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Philly hospitals test new strategy for ‘tranq dope’ withdrawal – and it keeps patients from walking out before their treatment is done

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theconversation.com – Kory London, Associate Professor of Emergency Medicine, Thomas Jefferson University – 2024-10-16 07:28:00

Philly hospitals test new strategy for ‘tranq dope’ withdrawal – and it keeps patients from walking out before their treatment is done

Patients suffering withdrawal from fentanyl and xylazine can require intensive care.

SDI Productions/E+ Collection via Getty Images

Kory London, Thomas Jefferson University

Unimaginable pain and restlessness. Vomiting so frequent and forceful that it can perforate the esophagus. Blood pressure and heart rate so high that they damage the heart. Sweating that drenches clothing and sheets. Nerve sensitivity that makes even the softest touch agonizing. A prolonged panic attack that is provoked and worsened by even mundane activities and conversations.

The withdrawal symptoms from “tranq dope” – the combination of the synthetic opioid fentanyl and the animal tranquilizer xylazine that dominates Philadelphia’s street opioids supply – tend to be far worse than those experienced by even the most severe heroin users of the past.

So it’s no surprise that people will do whatever they can to forestall them. That includes walking out of the hospital before their care is complete.

I’m an associate professor of emergency medicine who has spent a decade as an emergency physician working in Center City and South Philadelphia. I’ve spent most of that time directing projects to improve care for people who use drugs.

Beginning in 2022, our team – a group of emergency and addiction physicians – began experimenting with new approaches to treating tranq dope withdrawal.

We were able to reduce the likelihood of these patients leaving the hospital before treatment was complete by more than half – from 10% to just under 4%.

We also reduced the severity of their suffering, lowering their withdrawal scores – or how they rate their pain and other symptoms – by more than half.

Traditional treatments don’t work

Before tranq dope, treating opioid withdrawal in the emergency department was relatively straightforward, with well-studied, conventional protocols.

For patients without chronic pain, health care providers started buprenorphine, known by its brand name Suboxone, when patients showed signs of withdrawal.

Buprenorphine works by partially, rather than fully, stimulating opioid receptors in the body. This subtle difference relieves symptoms of withdrawal but reduces the risk of overdose if patients continue to use other opioids. It quite literally saves lives.

Tranq dope, however, created a much larger set of challenges.

Fentanyl and other synthetic opioids are dozens to hundreds of times more powerful than heroin. Xylazine, meanwhile, adds symptoms of sedative withdrawal to the mix: restlessness, adrenaline activation and agitation.

As synthetic opioids became pervasive in Philadelphia’s drug supply over the past decade, overdose deaths in the city tripled. Those numbers are beginning to decline, for reasons that remain unclear.

Torso of person wearing black tank top and dirty bandage from bicep to wrist

Fear of withdrawal can even prevent people with serious medical conditions from going to the hospital.

Jeff Fusco/The Conversation US, CC BY-ND

Meanwhile, tranq users started to share buprenorphine horror stories. They refused the medication due to a phenomenon called “precipitated withdrawal.” Precipitated withdrawal is a condition in which taking buprenorphine paradoxically makes withdrawal symptoms worse, rather than improving them. Due to the severity of their symptoms, some patients who precipitate severely even require treatment in the intensive care unit.

Furthermore, when patients did accept buprenorphine, their withdrawal symptoms were no longer being effectively controlled, even with very high doses. We were adrift.

Patients demand discharge

When people with severe substance use disorders are hospitalized, even compassionate staff members sometimes lose patience.

Being confined to a stretcher in a loud, chaotic environment, in withdrawal, with prior traumatic health care experiences, can lead patients to act out. They might repeatedly hit call bells, use inappropriate language, make impulsive decisions or sneak drugs into the hospital.

This creates a lot of stress for nurses and staff, and distracts from the care of others.

So when patients demand to leave before treatments are complete, exhausted care teams often quickly acquiesce. Traditionally, this was termed leaving “against medical advice,” but is now called “patient-directed discharge.”

Patient-directed discharge is associated with higher rates of mortality, permanent disability and rehospitalization.

Rates of patient-directed discharge can be 10 to 50 times higher in people with an opioid use disorder compared with the general public.

A cycle of mistrust can also form, where the expectation that a patient may leave again leads to a less engaged care team, which in turn can make patients more likely to leave.

At staff meetings, some compared the challenges of caring for these individuals to those experienced in the hardest parts of the COVID-19 pandemic.

New approach needed

Many physicians have been reticent to consider other options for treating opioid withdrawal. I believe there are two key reasons for this. One is the lack of Food and Drug Administration approval for alternative treatments. The other is that federal regulations consider addiction a behavioral rather than medical condition, effectively separating most doctors from the addiction care of these individuals.

