07.05.2016

Alternative therapy for testicular cancer video

Xenical helps you to achieve weight loss without suppressing your appetite.It is one of the most successful treatment for weight loss. Uterine fibroid embolisation is a minimally invasive treatment for symptomatic uterine fibroids. Fibroids are classified according to their position in the wall of the uterus (see figure 1). If the symptoms are of sufficient disturbance to lifestyle as to warrant an intervention, then there is a choice between surgery and uterine artery embolisation.
If future fertility is less important, then UAE provides similar efficacy to myomectomy but is a much less invasive procedure, has lower risk of complication, has a shorter recovery period. UAE is also an excellent alternative to hysterectomy in women who wish to avoid such surgery. The post-embolisation syndrome is caused by damage to the fibroids caused by cutting off their blood supply. You need to be jointly cared by an interventional radiologist and a gynaecologist, in conjunction with your GP. Your gynaecologist will also take part in your recovery and follow-up, as well as your on-going well women care. We also need to place a catheter in your bladder, so that the bladder will remain empty during the procedure.
After the procedure, you will be given PCA (patient controlled analgesia) pump that allow youself to administer the dose you need.
Redevelopment or resurgence of abdominal pain or fever, or development of foul smelling vaginal discharge might indicate either an infection or sloughing of fibroid. Context: Non-obstructive azoospermia (NOA) is an unfavorable prognostic condition for male infertility since spermatogenesis is disrupted. Our mission is to provide personalized, quality and innovative cancer care to patients throughout the state of Kansas in a compassionate and respectful environment; and to make available the most appropriate and current diagnostic and therapeutic modalities through our commitment to excellence in medical oncology and hematology. We have established several treatment centers throughout Kansas to serve our patients who otherwise would have to travel long distances to receive patient care. Oncology nurses, who have received extensive training in chemotherapy administration, staff the offices daily.
At the Cancer Center of Kansas, our primary focus is on the patients we treat and care for every day – the friends who walk through our doors and know they’re in good hands because, here, they feel at home and are around a team who have dedicated their lives to providing oncology care. Our care runs much deeper than your average provider, we focus a broad scope of services to ensure the highest quality care beginning with diagnosis and treatment plans. It is less invasive and has lower rates of complications and recovery time than either hysterectomy or myomectomy and often provides an excellent alternative to surgery. If fertility is a major priority then the fertility rate after myomectomy appears better than the fertility rate after UAE. 80% of patients can obtain good symptomatic relief from pain, heavy bleeding and pelvic pressure symptoms with UAE. The discomfort of the "post-embolisation syndrome" begins about 30 minutes after the embolisation.
This allows us to obtain a gynecologic and general medical history, a brief physical examination, and to review the imaging findings and to discuss the procedure with the patient. Since the bladder is directly in front of the uterus, X-ray dye collected in the bladder would obscure our view. Sperm retrieval (SR) coupled with intracytoplasmic sperm injection (ICSI) is the only option for men with NOA who seek fertility. Micro-dissection testicular sperm extraction as an alternative for sperm acquisition in the most difficult cases of Azoospermia: Technique and preliminary results in India. Men with NOA have highly dysfunctional testes, and although the overall picture is of testicular failure, rare foci of sperm production may exist in up to 60% of these individuals. Role of optimizing testosterone before microdissection testicular sperm extraction in men with nonobstructive azoospermia. Surgical sperm recovery for intracytoplasmic sperm injection: Which method is to be preferred? Testicular sperm extraction: Microdissection improves sperm yield with minimal tissue excision.
Conventional versus microdissection testicular sperm extraction for nonobstructive azoospermia. Prospective comparative study between microsurgical and conventional testicular sperm extraction in non-obstructive azoospermia: Follow-up by serial ultrasound examinations. Recovery of spermatogenesis after microsurgical subinguinal varicocele repair in azoospermic men based on testicular histology. Laboratory handling of epididymal and testicular spermatozoa: what can be done to improve sperm injections outcome. A comparison of menotropin, highly-purified menotropin and follitropin alfa in cycles of intracytoplasmic sperm injection.
