Diving Medicine & Decompression sicknessA Self Directed Learning Module For Medical Students

DIVING MEDICINE &
DECOMPRESSION
SICKNESS
A SELF DIRECTED LEARNING MODULE FOR MEDICAL
STUDENTS
Mike McGovern
Swansea College Of Medicine

Slide Show
If you are not already doing so, please ensure
you view this SDL as a slide show to ensure you
enjoy it fully. You can do this by going to the
‘View’ menu and clicking the ‘Slide Show’ icon.
Please also ensure your speakers are on.

Introduction
Diving is an enjoyable recreational past-time for
many, and is also an important commercial
activity in the fields of engineering, research &
fishing. Whilst usually a safe activity, the
pressure of the underwater environment has
many physiological effects on the body, which
can lead to pathology. This SDL will introduce
you to the basic physical principles underpinning
diving, and give you a basic understanding of
one pathology arising from them.

This SDL
 The aim of this SDL module is to allow medical
students to gain a basic understanding of the
principles of diving medicine
 No previous experience or knowledge of diving or
its related medicine is required
 This SDL will use an interactive slide show to
teach the basic principles, and an interactive quiz
to test learning
 Learning objectives will be used throughout the
SDL to guide your learning
 An optional soundtrack is included for your
enjoyment!

Navigating This SDL
This SDL is designed to be viewed in order. You should only need to click on
the screen to continue learning.
However, should you need to navigate, buttons are provided in the top right
corner of most pages. These will allow you to return to the last slide you
viewed, go back to the previous slide, go directly to a contents slide, or skip to
the next slide respectively:
Hyperlinks are also provided in a number of places to allow you to refer back
to relevant information covered earlier in the module. Hyperlinks look like this.

Contents
 Introduction – This SDL - Navigating This SDL – Learning Objectives
 PART ONE – The Physics
 Atmospheric Pressure – Pressure Underwater – The Liquid Phase & Pascal’s Principle – The Gas Phase &
Boyle’s Law – Dalton’s Law – Henry’s Law
 Re-cap
 PART TWO – Types Of Diving
 Vessel Diving - Snorkelling – Breath Hold Diving – SCUBA Diving
 Re-cap
 PART THREE – Decompression Sickness
 Decompression Sickness – Applying Henry’s Law – Pathophysiology – Presentation – Preventing
Decompression Sickness
 Re-cap
 PART FOUR – Management
 Acute Management – Recompression Therapy – Co-morbidities & Complications
 Re-cap
 TEST YOURSELF
 Question 1 – Question 2 – Question 3 – Question 4 – Question 5 – Question 6
 APPENDICES
 Further Reading - References
This SDL is designed to be completed in order. However, this contents page
gives you an idea of what is in store . Please click to the next slide to continue.

Learning Objectives
The learning objectives this SDL will cover are:
 To understand the basic physical laws
underpinning diving medicine
 To understand the different types of diving, and
how physical laws apply to them
 To understand the pathophysiology of
decompression sickness
 To know the principles of management of
decompression sickness, and link these to its
pathophysiology

Learning Objectives
 To understand the basic physical laws
underpinning diving medicine
 To understand the different types of diving, and
how physical laws apply to them
 To understand the pathophysiology of
 To know the principles of management of
decompression sickness, and link these to its
pathophysiology

Atmospheric Pressure
At sea level, our bodies have ~8km of atmosphere
above them. The air molecules that make up this
atmosphere are acted upon by gravity, causing their
mass to exert a pressure on our bodies below
them. Therefore, one can imagine each of us to be
supporting a tower of air molecules 8 km high.
Although atmospheric pressure does vary by small
amounts dependent on climatic conditions, the
weight exerted by the atmosphere on an area of
ground at sea level, of area 1m2, is approximately
10,000kg. This value of pressure (10,000 kg m-2) is
thus referred to as 1 atmospheric absolute (1
ATA), or 1 atmospheric pressure.
CLICK HERE FOR A TO HELP YOU WORK
Click again if you wish to stop the track – otherwise it will continue playing