As fentanyl and xylazine became ubiquitous in Philadelphia’s street dope, local hospitals reported astronomical rates of patient-directed discharge among these patients. This was happening despite the best efforts of hospital staffs that are deeply experienced in conventional opioid withdrawal treatment.

In 2021, an editorial in the Annals of Internal Medicine journal advocated for the use of short-acting opioids for some patients’ opioid withdrawal – which is already common practice in Canada. Short-acting opioids are medications doctors traditionally use to treat acute pain.

Philadelphia hospitals started experimenting with using these previously verboten medications. That included our team at Jefferson Health.

Under a bridge, a person crouches under a blanket in the foreground and two people talk in background

Overdose deaths in Philadelphia spiked as fentanyl and xylazine became more prevalent.

Jeff Fusco/The Conversation US, CC BY-ND

Oxycodone, hydromorphone and ketamine

By using short-acting opioids such as oxycodone or hydromorphone, combined with a low-dose version of buprenorphine, we prevented precipitated withdrawal and treated opioid withdrawal and pain in our patients.

The low-dose bupenorphine can be increased over time to steady doses. This shows patients that the medication is safe and provides them a bridge to long-term treatment.

The short-acting opioids replace the opioids that their bodies are frantically searching for. They reduce their pain and misery, and are decreased when their symptoms are controlled.

Patients with opioid use disorder will often do whatever they can to stay out of the hospital due to fear of withdrawal. Asking how withdrawal symptoms are managed, therefore, is often their first priority when hospitalized. We see this even when they have conditions that require complicated and time-sensitive treatments.

Owing to the vast amounts of opioids many of our patients use, we also give them additional strong medications, or “adjunctive therapies,” to supplement the effects of the short-acting opioids and low-dose buprenorphine. One is ketamine, an anesthetic that affects nerve impulses and is increasingly being used to treat depression, post-traumatic stress discorder and substance use disorders.

Ketamine is also an effective pain medication that can extend the effects of opioids and reduce the number of doses needed.

We additionally add muscle relaxants – which work similarly to xylazine – along with nausea medications and IV fluids, to help give patients a chance at healing.

Side effects and future problems

In patients who received our medications, the risks of serious side effects were minimal. The few patients who suffered serious adverse effects had other acute medical problems that could have contributed to the side effects. Almost all the side effects we saw were mild and resolved on their own.

As powerful synthetic opioids and other contaminants become pervasive in more U.S. cities, more emergency departments will need to figure out how to care for patients in withdrawal so that they don’t leave treatment.

It is our hope that this work will inspire others to do a better job of providing relief to patients suffering from this complicated and severe condition.The Conversation

Kory London, Associate Professor of Emergency Medicine, Thomas Jefferson University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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AI harm is often behind the scenes and builds over time – a legal scholar explains how the law can adapt to respond

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theconversation.com – Sylvia Lu, Faculty Fellow and Visiting Assistant Professor of Law, University of Michigan – 2024-11-22 07:25:00

One AI harm is pervasive facial recognition, which erodes privacy.
DSCimage/iStock via Getty Images

Sylvia Lu, University of Michigan

As you scroll through your social media feed or let your favorite music app curate the perfect playlist, it may feel like artificial intelligence is improving your life – learning your preferences and serving your needs. But lurking behind this convenient facade is a growing concern: algorithmic harms.

These harms aren’t obvious or immediate. They’re insidious, building over time as AI systems quietly make decisions about your life without you even knowing it. The hidden power of these systems is becoming a significant threat to privacy, equality, autonomy and safety.

AI systems are embedded in nearly every facet of modern life. They suggest what shows and movies you should watch, help employers decide whom they want to hire, and even influence judges to decide who qualifies for a sentence. But what happens when these systems, often seen as neutral, begin making decisions that put certain groups at a disadvantage or, worse, cause real-world harm?

The often-overlooked consequences of AI applications call for regulatory frameworks that can keep pace with this rapidly evolving technology. I study the intersection of law and technology, and I’ve outlined a legal framework to do just that.

Slow burns

One of the most striking aspects of algorithmic harms is that their cumulative impact often flies under the radar. These systems typically don’t directly assault your privacy or autonomy in ways you can easily perceive. They gather vast amounts of data about people — often without their knowledge — and use this data to shape decisions affecting people’s lives.

Sometimes, this results in minor inconveniences, like an advertisement that follows you across websites. But as AI operates without addressing these repetitive harms, they can scale up, leading to significant cumulative damage across diverse groups of people.

