Tobacco use and hiv

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  • (1) 20.6% of all adults (46.6 million people) by race and ethnicity the breakdown is as follows; 21.3% of African American adults, 23.2% of American Indian/Alaska Native adults, 12.0% of Asian American adults, 14.5% of Hispanic adults, 22.1% of white adults. On a more positive note; 94 million 41.1% of the whole US population were ever smokers 51.1 % of whom had quit smoking at the time of the survey. The prevalence among HIV patients quoted here are from different source (2) New York State Medicaid patients 428 respondents (66%) (3) Thomas Street Clinic (Harris County, Houston TX , 328 respondents. (46.9%) (4) 314 patients from University based HIV clinics 63% of whom identified their HIV risk factor as MSM and 9% heterosexual. (5)The largest sample was from the Swiss Cohort 7304 HIV patients in Switzerland 70% of AIDS patients and 47% of HIV infected.
  • Analysis of WIHS Study data suggest that smokers have 21% more likely to have poorer virologic response 15% more likely to have poorer immunologic outcomes and 49% more likely to have virologic rebound after initial viral suppression. In the Swiss Cohort information on smoking was collected on all patients after April 2000 the prevalence quoted was computed only based that population 2217. No lung cancers occurred in non smokers in that cohort. Involved a large cohort of HIV patients with a cancer diagnosis based on linkage with state cancer registries 302,834 individuals diagnosed prior to 1996. In this cohort the commonest non-AIDS defining cancer was lung cancer n = 808. The R.R for lung cancer in HIV patients in this cohort was 4.5 with 7.1 seen in women and 4.3 in men. Small study 259 patients within a chemoprevention trial, PCP occurred both in HAART and non-HAART compliant patients an the mean CD4 counts was 384. Moreover among HIV positive patients on HAART smokers were 3 x more likely to have CD4 counts <200 compared to non-smokers. In a small cohort of patients recruited in a Columbus OH Medical Center emphysematous changes identified by CT scan in 14/38 HIV positive individuals with more than 12pyr smoking history compared with 0/14 non HIV patients with similar smoking histories.
  • Small study 259 patients within a chemoprevention trial, PCP occurred both in HAART and non-HAART compliant patients an the mean CD4 counts was 384. Moreover among HIV positive patients on HAART smokers were 3 x more likely to have CD4 counts <200 compared to non-smokers.
  • (1) Between 1996 – 1999, the French Health Agency used surveys of Physicians, Emergency Rooms, ICUs, Cardiologist and also through other forms of surveillance to collect data on MI among HIV patients. Among HIV patients the calculated incidence of MI was 5.5 per 1000 person years. (2) All the lung cancers in the Swiss Cohort occurred in smokers. The data for lung cancer was combined lung, trachea and bronchus. In the Swiss Cohort information on smoking was collected on all patients after April 2000 the prevalence quoted was computed only based on that population 2217. No lung cancers occurred in non smokers in that cohort.
  • (1) WIHS Study data Risk of Anal Adenocarcinomas was higher in patients who had never been on HAART compared with those with prior HAART history. (2) 33% increased risk of HPV persistence was from study in Senegal with about 25% commercial sex workers thus smoking and having multiple sexual partners may be confounding this relationship. The persistence of HPV among smokers in the Senegalese was only in univariate analysis and adjusting for potential confounding variables failed to show this to be significant. The study from the WIHS data did not show any association between HPV persistence in HIV infected women and smoking.
  • Table 2. Relationship between Exposure to Protease Inhibitors, Nonnucleoside Reverse-Transcriptase Inhibitors, and Other Cardiovascular Risk Factors and the Rate of Myocardial Infarction. Data Collection on Adverse Events of Anti-HIV Drugs (DAD) Study was conducted on data collected on 23,437 HIV infected patients, these patients contributed 94,469 person years of follow-up. Incidence of myocardial infarction in this study was 1.53 per 1000 person years in those not on PIs and 6.01 per 1000 person years in those exposed to PIs for more than 6 yrs after adjusted for other potential confounding factors the relative risk of MI with PI use was 1.16 per year of PI use. The most significant predictive variables in this study were however prior MI with a relative risk of 4.64 and Current Tobacco use 2.92. Data was from 188 clinics in 21 countries in Europe, Australia and the USA.