Pressure Underwater
Sea water is approximately 800 times
more dense than air. Therefore, it
exerts much greater pressure on the
body of a diver.
For every 10m below the surface a
person dives, he is subjected to an
additional pressure of 1ATA.
Therefore, at 30m, a diver will
experience a pressure of 4 ATA (1 ATA
exerted by the atmosphere, & 3 ATA
exerted by the 30m of water above
him).
This added pressure is of particular
relevance to the diver’s respiratory
system, where the (compressible) gas
phase meets the (relatively
Sea Level
10 m

The Liquid Phase & Pascal’s
Principle
Liquids are made up of particles that are in close contact with one another, but
that are able to move over one another, or flow. The close contact of these
particles means that liquids are relatively incompressible, except under
extremely high pressure.
Pascal’s Principle states that ‘Pressure applied to a liquid will be transmitted
equally throughout the liquid’.
As the human body is composed mainly of liquid, Pascal’s Principle explains its
behaviour under pressure. A diver’s body transmits the pressure of the water
acting upon it equally throughout its liquid phase, which does not compress.
However, the body is also composed of a number of gas filled spaces, the
largest of which is the lungs…
Despite pressure being applied, the liquid is
incompressible as the particles within it are so tightly
packed together.
The pressure that is applied is spread evenly throughout
the liquid.
Click the arrow to
put the liquid
under pressure

The Gas Phase & Boyle’s Law
Gases are made up of particles separated from each other with large amounts of space
between them. The particles have negligible interactions with each other, and move randomly.
The energy with which they move (or their temperature) determines the pressure they exert on
the walls of any container they are within.
As a result of the large amount of space between particles, gases are easily compressed by
even relatively low pressures.
Boyle’s Law states that ‘at constant temperature, the volume of a gas varies inversely with
the pressure’.
The lungs are the largest gas filled spaces within the body, and are surrounded by tissue
composed mainly of matter in the liquid phase. As Pascal’s Principle makes clear, this
tissue is relatively incompressible, and any pressure applied to it is distributed evenly
throughout it. Thus, when diving, pressure exerted on the body is distributed throughout
the tissue and exerted on gas, i.e. the lungs. If gas within the lungs remains at the same
pressure, Boyle’s Law makes clear the lungs will reduce in volume at a rate inversely
proportional to the pressure, which is itself proportional to the depth.
Gas compress easily due to the large amount of space
between particles. This space is reduced with increased
pressure.
Provided temperature remains constant, the volume of the
gas will be inversely proportional to the pressure applied
to it.
Click the arrow to
put the gases
under pressure

Dalton’s Law
Two more laws are particularly important to diving medicine, especially for an
understanding of respiration in divers.
Firstly, Dalton’s Law states that ‘The partial pressure of a gas in a mixture is
proportional to its percentage by volume in the mixture’.
= O2 molecule
= N2 molecule
Q. If the diagram to the left illustrates a mixture of gas at a
total pressure of 1kPa, what is the partial pressure of N2 in
the mixture?A. As there are 5 N2 molecules & 5 O2 molecules in the
mixture shown, the percentage volume of N2 is 50%.
The partial pressure of N must therefore be the total pressure
multiplied by the percentage by volume, or 1kPa x 0.5 =
0.5kPa
CLICK FOR THE ANSWER
Dalton’s Law and the concept of partial pressures are important for an
understanding of how gases dissolve in liquids – a process which is
governed by Henry’s Law...

Henry’s Law
Henry’s Law states that ‘At a constant temperature, the amount of a given
gas that dissolves in a given type and volume of liquid is directly
proportional to the partial pressure of that gas in equilibrium with that
liquid’.
Therefore, the dissolution of respiratory gases in a diver’s blood is directly
related to the partial pressure of those gases within the diver’s lungs (or
specifically his alveoli). This will become important as we move on to discuss
As the partial pressure increases, the gas in
gaseous form is compressed. Thus more enters
solution to decrease pressure, until an
equilibrium is again reached.
As pressure falls, the equilibrium moves back
towards the right. Therefore gas leaves solution
& returns to its gaseous form until the new
equilibrium point is reached.
CLICK TO ANIMATE

Re-cap of Part 1- The Physics
So far, we have learned:
 1ATA (Atmospheric Absolute) is roughly equivalent to the pressure
exerted by the atmosphere at sea-level
 For every 10m below sea-level a person dives, pressure increases
by a further 1ATA
Liquids, which the majority of matter in a diver’s tissue is composed
of, are relatively incompressible & distribute pressure evenly
throughout the liquid
Gases, which a number of spaces (including the lungs) within a
diver’s body are filled with, are easily compressible
A gas’ volume is inversely proportional to the pressure exerted upon it
 How to calculate the partial pressure of a gas in a mixture, and that
the partial pressure of a gas within a diver’s lungs is related to the
amount of that gas that will dissolve in his blood