Circulating progesterone levels and ongoing pregnancy rates in controlled ovarian stimulation cycles for in vitro fertilization: Analysis of over 4000 cycles. Highly efficient vitrification for cryopreservation of human oocytes and embryos: The cryotop method. Microsurgical versus conventional single-biopsy testicular sperm extraction in nonobstructive azoospermia: A prospective controlled study. Sperm pellet analysis: A technique to detect the presence of sperm in men considered to have azoospermia by routine semen analysis.
Our services also include a bone marrow transplant center, research department, diagnostic imaging, laboratory, and an oral medications center.
The recovery is much quicker than hysterectomy, the complication rate is lower and the uterus is preserved. They flow down the uterine artery and block up the arteries at the 0.5mm level of artery diameter. We will start an intravenous line to give you fluid, sedatives and pain relief medications. If any of these symptoms occur, please try to contact us immediately, or present to your GP or gynaecologist. Among the SR techniques, microdissection testicular sperm extraction (micro-TESE) has been applied with encouraging results.
At CCK, you will have a personal experience and each treatment plan is customized to best fit your diagnosis, health history and lifestyle.
The great majority of fibroids do not cause symptoms but are a chance finding on an ultrasound of the uterus being performed for some other reason. A thin plastic tube ("angiogram catheter") is passed into the artery at the top of the right leg. This type of embolisation will kill the fibroids (which have a precarious blood supply) but will not damage the normal tissues of the uterus. We treat this pain with non-steroidal anti-inflammatory either as tablets or suppositories as well as injections of narcotics such as pethidine, morphine or fentanyl depending on patient preference. It the symptoms are serious and urgent (eg after hours), you should present to emergency department for initial assessment and ask the emergency doctors to contact interventional radiologist and your gynaecologist for advice. Aims: We describe how we implemented the micro-TESE procedure and present initial micro-TESE experience in a group of men with NOA and poor prognosis for SR. Human Assisted Reproductive Technology: Future Trends in Laboratory and Clinical Practice, 1 st ed.
When the left uterine artery is blocked the fine micro-catheter is repositioned in the horizontal segment of the right uterine artery and the particles are injected into the right uterine artery to block the outflow at 0.5mm level of arterial diameter (See Figure 3). The more severe pain normally lasts 12 - 24 hours but is well controlled with medication.
A pregnancy test is needed if the procedure is done more than 10 days since the beginning of your last menstrual cycle.
It is often advisable to have one night in hospital for pain relief and then be discharged home the day after the procedure.
Materials and Methods: An Assisted Reproductive Technology (ART) facility was setup to perform SR using microsurgery.
Due to the fact that both the existence and the geographic location of islets of normal spermatogenesis are unpredictable, several testicular specimens may be required until sperm is found. The tube is passed into each internal iliac artery using imaging guidance to track the position of the tube. Pain tablets such as digesic or panadeine forte will be supplied to ease further discomfort. Fourteen men with NOA and previous failed retrievals or unfavorable histologic results underwent micro-TESE while their female partners received ovarian stimulation for oocyte pickup (OCP).
The removal of large amounts of tissue may compromise the success of future retrieval attempts and is associated with transient or permanent adverse effects in the testis that may lead to hypogonadism. Micro-TESE was performed the day prior to OCP and testicular sperm were used for sperm injections. A finer tube 9measuring 0.8mm diameter) is then passed into the horizontal part of the left uterine artery. Mann-Whitney and Fisher exact test were used to compare characteristics of men with successful and failed SR. The purpose of this study is to report our initial clinical and laboratory experience with microsurgical SR in a group of men with NOA and poor prognosis for SR. A clear microscopic distinction between enlarged and collapsed seminiferous tubules was seen in 35.7% of the cases, and sperm were retrieved in all but one of these cases. In addition, we describe the technical aspects of the microsurgical procedure for those considering implementing micro-TESE in their centers.


Patients with successful and failed retrieval did not differ with respect to baseline characteristics, use of medical therapy, presence of varicocele, and testicular histology. Sperm injections resulted in normal fertilization and embryo cleavage of 64% and 75%, respectively. The eligibility criteria were as follows: (i) Previous unsuccessful SR by either percutaneous TESA (n = 4) or conventional TESE (n = 3) or (ii) histopathology results from a diagnostic testicular biopsy revealing the presence of Sertoli-cell only (SCO) or maturation arrest (MA) (n = 6). A single patient with nonmosaic Klinefelter syndrome (KS) and severely hypotrophic testes (combined left + right testicular volume of 10 cc) who have not met the selection criteria, for neither a previous SR attempt nor a diagnostic testis biopsy had been performed prior to the micro-TESE, was included. Conclusions: We were successful in integrating the micro-TESE procedures to the in vitro fertilization (IVF) laboratory. A complete evaluation, including history, physical examination, and hormone profile, was available for all patients, as previously described.