  • Studies suggest that HIV patients have a significant increase risk of MI at all age groups. A study by Triant et al comparing MI rates among HIV infected patients from a Hospital database in Boston Massachusetts shows MI rates as high as 4.65 per 1000 person years compared to 0.88 per 1000 person years in HIV patients ages 15 – 34 yrs compared with HIV uninfected. (Triant et al, J Clin Endocrinol Metab, 2007) This may suggest that HIV specific changes such as chronic immune activation and metabolic changes related to HIV disease and its therapy may be accelerating atherosclerotic changes. Tobacco use is believed to further damage endothelium in small and medium sized vessels thereby increasing risk of myocardial infarction.
  • Figure 1. Estimated Relative Risk of Myocardial Infarction after Quitting Smoking. Relative-risk estimates are adjusted for age; 95% confidence intervals are indicated by vertical lines. The relative risk for men who never smoked is 1.0. Study was a case control study of the effects of smoking on risk of MI in 1873 MI cases and 2775 controls.
  • Study of HIV patients in a low income HIV Clinic affiliated with Harris County Hospital in Houston TX. Lifetime smoking prevalence in this group was 62.8% with a 46.9% current smoking rate. Participants with at least a 4-year college degree were significantly more likely to have quit smoking compared with participants with a high school degree or less ( p~.041). Several studies suggest higher smoking rates of 34 – 50% among MSMs compared to the general population. This study of urban gay men from 4 US cities, Chicago IL, Los Angeles CA, San Francisco and New York HY revealed a rate of 31.4%. A review of the literature suggest smoking rates of 38 – 59 % smokers among gay and lesbian youth.
  • 2. Burkhalter, JE et al, 2005; Nicotine and Tobacco Research, 7(4), 511–522 in a survey among New York State Medicaid patients found 58 % of HIV positive smokers were either contemplating quitting 40% and 18% were preparing to quit smoking. 3. In a survey of HIV positive smokers in a HIV Clinic in San Francisco revealed that 68% of respondent were considering quitting smoking, 72 % of smokers reported prior quit attempts men 81% and women 40%.
  • 0-2 : Very low Dependence 3 – 4 : Low Dependence 5 – : Moderate Dependence 6 – 7 : High Dependence 8 – 10 : Very High Dependence Question # 1 is very highly predictive of successful quitting and also correlates highly with cotinine levels.
  • These graphic labeling was blocked by Big Tobacco R.J Reynolds and Phillip Moritiz the companies argued that the F.D.A. could not prove that these images would make a significant difference in smoking rates in the United States.
  • Mild itching, redness, burning, and stinging at the application site may occur, upset stomach and diarrhea, nausea, vomiting, dizziness, flushing, or headache may also occur.
  • It is (±)-1-(3-chlorophenyl)-2-[(l,l-dimethylethyl)amino]-l-propanone hydrochloride. Some side-effects include seizures 1/1000 users Common SE include dry mouth, insomnia, skin rash, pruritus, hypersensitivity reactions, hypertension, increased appetite and anorexia Contraindicated in patients with seizure disorder. Contraindicated in the immediate quit period for patients with prior alcohol or benzodiazepine use Avoid use in patients with history of Bipolar disorder on account of believe that it could cause unopposed mania and agitation. Black box warning of serious neuropsychiatric side-effects such as depression with suicidal ideation and completed suicides. Zyban is metabolized by the Cytochrome P2B6 isoenzyme and thus ritonavir which is a potent inducer can reduce peak plasma concentrations of Bupropion Norvir 100mg BID reduces Cmax by 21% Kaletra 400/100 BID reduces Cmax by 57% Co administration with beta-blockers may require dose adjustment of beta-blockers unusually downward Zyban in a placebo controlled study showed 6mth quit rates of 33% Zyban+NRT and 30% for Zyban alone compared with 13% with placebo. At 12 mths – 28% for Zyban+NRT and 23% for Zyban compared with 8% for placebo patients. Difference between Zyban and Zyban+NRT was not significant. Pregnancy category C. Study of antidepressant use in pregnancy showed no increased teratogenicity compared to other antidepressant 1,213 were on bupropion in that study.