Vessel Diving
Vessel diving refers to diving in thick-walled vessels, including submarines &
rigid suits.
Vessel divers are protected from ambient pressure (i.e. the pressure that
would be otherwise exerted on them by the underwater environment) by the
rigid walls of their vessels. These walls maintain a pressure of ~1ATA within
the vessel no matter what the pressure of the outside environment may be.
Therefore, vessel divers are not subject to the changes in pressure and their
physiological effects that other divers are.

Snorkelling
Snorkelers use a long tube to allow them to breathe air from sea level
whilst swimming a short distance below the sea’s surface. Snorkelers
therefore breathe (& fill their lungs with) air at normal atmospheric
pressure, but are subject to the increased pressure of the water around
them.
The difference between the pressure of the air snorkelers breathe & the
pressure of the water around them limits the depths they are able to
reach to just a few metres :- As the pressure of the water around the
snorkeler rises, it is increasingly difficult for him/her to enlarge the
thorax. This makes it more & more difficult to reduce pressure in the
lungs to less than 1ATA - the level required to suck in air from the
surface & inspire.

Breath-hold Diving
Breath-hold diving is the
practice of diving whilst holding
one’s breath. Recreational free-
divers & pearl divers are able to
reach depths of over 70m on
one breath, helped by the
diving response; an oxygen-
conserving reflex on immersion
of the face that triggers apnoea,
bradycardia & vasoconstriction.
As breath hold divers descend,
the increased pressure of the
water around them causes their
lungs to shrink in volume, and
the diaphragm is sucked
upwards into the thorax. Thus,
the air inside their lungs is
compressed, and its pressure
increases to that of the
CLICK TO ANIMATE
0m
40m
20m

SCUBA Diving
SCUBA Diving utilises special breathing apparatus that supplies air (or other
gas mixtures) at ambient pressure. This allows scuba divers to maintain a
constant lung volume underwater; as they descend, their breathing apparatus
allows them to increase the pressure of air in their lungs to the level of the
water around them every time they take a breath.
However, as the pressure of the air inside the lungs increases, the partial
pressures of the gases within them also increase proportionally, in
accordance with Dalton’s Law. This in turn effects how these gases dissolve
in blood, as made clear by Henry’s Law. This can lead to pathology, as we
will learn in the next part of the SDL.

Re-cap of Part 2- Types Of
Diving
In part 2, we have learned about different types of diving, including:
 Vessel Diving in which divers are not subjected to pressure
changes, as the rigid walls of the vessel containing them protects
divers from ambient pressure.
 Snorkelling where divers breathe air at 1 ATA from the surface, but
are subjected to higher pressures by the water around them. This
makes inspiration impossible at depths greater than a few metres.
 Breath-hold diving where divers hold a constant amount of air in
their lungs. As divers descend, the ambient pressure increases. The
volume of the diver’s lungs therefore decrease, with a corresponding
increase in pressure of the air inside them to match ambient
pressure.
 Scuba diving where divers breathe air compressed to ambient
pressure. This allows scuba divers to maintain a constant lung
volume, with the pressure of the air inside the lungs varying with
changes in ambient pressure.

Part 3 – Decompression
Sickness

Decompression Sickness
Decompression sickness (DCS) arises in persons moving from a high pressure to a low pressure
environment, and is caused by gas (principally nitrogen) dissolved in the body leaving solution and
forming bubbles. Therefore, in divers it occurs on or shortly after ascent.
Decompression sickness principally occurs in SCUBA divers, who spend long periods at depth.
However, the disease may also occur in breath hold divers who, as we have seen previously, also
expose their respiratory system to high pressure. Decompression sickness may also occur at altitude,
most commonly when flying in unpressurised aircraft.
Decompression sickness may also be referred to as:
The term arose from the strange shape sufferers are thrown
into by the resulting musculoskeletal pain, & its resemblance
to ‘The Grecian Bend’, a Victorian dance move.
The term arises from the first cases of DCS, which
were noted amongst bridge builders who had
worked in pressurised caissons – pressurised
vessels used to allow the building of bridge
CLICK TO DISCOVER THE TERMS’
HISTORIES