Our initial experience with micro-TESE applied to the most difficult cases of azoospermia is reassuring.
Additionally, physical examination was used to detect or exclude the presence of a varicocele. Azoospermia was confirmed on at least two different centrifuged ejaculates according to World Health Organization guidelines.
Hormonal evaluation including serum determination of follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol, and total testosterone was obtained within 3-4 months prior to the micro-TESE attempt.
None of our patients was taking exogenous testosterone therapy within at least 6 months prior to the time of therapy.The patients and their female partners were given the option of either undergoing directly to micro-TESE concomitant to ovarian stimulation and oocyte retrieval, with cancellation of the sperm injection cycle if sperm were not retrieved, or having a trial micro-TESE with sperm cryopreservation and subsequent intracytoplasmic sperm injection (ICSI) attempt. Technical informationMicrodissection testicular sperm extractionAll micro-TESEs were performed by the same team of urologists (SCE and DR) over a 7-day period, in May 2012, in the day prior to oocyte aspiration. Patients were asked to collect a semen specimen by masturbation immediately before the procedures to confirm azoospermia.
A senior urologist (SCE) with expertise in microsurgery was responsible to setup and implement the technique of micro-TESE as previously reported.
Procedures were performed under epidural anesthesia with the patient positioned on an operating table in a supine position.
After skin disinfecting and draping, the scrotal skin was stretched over the anterior surface of the testis, and a 2.5-cm transverse incision was placed. This amount of excised tissue yields a sufficient number of ST (>50 cross-sections) to perform an adequate quantitative analysis. If enlarged tubules were not seen, then two to three random micro-biopsies were performed at the upper, medium, and lower testicular poles. The surgeon was promptly informed about the results of initial microscopic examination of each extracted specimen, which were delivered by the embryologist in approximately 3-5 minutes.
This was possible since the operating room and the IVF lab were located side-by-side with a communicating pass-through window. Following hemostasis, the tunica vaginalis was closed in a running fashion using 5-0 absorbable suture. Last, the skin was closed with continuous subcuticular 5-0 Vycril suture, and a fluffy-type dressing and scrotal supporter were placed. The procedures were carried out at the contralateral testicle, as described earlier, when an insufficient number or no sperm have been found at initial laboratory examination. Bed rest and application of ice packing over the scrotum were recommended for the first 48 hours. Patients were instructed to remove the scrotal dressing after 24 hours, and were encouraged to take warm showers, and to wash the incision area with soap and water after 24 hours post-operatively. Patients were instructed to resume a normal diet and increase daily activities to a normal level over a 3 to 4 day period. Patients were instructed to abstain from sports activities, heavy lifting, and sexual intercourse for 10 days, and were informed of the likelihood of scrotal swelling, ecchymosis at the wound site as well as mild discomfort that usually subside in approximately 1 week. These include fever, persistent pain and swelling, bleeding or excessive fluid leaking from the wound. The diameter of the tubules was determined using a digital imaging system (CIVA, Hamilton-Thorne, USA) attached to the inverted microscope. For this, the operator used the system to capture the images of individual ST at ×100 magnification. Measurements were taken in microns from edge to edge of the most dilated tubules, and the larger one from each patient was considered for analysis [Figure 3].
Subsequently, mechanical mincing of the STs was carried out using two needled-tuberculin syringes (one was used to hold the tubules in place at the bottom of the dish while the other squeezed and opened the tubules). Homogenates were then examined on a warm staged inverted microscope at ×200-400 magnification to confirm the presence of sperm. When sperm were not observed after initial microscopic examination, extensive mechanical processing and searching were undertaken.
For this, cell suspensions were diluted with sperm medium and centrifuged at ×300 g for 7 minutes. The supernatants were discharged and the pellets were resuspended in approximately 0.2 mL of sperm culture medium. Several petri dishes containing numbered microdroplets under mineral oil were prepared for sperm search and pick-up, and each microdroplet was loaded with approximately 1 μL of testicular cell suspension. Culture media temperature during sperm handling and processing was kept in the range of 32-37°C.
