaced rib fractures.

Thus, the decision to offer these patients' surgical intervention needs to be based on a composite score using the number of ribs fractured, displacement of the fractures, pain score, oxygen requirements, and pulmonary function (spirometry). Two such scoring systems have been proposed: The SCARF score and the RibScore.[90],[91] The RibScore is a radiographic scoring system based on computed tomographic findings, and the SCARF score is a bedside assessment tool based on spirometry, respiratory rate, numeric pain score, and cough. While both tools are useful, neither is comprehensive since the radiographic findings, degree of pain, and pulmonary function must all be taken together to assess the need for operative intervention.

With this in mind, the author created an algorithm that combines all of these variables and yet is simple to follow [Figure 2]. The first step after the initial evaluation is to obtain a computed tomography (CT) scan of the chest to assess the number of rib fractures and the degree of displacement. A plain chest radiograph is not sufficient since such images cannot adequately assess low posterior or very anterior rib fractures, miss 50% of the fractures detected by CT scan, and only have a 40% sensitivity to detect rib fractures.[92],[93] If the radiographic evaluation also shows a traumatic brain injury, liver injury, or other life threatening injuries, these should take priority and the rib fractures can be assessed at a later time. Although repairing rib fractures in patients with traumatic brain injury has been shown to be safe and actually decreases 30-day mortality, the majority of surgeons surveyed from the Chest Wall Injury Society would disqualify such patients from rib stabilization.[11],[94]{Figure 2}

If no other significant injuries are identified, the next step is to assess the rib fractures by number and displacement on CT scan as discussed above. Because significant displacement and more than three rib fractures have been shown to be predictive of increased pain, risk of pneumonia, prolonged mechanical ventilation, and disability with failure to return to work, these patients should be referred for rib plating.[3],[4],[5],[6],[7],[9],[10],[11],[12],[13],[14],[15],[16],[25],[26],[27],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[45],[46],[47],[48],[49],[55],[56],[57],[59],[63],[64],[65],[66],[67],[68],[70],[89] Those patients with three or fewer fractures and no significant displacement (<5 mm) should be evaluated by the SCARF assessment tool to assess pulmonary function, since spirometry has been shown to be predictive of complications and outcome [Table 3].[88],[89],[90],[95],[96],[97],[98]{Table 3}

A SCARF Score of three or higher is predictive of complications, and these patients should also be referred for rib plating. A SCARF score of two or less reassures the physician that this patient will have a successful outcome with only pain control and supplemental oxygen as needed.

 Discussion



The author has been performing rib plating on trauma patients for 12 years in a nonacademic, private practice and has personally witnessed the benefits that patients receive with a stable thoracic cage. But without rib stabilization, rib movement will continue to cause pain and the jagged edges of fractured ribs close to the lung are commonly the cause of recurrent pneumothoraces, both on the hospital ward and after discharge. The four most common reasons for readmission to the hospital after rib fractures are for pain control (5%–10%), recurrent or worsened hemothorax/pneumothorax (10%–38%), pneumonia (6%–14%), and the late development of empyema (14%); all of which are surprisingly high in nonstabilized rib fracture patients.[39],[68],[99],[100],[101] The goal and benchmark for many trauma and ICU patients is decreased length of stay and prevention of complications. And avoiding surgery will prevent surgical complications. However manuscripts that document quality metrics of only hospital length of stay and pain control “success” without rib plating do not tell the whole story when those articles fail to discuss the high readmission rates in such patients. In a review of 158 trauma patients who required readmission to the ICU after initial discharge, 30% were due to complications from rib fractures.[102]

As shown in the data previously presented, rib fracture stabilization clearly decreases the duration of mechanical ventilation, incidence of pneumonia, need for tracheostomy, ICU length of stay, and pain in patients with both flail and nonflail rib fractures. Other than a lack of physicians trained to perform rib plating within an institution, there is no reason that surgery should not be offered to any patient with a significant number of rib fractures when the evidence supporting its use is now overwhelming. Articles such as the recent review in 2020 by Tignanelli which pontificate “evidence-based practices” from the 1990s, and not rib plating, is clearly out of date with contemporary surgical strategy.[103] And as is often the case, articles such as this are written by nonthoracic surgeons who do not perform rib plating as a part of their practice and want to adhere to nonoperative strategies citing “evidence-based practice” from long ago, while ignoring most of the recent evidence out there. A survey of surgeons from the international Chest Wall Injury Society found that 84% of the surgeons would recommend rib plating for three or more displaced fractures in patients without a contraindication for surgery.[11]

Another somewhat concerning statistic is that while rib plating has increased by 76% nationally in the past few years, the greatest utilization of rib plating in trauma patients is not occurring at Level 1 trauma centers, but in the smaller Level 2 and 3 centers, and community hospitals.[104] Smaller trauma centers have been shown to get nonemergent patients into the operating room faster than Level 1 centers, and Level 1 centers have been shown to have longer wait times for urgent cases.[105],[106] This lack of easy access to the OR may translate into a preference for nonoperative management of rib fractures in these centers. However, the exact reason for this rapid growth in the community hospitals is unknown.

Ultimately, it is likely to take another one or two prospective, randomized trials to really drive the benefits of rib plating home. And fortunately, the FixCon trial will give us that data.[107] This trial will examine the benefits of rib plating compared to conservative therapy for patients with three or more simple rib fractures with at least one fracture having some degree of displacement. The primary outcome is the 30-day incidence of pneumonia and the secondary outcomes are duration of mechanical ventilation, pain, length of stay, complications, quality of life, and productivity loss. Follow-up is scheduled from 2 weeks to 12 months. This will be a pivotal trial in expanding the use of rib plating.

 Conclusions



Rib plating has already shown great benefits in both flail and nonflail rib fractures. Both prospective and retrospective data document a decreased duration of mechanical ventilation, decreased mortality, less pain, decreased incidence of pneumonia, decreased need for tracheostomy, decreased length of ICU stay, faster return to work, less overall cost, and better pulmonary function at 6 months. The proposed algorithm based on the presented data allows any physician to easily determine which patients are appropriate for rib plating.

Availability of data and material

All data generated and analyzed in this study are included in the article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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