Applying Henry’s Law
Reference to Henry’s Law tells us that the solution of a gas in a liquid is dependent on:
• The partial pressure of that gas
• The solubility of that gas in that liquid
• Time, which must be allowed for any new equilibrium to be reached once a new
pressure has been established.
These three factors are important in explaining how decompression sickness occurs. Click to
find out more:
Partial
PressureAt high partial pressures of N2,
(such as on deep dives), large
amounts of N2 dissolve in the
blood & distribute through the
body in a dissolved state. When
the diver ascends, pressure on
the liquids of the body
decreases, and N2 is able to
leave solution. If the rate of
pressure change is too rapid, N2
will accumulate before it can be
eliminated by the lungs. It may
form bubbles in cells, in the
circulation & in other spaces,
causing pathology.
Solubility
Nitrogen is the main gas
responsible for
rather than oxygen, due to
its high solubility in blood
and the large fraction of air it
makes up . Therefore, more
nitrogen dissolves in blood &
the body’s liquid
compartments at high
pressure, and more is able
to leave solution and form
bubbles/emboli.
Divers are more likely to
suffer from decompression
sickness after long dives
at high pressure, as
nitrogen has more time to
dissolve in the high
pressure conditions
experienced. This explains
why decompression
sickness is more common
in SCUBA divers, where
divers may spend hours
under water, as opposed
to breath-hold divers,
where dives are very short
Time

Pathophysiology
The formation of nitrogen bubbles within the body cause pathology through a number of
mechanisms. These include:
Embol
iBubbles forming in
the blood can
disrupt blood flow
Ischaem
iaBlood flow
obstruction can lead
to ischaemia &
infarction of
tissue/organs
Cell Disruption
Bubbles forming
within cells can
damage their
internal structure &
lead to loss of
Large bubbles forming in the
vasculature may cause vessels
to rupture. Similarly, bubbles
forming in other spaces (e.g.
The lungs) may cause them to
rupture
Tissue Rupture
Coagulation
The gas:blood interface can
activate clotting factors,
leading to intravascular
coagulation
Mechanical
CompressionLarge bubbles may
compress
surrounding
structures, causing
damage & leading
Inflammation
The gas: tissue interface
can activate complement,
other inflammatory
pathways & inflammatory
cells, leading to an acute
inflammatory response
CLICK TO DISCOVER EACH
PATHOLOGICAL MECHANISM

Presentation
Symptoms of decompression sickness may develop from minutes to 48 hours (or
occasionally longer) after an ascent, and their progression may be continuous or
relapsing & remitting.
Due to the multiple pathological mechanisms at play, symptoms are numerous & varied.
Some of the most common symptoms are listed below. Click on them to find more
information.
Musculoskeletal
PainThe most common symptom,
occurring in up to 80% of patients.
May range from ‘niggling aches’ to
severe joint pain & muscle
splinting. Most commonly affects
the upper limbs.
Skin Rashes
Mottling & marbling of the skin may
occur, occasionally progressing to an
‘orange peel’-like discolouration. May
be associated with itching or burning
sensations.
Neurological
SymptomsSymptoms are varied, and may be
dynamic. Spinal symptoms are
most common, including lower
back pain & lower body
paraesthesia /paralysis. Other
symptoms include psychological
changes, intellectual/visual
Respiratory
SymptomsChest pain & non-productive
coughing are the most common
respiratory symptoms, and may
progress to severe dyspnoea &
respiratory distress. Haemoptysis
may also occur.
Aural Symptoms
Labyrinthine symptoms, including
nausea, vertigo & nystagmus, may
be combined with hearing
symptoms, including hearing loss
& tinnitus