Spermatozoa were identified and picked up for ICSI using the microinjection micropipette and transferred to a microdroplet of polyvynilpyrrolidone. Selected spermatozoa based on morphologic characteristics were immobilized, aspirated into the micropipette, and injected into the cytoplasm of metaphase-II oocytes. Sperm immobilization was carried out by firmly touching the tip of injection pipette to the transition zone between mid-piece and sperm tail.
Embryo cleavage was checked approximately 48 and 72 hours after ICSI and the number, symmetry, and expansion of the blastomeres, multinucleation, anomalies of the zona pellucida, and the rate of cytoplasmic fragmentation were recorded. The embryos were classified as top quality when they had three to four symmetrical blastomeres on the second day of culture and seven to eight symmetrical blastomeres on the third day, with no multi-nucleation, grade I (no fragmentation) or grade II fragmentation (up to 20% of the perivitelline space with fragments), and no abnormalities in the zona pellucida. For ovarian stimulation, initial daily doses of 150-375 IU of recombinant human FSH (Gonal-F ® , MerckSerono, India) were used. The initial dose of gonadotropin was determined by the treating physician taking into account female parameters such as age, body mass index, serum anti-Mullerian hormone (AMH) levels, serum FSH levels measured on day 2 or 3 of the menstrual cycle, baseline ovarian volume on transvaginal ultrasound (TVUS), and number of antral follicles seen on TVUS scan on days 2 or 3 of the menstrual cycle prior to ovarian stimulation.
Ultrasound assessment between the fifth and eighth days of stimulation was performed to determine if gonadotropin dose adjustments were required; if prevention of ovarian hyper-response was deemed necessary, the dose was reduced. There was no dose increase of gonadotropin during stimulation, even in cases of poor ovarian response. Oocyte retrieval was performed under local anesthesia and guided by TVUS, 35 hours after hCG administration. After oocyte aspiration, follicular fluid was examined for cumulus-corona-oocyte complexes. The isolated oocytes were then mechanically denuded and classified according to nuclear maturity. The fertilized oocytes were maintained in culture until transfer of the embryos to the uterine cavity guided by abdominal ultrasound on the third or fifth day of embryo culture. Embryos were then moved to the vitrification solution containing 15% ethylene glycol and 15% DMSO and 0.6 M sucrose, and subsequently loaded onto cryotop and plunged in liquid nitrogen within 60 seconds. Embryos were then moved to 0.5 M sucrose solution for 3 minutes and transferred to culture media after equilibration and washing in MOPS buffer for 10 minutes. Definitions and criteria Success on micro-TESE was reported as the collection of any number of motile or immotile spermatozoa that allowed sperm injections to be performed. MA was defined as absence of mature spermatozoa, despite normal early stages of spermatogenesis. Normal spermatogenesis was defined as the presence of tubules exhibiting all stages of the spermatogenesis up to mature sperm. Biochemical pregnancy was determined by measuring serum beta-hCG levels 15 days after egg retrieval.
Clinical pregnancies were confirmed by a gestational sac with an embryo showing cardiac activity on ultrasound at weeks 6-7. Miscarriage was considered when nonviable clinical pregnancy was noted on ultrasound up to gestational week 20.
Demographics and baseline characteristics of patient population, success of sperm acquisition, presence of motile sperm and surplus sperm for cryopreservation were obtained. Ethics Signed informed consent was obtained from every couple prior to enrollment into the micro-TESE and ICSI program, including permission to use their data for analysis with guarantees of confidentiality. The study was exempted of institutional review board (IRB) approval since it involved the analysis of records from established clinical practices.
Statistics Patient demographics and outcomes of sperm injection cycles were analyzed descriptively. Mann-Whitney U test and Fisher exact test were used to compare demographic parameters and baseline characteristics of men with successful and failed SRs. Testicular sperm was obtained in 50% of the retrieval attempts in the etiology categories of cryptorchidism (postorchidopexy), postorchitis, and idiopathic. Among the men who had failed SRs, one had KS, one had a history of cryptorchidism and orchidopexy performed at age 20, and the remaining five had idiopathic NOA.