  • Chantix is the first partial agonist of the α 4 β 2 Nicotinic acetylcholine receptor. Common side-effects include, nausea, constipation, gas, vomiting, heartburn, bad taste in the mouth, changes in appetite, insomnia, strange dreams or nightmares Headache. There is a black box warning for serious neuro-psychiartric side effects such as depression and behavior change or hostility or suicidal ideation. Increased risk of cardiovascular events in patients taking chantix compared to placebo (1.1% non fatal MI in treatment group compared with 0.3% in placebo) 52 week follow up need revascularization -2.0% in treatment group compared to placebo 0.6% Cardiovascular death – 0.3% treatment arm vrs 0.6% in placebo. Manufacturers have not reported any significant drug interactions.
  • Tobacco use and hiv

    1. 1. TOBACCO USE AND HIV
    2. 2. Epidemiology of Tobacco Use <ul><li>Prevalence of Tobacco use in USA 20.6% 1 </li></ul><ul><li>Prevalence among HIV positives 45 – 74% 2,3,4 </li></ul><ul><li>Prevalence in Swiss Cohort – 72% 5 </li></ul><ul><li>Among HIV patients who used IV drugs – 96% 5 </li></ul><ul><li>A comparative analysis within the NHIS Survey suggests that MSMs are 2.3X more likely to smoke compared to general male population 6 </li></ul><ul><li>Tobacco use data CDC 2010 </li></ul><ul><li>Vital Signs: Current Cigarette Smoking Among Adults Aged ≥18 Years - United States, 2009 - Morbidity and Mortality Weekly Report 2010;59(35):1135–40 [accessed 2011 Aug. 11]. </li></ul><ul><li>Burkhalter, JE et al, 2005; Nicotine and Tobacco Research, 7(4), 511–522 </li></ul><ul><li>Gritz, ER et al, 2004; Nicotine and Tobacco Research, 6(1), 71–77 </li></ul><ul><li>Webb, MS et al, Journal of Behavior Medicine, 30(5), 371–383 </li></ul><ul><li>Clifford GM , Polesel J, Rickenbach M, et al, JNCI J Natl Cancer Inst (2005) 97 (6): 425-432 </li></ul><ul><li>McKirnan D et al, 2006, Substance Use & Misuse, 41:1197–1208 </li></ul>
    3. 3. Tobacco use and HIV patient <ul><li>Tobacco use reduces effectiveness of HAART therapy 1 </li></ul><ul><li>High rates of lung and bronchial cancers in HIV patients is associated with high prevalence of smoking among HIV patients 2,3 </li></ul><ul><li>HIV patients who smoke have an increased risk of bacterial pneumonia 4 </li></ul><ul><li>HIV positive smokers have 56% increased risk of PCP compared to non-smokers 4 </li></ul><ul><li>Long term Tobacco use is associated with increased risk of Pulmonary Tuberculosis about 3x among HIV patients 4 </li></ul><ul><li>HIV patients with COPD who smoke progress faster. 5 </li></ul><ul><li>Feldman JG, Minkoff H, Schneider MF et al, Am J Public Health 2006, 96: 1060 – 1065 </li></ul><ul><li>Clifford GM , Polesel J, Rickenbach M, et al, JNCI J Natl Cancer Inst (2005) 97 (6): 425-432 </li></ul><ul><li>Frisch M, Biggar RJ, Engels EA, Goedert JJ. JAMA 2001;285:1736 –1745 </li></ul><ul><li>Miguez-Burbano MJ et al, Addiction Biology 2003: 8 , 39 - 42 </li></ul><ul><li>Diaz PT, King MA, Pacht ER, et al. Ann Intern Med 2000;132: 369–372. . </li></ul>
    4. 4. Tobacco use and incidence of PCP Miguez-Burbano MJ et al, Addiction Biology 2003: 8 (1) 39 - 42