Preventing Decompression
Sickness
Divers can avoided decompression sickness by
taking regular decompression stops when ascending
from depth. Divers ascend a few metres, then remain
at that depth for a period of time. This allows nitrogen
to come out of solution at a rate slow enough to
prevent it accumulating as bubbles within the body.
The nitrogen is then eliminated by the lungs, as
shown in the animation to the right.
Divers use decompression tables to calculate the
number, depth & length of decompression stops
required after a dive. The deeper & longer a dive has
been, the more nitrogen will be dissolved in the
body. Hence, more and longer stops are required to
allow the larger volumes of nitrogen dissolved in the
body to be eliminated.
Decompression tables are calculated based on
models of gas solution in various tissue
compartments ultimately derived from Henry’s Law.
Staying within the limits of the tables will, in the vast
majority of cases, prevent decompression sickness.
However, the tables cannot predict all physiological
factors, and decompression sickness may still occur
CLICK HERE TO
ANIMATE
0m
40m
20m
N2 N2

Re-cap of Part 3- Decompression
Sickness
In part 3, we have learned about the pathophysiology & presentation
of DCS, including:
 That nitrogen bubbles form in blood & tissues
 Snorkelling where divers breathe air at 1 ATA from the surface, but
are subjected to higher pressures by the water around them. This
makes inspiration impossible at depths greater than a few metres.
 Breath-hold diving where divers hold a constant amount of air in
their lungs. As divers descend, the ambient pressure increases. The
volume of the diver’s lungs therefore decrease, with a corresponding
increase in pressure of the air inside them to match ambient
pressure.
 Scuba diving where divers breathe air compressed to ambient
pressure. This allows scuba divers to maintain a constant lung
volume, with the pressure of the air inside the lungs varying with
changes in ambient pressure.

Acute Management
Severe decompression sickness can be a medical emergency. Prompt resuscitation
measures can therefore save lives.
Basic principles of acute management are listed below. Click on each to discover more.
Administration Of
O2
100% oxygen should be
administered via a non-
rebreathe mask. This will
improve O2 saturations and
thus supply to any ischaemic
tissues.
Fluid Resuscitation
Hypovolaemia often occurs in
divers suffering
decompression sickness due
to dehydration, increased
capillary permeability caused
by inflammation & increased
diuresis due to cold. IV
crystalloids should therefore
be given .
Lie Patient
HorizontallyLying patient horizontally
limits air emboli rising, and
therefore may reduce the
chances of emboli reaching
the brain. The recovery
position should be utilised in
the event of vomiting.
Warming
Wetsuits should be removed
& passive re-warming of
patients should be
commenced to prevent
hypothermia.
However, the definitive treatment for decompression sickness is recompression therapy.
Patients should therefore be evacuated to a recompression chamber as soon as is possible.
If flying, care should be taken to maintain low altitude, so that the disease is not compounded
by a further drop in pressure.

Recompression Therapy
Recompression therapy is the definitive
treatment for decompression sickness.
Patients are placed in a chamber, and
pressure is increased to that of the
deepest part of the dive, or until
symptoms are relieved. This causes
nitrogen bubbles within the vasculature &
tissues to first shrink and then dissolve.
Pressure is then slowly returned to 1ATA,
at a rate that allows excess nitrogen to
be eliminated by the lungs. This process
may take hours or even days.
During the treatment, patients usually
breathe 100% oxygen delivered at the
pressure within the chamber. This
prevents further nitrogen (or other inert
gases) entering the bloodstream &
tissues, and creates a diffusion gradient
across the alveolar membrane that
accelerates excess nitrogen elimination
N2
N2
N2
N2
CLICK TO ANIMATE
1 ATA
5 ATA
3ATA

Co-morbidities & Complications
Pulmonary Over-
Pressurisation
SyndromePOPS occurs on fast
ascents, when divers who
have lungs full of
compressed air fail to exhale.
As ambient pressure
reduces, the lungs expand
and rupture, leading to
pneumothorax,
pneumopericardium &
surgical emphysema.
Large air emboli may also
pass into the pulmonary
arteries & on into the arterial
circulation. These usually
pass cephalad if the diver is
upright, & may occlude the
arteries supplying the brain
producing devastating
Oxygen Toxicity
Breathing high partial
pressures of O2 for prolonged
time periods can produce
acute CNS toxicity.
Symptoms include behaviour
disturbance, hallucinations,
syncope & convulsions.
Oxygen toxicity may be fatal
when underwater, and so
care must be made to reduce
O2 content of gas mixtures
for deep dives. In
recompression chambers, O2
toxicity can be treated by
withdrawing O2 &
administering
benzodiazepines to prevent
convulsions.
Dehydration
Divers often become
dehydrated due to salt water,
the warm climates preferred
by divers, and increased
diuresis due to low water
temperatures. This may
aggravate symptoms &
contribute to any
hypovolaemia that may occur
SIRS & DIC
As previously discussed,
nitrogen bubbles may
activate inflammatory &
clotting mechanisms. These
can lead to widespread
inflammation & coagulation
as occurs in Severe
Respiratory Response
Syndrome & Disseminated
Intravascular Coagulation
Numerous co-morbidities & complications can occur in conjunction with, or as a result of
decompression sickness. Some examples are included below. Click on each to find out
more.