Mean operative duration of unilateral and bilateral procedures were 84 (range 45-120) and 152 (range 120-195) minutes [Table 3]. We correlated the histopathology results with intraoperative findings, and noted that uniform tubule size and opacity was a common pattern of MA.


In such cases, excised fragments were taken at random since no clearly distinction among tubules was possible using the operating microscope. In cases of SCO, a clear microscopic distinction between collapsed and enlarged tubules was possible in five (55.5%) cases.
Of them, testicular sperm were retrieved in four (80%) cases.Spermatozoa were identified at initial laboratory screening in all but one case. In the latter, sperm was found after extended laboratory processing after a failed initial screening.
Sperm retrieval rates (SRRs) did not differ between men who responded or not to medical therapy (83% vs. There were no differences between patients with successful and failed micro-TESE with respect to the proportion of medical therapy administration, posttherapy testosterone levels, presence of varicocele, testicular histology categories, and male baseline characteristics [Table 4]. In the remaining, injections were carried out using the hyposmotic swelling test to assess sperm vitality. One cycle was cancelled due to abnormal fertilization, whereas four fresh transfers were cancelled due to elevated serum progesterone levels on the day of hCG administration. Of these, 11 were from patients who had their fresh transfers cancelled due to elevated serum progesterone levels. Three frozen-thawed embryo transfers were carried out with an average of 1.5 (range 1-2) embryos, and two of them resulted in clinical pregnancies that are currently ongoing.
A cumulative SRR of 50% was obtained and sperm injections using the retrieved testicular sperm were carried out for all successful cases. Normal fertilization after sperm injections was achieved in 64% of the oocytes and morphologically normal cleaved embryos for transfer were available for all but one couple.
NOA is an untreatable condition associated with testicular failure that comprises a spectrum of testicular histopathology resulting from various causes that include genetic and congenital abnormalities, postinfectious, exposure to gonadotoxins, trauma, endocrine disorders, and idiopathic.
Given the fact that our center's policy mandates the use of the couple's own genetic material during ART, we opted to implement the microsurgical method for SR due to the reported higher effectiveness of this procedure to retrieve testicular sperm in NOA.
Retrieval rates ranging from 35% to 77% have been reported for micro-TESE, [2],[3],[6],[10],[17] and more importantly, controlled series demonstrated that micro-TESE performed better than conventional sperm extraction (TESE) or percutaneous aspirations (TESA).
In addition, we confirmed the presence of azoospermia by analyzing centrifuged semen specimens obtained immediately before the procedures since rare sperm may occasionally spill over into the ejaculates of such patients. Men with NOA have a mean of 0-3 mature spermatids per seminiferous tubule, thus explaining why rare sperms are occasionally found in their ejaculates. Furthermore, surplus sperm for freezing were available in nearly half of the men with successful retrievals. This is advantageous since cryopreservation may prevent the need for future retrievals in case ICSI fails.
However, studies have reported conflicting findings with regard to the reproductive potential of fresh and frozen-thawed testicular sperm from men with NOA.
Despite this controversy, repeated micro-TESE, if needed, may result in successful SR of approximately 82% enabling ICSI to be performed with fresh sperm. Implementation of micro-TESE in a clinical ART setting requires the availability of an operating room equipped with a top-quality operating microscope located next door to the IVF laboratory. In our series, the mean operative time was approximately 2 hours; however, operations ranged from 45 minutes to more than 3 hours. Furthermore, spermatozoa was identified at initial laboratory screening in all but one case that required extended laboratory processing to find sperm after a failed initial screening. Our results are corroborated by a recent series in which the best chance of sperm recovery during micro TESE occurred within the first 2 hours of the operation.
However, in up to 37% of operations in the aforementioned study more than 4 hours were required to achieve success. Proper identification of testicular vessels under the tunica albuginea is made prior to the placement of an incision into the testis. Microsurgery also allows preservation of intratesticular blood supply; excellent hemostasis is achieved, thus reducing the chance of complications due to hematoma formation and testicular devascularization as it may occur in cases of conventional TESE. However, men with KS should be monitored closely for hypogonadism since androgen production is restored to only 50-75% of preoperative values after micro-TESE.
Selection of spermatozoa from a smaller population of contaminating testicular cells facilitates the laboratory steps of this complex process.