    5. 5. Health Effects of Smoking in HIV Patients (I) <ul><li>In the Monica database in France risk of MI is 1.52 per 1000 person years 1 </li></ul><ul><li>Among HIV patients MI incidence was 5.0 – 5.5 per 1000 person years suggestive of at least 3-3.5 fold increase 1 </li></ul><ul><li>HIV infected smokers have a 2.8 times increased risk of lung cancer 2 </li></ul><ul><li>The risk of lung cancer in HIV positive IV drug users is 12.6 times according to data from the Swiss Cohort 2 </li></ul><ul><li>Vittecoq D, Escaut L, Chironi G, et al; AIDS 2003; 17 (suppl. 1): S70 – S76 </li></ul><ul><li>Clifford GM , Polesel J, Rickenbach M, et al, JNCI J Natl Cancer Inst (2005) 97 (6): 425-432 </li></ul>
    6. 6. Health Effects of Smoking in HIV Patients (II) <ul><li>Smoking is associated with a 33% increased risk of HPV infection in women 1 </li></ul><ul><li>HIV positive smokers are 33% more likely to have persistence of HPV infection 2 </li></ul><ul><li>Analysis of data from the MACS Cohort shows a R.R. of 3.9 for Anal Squamous cell cancers in HIV positive smokers vrs non-smokers 3 </li></ul><ul><li>Minkoff, H., Feldman JG et al, 2004, J Infect Dis. 189 (10): 1821-1828. </li></ul><ul><li>Rowhani-Rabar, A, Hawes SE et al, 2007, J Infect Dis. 196:887–94 </li></ul><ul><li>D’Souza, G, Wiley D.J. et al, 2008, J Acquir Immune Defic Syndr;48:491–499 </li></ul>
    7. 7. Relationship between Smoking and other Cardiovascular Risk Factors and the Rate of Myocardial Infarction The DAD Study Group. N Engl J Med 2007;356:1723-1735 Cardiovascular Risk Factor Relative Risk of Heart Attack p-value Protease Inhibitor use per additional year 1.10 (1.04 – 1.18) 0.002 Age per additional 5 yrs 1.32 ( 1.23 – 1.41) < 0.001 BMI > 30 1.34 (0.86 – 2.09) 0.19 Family History of Heart Dx 1.40 (0.92 – 1.91) 0.08 Current Smoker 2.92 (2.04 – 4.18) < 0.001 Former Smoker 1.63 (1.07 – 2.48) 0.02 Previous CVS event 4.64 (3.22 – 6.69) < 0.001 Diabetes 1.86 (1.31 – 2.65) < 0.001 Hypertension 1.30 (0.99 – 1.72) 0.06 Total Cholesterol per mmol 1.26 (1.19 – 1.35) < 0.001 HDL per mmol 0.65 (0.48 -0.88) 0.05
    8. 8. HIV Viral Replication Immune activation Inflammation Macrophage Recruitment Endothelial Dysfunction Hypertension Smoking Genetics Anti-retroviral Therapy Insulin Resistance & Diabetes Atherosclerosis Dyslipidemia Modified from: Currier J.S., Topics in HIV Medicine, 2009, 17(3); 98-103 CARDIOVASCULAR DISEASE IN HIV
    9. 9. Estimated Relative Risk of Myocardial Infarction after Quitting Smoking . Rosenberg L et al. N Engl J Med 1985;313:1511-1514 .
    10. 10. © 2003 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 6 Cardiovascular disease risk factors in HIV patients - association with antiretroviral therapy. Results from the DAD study. Friis-Moller, Nina; Weber, Rainer; Reiss, Peter; Thiebaut, Rodolphe; Kirk, Ole; Monforte, Antonella; Pradier, Christian; Morfeldt, Linda; Mateu, Silvia; Law, Matthew; El-Sadr, Wafaa; De Wit, Stephan; Sabin, Caroline; Phillips, Andrew; Lundgren, Jens AIDS. 17(8):1179-1193, May 23, 2003. Fig. 1. Prevalence of elevated total cholesterol (>= 6.2 mmol/l) according to current antiretroviral therapy (ART), CD4 cell count (a) and HIV RNA (b) at baseline. The six ART categories are: naive (ART naive), no ART (treatment-experienced, but not currently receiving antiretroviral therapy), NRTI (currently receiving only NRTI), NNRTI (currently receiving NNRTI and NRTI but not PI), PI (currently receiving PI and NRTI but not NNRTI), and PI/NNRTI (currently receiving PI, NNRTI and NRTI). Cardiovascular disease risk factors in HIV patients - association with antiretroviral therapy. Results from the DAD study.