Re-cap of Part 4 – Management Of
DCS
In part 4, we have learned about the management of DCS, including:
 Its Acute Management – Lying the patient flat, administration of
oxygen, fluid resuscitation & passive re-warming
 Recompression Treatment – Increasing ambient pressure results in
nitrogen bubbles shrinking & eventually dissolving. Slowly reducing
the pressure as the patient breathes oxygen then allows nitrogen to
be eliminated from the lungs without bubbles accumulating
 Some of the Co-morbidities & Complications that may exist in
divers suffering from decompression sickness, including POPs, DIC,
SIRS & oxygen toxicity.

Test Yourself
The following section will allow you to check
your learning with a number of interactive
questions

Question 1
At a depth of 50m below sea level, what pressure
will a diver experience?
CLICK ON THE CORRECT ANSWER
1 ATA
7 ATA 6 ATA
5 ATA

Question 2
In a gas mixture of 10% Oxygen, 20% Nitrogen
and 70% Helium at a total pressure of 1000kPa,
what is the partial pressure of Oxygen?
10kPa
300 kPa
100 kPa
150 kPa

Question 3
In which type of diving does a diver hold a fixed
amount of air in their lungs which varies in volume
according to depth?
Breath-hold
Diving
Snorkelling Scuba Diving
Vessel Diving

Question 4
A diver is most likely to suffer from decompression
sickness if he has...
CLICK ON THE BEST ANSWER
Made a breath-hold dive
to 75m with no
decompression stops on
ascent
Made a 2 hour SCUBA
dive to 40m with no
ascent
Made a 6 hour dive in a
submarine with no
ascent
Made a 20 minute SCUBA
dive to 50m with no
decompression stops

Question 5
When treating a patient with decompression
sickness, what intervention is NOT appropriate?
Administer 100%
O To Maintain
Sats
Passively Re-
Warm The Diver
To Avoid
Hypothermia
Keep The Diver
Sat Up To Aid
Breathing
Give IV Fluids To
Counter
Hypovolaemia

Question 6
Symptoms of Decompression Syndrome May
Include...
CLICK ON THE BEST ANSWER
Urinary & Faecal
Incontinence
Vomiting &
Dizziness
Visual
Disturbance
Shoulder Pain

Further Reading
Should you wish to find out more about diving
medicine:
 Dave Williams’ article provides a useful
introduction to the topic
 The Scottish Diving Medicine Website contains
a host of useful information
 Bennett & Elliott’s ‘Physiology & Medicine Of
Diving' provides an in-depth look at all aspects of
diving medicine

Thank You
Thank you for taking the time to complete this
SDL.
I hope you have enjoyed it.

References
 Sources Of Information:
 Pulley, SA. ‘Decompression Sickness’. Medscape
Reference. 2009. Available at
http://emedicine.medscape.com/article/769717-
overview - Accessed 3/6/11
 Ward, JP; Ward, J; Leach, RM; Wiener, CM. The
Respiratory System At A Glance (2nd ed.). 2006;
Blackwell, Oxford
 Williams, D. ‘Bubble Trouble: An Introduction To
Diving Medicine’. Bristish Journal Of Anaesthesia
2002; 2(5) pp.144-147

References (cont.)
 Images – All images from clip art/self-designed
except:
 ‘Red Bubbles I’ by Ting Yi Chan
 ‘The Grecian Bend’ by Thomas Worth
 Caisson Schematic by Yk Times
 ‘Decompressed’ by Lens Adventurer
 N.B. All images referenced are free of copyright restrictions
 Music
 ‘Under Pressure’ by David Bowie & Queen
 ‘Apply Some Pressure’ by Maximo Park
 ‘Pressure Drop’ by Toots & The Maytals
 ‘Doctor Robert’ by The Beatles

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