We experienced more ease for sperm search, less contamination and blockage of the microinjection needle with cells and debris that resulted in greater speed for sperm pick-up and injections.To date, there are still no absolute preoperative predictive factors for successful SR in NOA. Follicle-stimulating hormone, testosterone levels and testes volume reflect global testicular function and not the presence of a site of normal sperm production within a dysfunctional testis. SRRs by micro-TESE are significantly higher in hypospermatogenesis (93%) compared with MA (64%) and SCO (20%).
This observation indicates that sperm production is distributed in a heterogeneous pattern within the testis and histologic assessment of a single testicular fragment is limited in its ability to determine the presence of rare foci of sperm production in NOA.
We were able to retrieve testicular sperm in approximately half of the men in whom the predominant histopathology pattern was SCO or MA. Interestingly, sparse STs containing foci of germ cells were observed in SCO cases, thus reaffirming the heterogeneity of sperm within the testis. In our series, the diameter of the excised STs was the only parameter associated with the chance of obtaining sperm. Notably, a clear distinction between collapsed and enlarged tubules was possible in one-third of our cases and sperm were retrieved for all but one patient.
Conversely, the presence of a uniform pattern of collapsed tubules with none different in size was associated with failed retrievals in all cases. Along the same lines, we were not able to make a distinction on which tubules to extract in cases where all tubules were uniformly normal in size. Histologic evaluation revealed that such cases were classified as MA in which ST contained germ cell and were therefore normal in size. Hence, it was impossible to distinguish the ones with full maturation to spermatozoa, if any, by using the operating microscope. Current research is focusing on novel tools that can aid in the identification of sperm-producing tubules without the need of tissue removal.
Multiphoton microscopy has been applied successfully to differentiate normal from abnormal spermatogenesis in an ex vivo rodent model, and encouraging preliminary results have been reported in humans.
Last, full field optical coherence tomography, which uses a safe light source with apparent no detrimental effect on sperm quality, was recently described as a useful tool to facilitate real-time visualization of spermatogenesis in an ex vivo rodent SCO model. Adequate levels of intratesticular androgenic bioactivity are essential to sustain spermatogenesis that might be compromised in NOA.
It has been shown that SR rates were increased by 1.4-fold in KS men who responded to medical therapy. Moreover, the proportion of men with successful and failed retrievals who received medical therapy, as well as their pre- and posttreatment endocrine profile, was not different.
Nevertheless, these findings should be interpreted with caution since our sample population is too small to draw valid conclusions. Despite being greatly anticipated in men with NOA who will be halted in their attempt to conceive due to absence of testicular sperm on retrieval, medical treatment is still under investigation.
Fertilization and embryo development after ICSI were in agreement with those reported in the literature, [1],[3],[9],[29],[30],[31],[32] and an ongoing cumulative pregnancy rate per transfer of 28.5% was reassuring. Indeed, the literature is rich in studies focusing at sperm injection outcomes after sperm acquisition. Fertilization and implantation rates are lower in NOA compared with obstructive azoospermia and ejaculated sperm.
As a result, the ability of the male gamete to activate the egg and trigger formation and development of a normal zygote and a viable embryo is impaired. The main limitation of our study is the small patient cohort and the few data on sperm injection outcomes. Despite of that, we add to the existing literature by providing technical details of how we successfully implemented micro-TESE in our ART settings, and by reporting our initial experience with micro-TESE and ICSI.
Our initial results with micro-TESE are reassuring and the information provided can be useful for doctors treating male infertility who wish to improve the chances of SR during TESE. In addition, our histopathology data can be used as a counseling tool for doctors dealing with men with NOA seeking fertility advice as for the presence of SCO is not an indicator of absolute sterility.
A future direction would be the collection of additional data including the obstetric and short-term neonatal profile of babies born from such fathers.
As such, open surgical testicular SR is recommended to optimize the chances of finding sperm. Our data reaffirm the existing knowledge that micro-TESE provides success in approximately 50% of men with NOA.
Our initial experience with micro-TESE was associated with minor complications, and with marked reduction in time processing of testicular specimens. We were successful in implementing the technique to our andrology department, and in integrating the laboratory steps to our current embryology laboratory.
Micro-TESE has shown to be a promising option to retrieve spermatozoa from the most severe cases of NOA.



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