    11. 11. Psychosocial Aspects of Smoking and HIV <ul><li>HIV positive patients are 2 times more likely to be smokers 1 </li></ul><ul><li>MSMs are more likely to be smokers compared with heterosexuals 2, 3 </li></ul><ul><li>In the US HIV patients tend to be socio-economically disadvantaged and are more likely to have social networks with more smokers 4, 5 </li></ul><ul><li>High rates of depression and drug use among HIV patients 4 </li></ul><ul><li>Individual self efficacy is one of the strongest predictors of successful quit attempt 5 </li></ul><ul><li>Gritz ER, Vidrine DJ, et al, 2004; Nicotine and Tobacco Research, 6(1), 71–77 </li></ul><ul><li>Greenwood GL, Paul JP, et a, 2005; Am J Public Health;95:145-151 </li></ul><ul><li>Ryan H, Wortley PM, et al, 2001 Amer. Jour. Prev. Med. 21(1), 142 – 149 </li></ul><ul><li>Reynolds N. 2009, AIDS Educ. Prev. 21, Suppl. A, 106 – 121 </li></ul><ul><li>Lloyd-Richardson, E. E. et al, 2008; Amer. Jour. Health Beh, J2(1). 3 -15 </li></ul>
    12. 12. SMOKING CESSATION <ul><li>70% of the 45million smokers in the US report they wish to quit 1 </li></ul><ul><li>44% of all smokers attempt to quit each year 1 </li></ul><ul><li>HIV positive smokers are just as willing to quit as other smokers 2, 3 </li></ul><ul><li>Morbidity and Mortality Weekly Report 2002;51(29):642–5 [accessed 2011 Aug 11]. </li></ul><ul><li>Burkhalter, JE, Springer CM et al, 2005; Nicotine and Tobacco Research, 7(4), 511–522 </li></ul><ul><li>Mamary EM, Bahrs D, Martnez S, AIDS PATIENT CARE and STDs, 2002 16 (1) 39 - 42 </li></ul>
    13. 13. Tobacco Use History <ul><li>Introduction to Healthy Tobacco Free Life </li></ul><ul><li>Onset of habit </li></ul><ul><li>Longest periods of abstinence and circumstance </li></ul><ul><li>Current smoking habits – Intensity and Frequency </li></ul><ul><li>Determination of Nicotine dependence </li></ul><ul><li>Living situation and smokers and non-smokers in the home </li></ul><ul><li>Prior quit attempts and results </li></ul>
    14. 14. The Fagerstrom Nicotine Dependent Test Heatherton TF, Kozlowski LT, et al; A Revision of the Fagerstrom Tolerance Questionnaire; British Journal of Addiction 1991; 86: 1119 - 27
    15. 15. The Financial Costs of Smoking Cost $6.65 per pack At 1 pack per day, Weekly cost = $46.55 Monthly cost = $205 Annual cost = $2,427 Half a pack per day Weekly cost = $23.27 Monthly Cost = $102 Annual cost = $1,213 6 cigarettes a day Weekly cost = $13.30 Monthly cost = $60.00 Annual cost = $720 <ul><li>Potential Gains of Quitting </li></ul><ul><li>For a 1 pack per day smoker </li></ul><ul><ul><ul><li>Save enough for a full tank of gas in a week </li></ul></ul></ul><ul><ul><ul><li>In one month one could buy a Nintendo Wii or similar high end video game </li></ul></ul></ul><ul><ul><ul><li>In two months you could buy a 40inch flat screen TV </li></ul></ul></ul><ul><ul><ul><li>In a year enough money for a vacation package for two </li></ul></ul></ul><ul><ul><ul><li>In 5yrs enough money for to pay for a fairly nice car </li></ul></ul></ul><ul><ul><ul><li>In 15 yrs enough for a down payment on a house </li></ul></ul></ul>Source: Wikipedia, the free encyclopedia
    16. 16. Individualized Motivational Speech <ul><li>5 A’s </li></ul><ul><li>Ask - Ask about Tobacco use at every visit </li></ul><ul><li>Advise – Strongly urge all smokers to quit </li></ul><ul><li>Assess – Determine willingness to make a quit attempt </li></ul><ul><li>Assist – Aid client in quitting </li></ul><ul><li>Arrange – Schedule follow-up contact </li></ul>Source: US Food and Drug Administration; 2011 Proposed Tobacco Warning Labels
    17. 17. Behavior Therapy Can Fam Physician 2008;54:994-999
    18. 18. What Happens When People Quit Smoking <ul><li>Irritability </li></ul><ul><li>Anxiety </li></ul><ul><li>Difficulty concentrating </li></ul><ul><li>Increased appetite </li></ul><ul><li>Cravings to smoke </li></ul><ul><li>Insomnia </li></ul><ul><li>Fatigue </li></ul><ul><li>Headache </li></ul><ul><li>Cough </li></ul><ul><li>Sore throat </li></ul><ul><li>Constipation, gas, stomach pain </li></ul><ul><li>Dry mouth </li></ul><ul><li>Sore tongue and/or gums </li></ul><ul><li>Postnasal drip </li></ul><ul><li>Tightness in the chest </li></ul>The Five D's Delay until the urge passes - usually within 3 to 5 minutes. D istract yourself. Call a friend or go for a walk. D rink water to fight off cravings. D eep Breaths - Relax! Close your eyes and take 10 slow, deep breaths. D iscuss your feelings with someone close to you or at the support group How to Handle Withdrawal Symptoms Nicotine withdrawal symptoms
    19. 19. Drug Therapy <ul><li>Nicotine patches </li></ul><ul><li>What is it? </li></ul><ul><li>Why must I use a patch if I am trying to quit nicotine in cigarettes? </li></ul><ul><li>How long I am going to use this medication for? </li></ul><ul><li>What if I want to smoke whilst having the patch on? </li></ul><ul><li>How must I apply the patch? </li></ul><ul><li>Does the patch have side-effects? </li></ul><ul><li>Can I add a second patch if I have cravings with a single patch? </li></ul><ul><li>What if I am unable to quit after </li></ul><ul><li>completing a full course of </li></ul><ul><li>treatment ? </li></ul><ul><li>What if the patch falls off? </li></ul><ul><li>Can I take a bath with the patch? </li></ul><ul><li>What if I get redness at the site of application of the patch? </li></ul>Source: Sunday Mirror UK
    20. 20. Zyban <ul><li>What is Zyban? </li></ul><ul><li>How does it work to help me quit? </li></ul><ul><li>When must I start this medication? </li></ul><ul><li>How long will I need to take this medication? </li></ul><ul><li>Are there any side-effects of this medication? </li></ul><ul><li>What if I forget to take my medication in the morning? </li></ul><ul><li>Would this medication interact with my HIV medications? </li></ul><ul><li>Would this medication interact with other medications that I take? </li></ul>
    21. 21. Chantix <ul><li>What is Chantix? </li></ul><ul><li>How does it work to help me quit? </li></ul><ul><li>When must I start this medication? </li></ul><ul><li>How long will I need to take this medication? </li></ul><ul><li>Are there any side-effects of this medication? </li></ul><ul><li>Will this medication change my behavior </li></ul><ul><li>I have heard that you can get a heart attack if you take Chantix, is this true? </li></ul><ul><li>What if I forget to take my medication in the morning? </li></ul><ul><li>Would this medication interact with my HIV medications? </li></ul><ul><li>Would this medication interact with other medications that I take? </li></ul>Source: OnThePharm
    22. 22. Pharmacotherapy Can Fam Physician 2008;54:994-999
    23. 23. Summary <ul><li>Health Impact of Tobacco use appears to be accelerated in HIV patients </li></ul><ul><li>HIV patients by virtue of certain socio-cultural characteristics are more likely to be smokers </li></ul><ul><li>Smoking cessation interventions have proven more challenging in HIV patients </li></ul><ul><li>HIV patients are however just as willing to quit as all other smokers </li></ul><ul><li>Use of combined behavioral intervention and pharmacotherapy has shown some success in this population </li></ul>
    24. 24. Online Resources <ul><li>http://mdquit.org/quitline </li></ul><ul><li>http://www.smokefree.gov/ </li></ul><ul><li>http://www.lungusa.org/stop-smoking/ </li></ul><ul><li>http://www.cancer.org/Healthy/StayAwayfromTobacco/index </li></ul><ul><li>http://apps.nccd.cdc.gov/StateSystem/Default/Default.aspx </li></ul><ul><li>1-800-QUIT-NOW OR 1-800-784-8669 </li></ul>

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