Consider the example of social media algorithms. They are ostensibly designed to promote beneficial social interactions. However, behind their seemingly beneficial facade, they silently track users’ clicks and compile profiles of their political beliefs, professional affiliations and personal lives. The data collected is used in systems that make consequential decisions — whether you are identified as a jaywalking pedestrian, considered for a job or flagged as a risk to commit suicide.

Worse, their addictive design traps teenagers in cycles of overuse, leading to escalating mental health crises, including anxiety, depression and self-harm. By the time you grasp the full scope, it’s too late — your privacy has been breached, your opportunities shaped by biased algorithms, and the safety of the most vulnerable undermined, all without your knowledge.

This is what I call “intangible, cumulative harm”: AI systems operate in the background, but their impacts can be devastating and invisible.

Researcher Kumba Sennaar describes how AI systems perpetuate and exacerbate biases.

Why regulation lags behind

Despite these mounting dangers, legal frameworks worldwide have struggled to keep up. In the United States, a regulatory approach emphasizing innovation has made it difficult to impose strict standards on how these systems are used across multiple contexts.

Courts and regulatory bodies are accustomed to dealing with concrete harms, like physical injury or economic loss, but algorithmic harms are often more subtle, cumulative and hard to detect. The regulations often fail to address the broader effects that AI systems can have over time.

Social media algorithms, for example, can gradually erode users’ mental health, but because these harms build slowly, they are difficult to address within the confines of current legal standards.

Four types of algorithmic harm

Drawing on existing AI and data governance scholarship, I have categorized algorithmic harms into four legal areas: privacy, autonomy, equality and safety. Each of these domains is vulnerable to the subtle yet often unchecked power of AI systems.

The first type of harm is eroding privacy. AI systems collect, process and transfer vast amounts of data, eroding people’s privacy in ways that may not be immediately obvious but have long-term implications. For example, facial recognition systems can track people in public and private spaces, effectively turning mass surveillance into the norm.

The second type of harm is undermining autonomy. AI systems often subtly undermine your ability to make autonomous decisions by manipulating the information you see. Social media platforms use algorithms to show users content that maximizes a third party’s interests, subtly shaping opinions, decisions and behaviors across millions of users.

The third type of harm is diminishing equality. AI systems, while designed to be neutral, often inherit the biases present in their data and algorithms. This reinforces societal inequalities over time. In one infamous case, a facial recognition system used by retail stores to detect shoplifters disproportionately misidentified women and people of color.

The fourth type of harm is impairing safety. AI systems make decisions that affect people’s safety and well-being. When these systems fail, the consequences can be catastrophic. But even when they function as designed, they can still cause harm, such as social media algorithms’ cumulative effects on teenagers’ mental health.

Because these cumulative harms often arise from AI applications protected by trade secret laws, victims have no way to detect or trace the harm. This creates a gap in accountability. When a biased hiring decision or a wrongful arrest is made due to an algorithm, how does the victim know? Without transparency, it’s nearly impossible to hold companies accountable.

This UNESCO video features researchers from around the world explaining the issues around the ethics and regulation of AI.

Closing the accountability gap

Categorizing the types of algorithmic harms delineates the legal boundaries of AI regulation and presents possible legal reforms to bridge this accountability gap. Changes I believe would help include mandatory algorithmic impact assessments that require companies to document and address the immediate and cumulative harms of an AI application to privacy, autonomy, equality and safety – before and after it’s deployed. For instance, firms using facial recognition systems would need to evaluate these systems’ impacts throughout their life cycle.

Another helpful change would be stronger individual rights around the use of AI systems, allowing people to opt out of harmful practices and making certain AI applications opt in. For example, requiring an opt-in regime for data processing by firms’ use of facial recognition systems and allowing users to opt out at any time.

Lastly, I suggest requiring companies to disclose the use of AI technology and its anticipated harms. To illustrate, this may include notifying customers about the use of facial recognition systems and the anticipated harms across the domains outlined in the typology.

As AI systems become more widely used in critical societal functions – from health care to education and employment – the need to regulate harms they can cause becomes more pressing. Without intervention, these invisible harms are likely to continue to accumulate, affecting nearly everyone and disproportionately hitting the most vulnerable.

With generative AI multiplying and exacerbating AI harms, I believe it’s important for policymakers, courts, technology developers and civil society to recognize the legal harms of AI. This requires not just better laws, but a more thoughtful approach to cutting-edge AI technology – one that prioritizes civil rights and justice in the face of rapid technological advancement.

The future of AI holds incredible promise, but without the right legal frameworks, it could also entrench inequality and erode the very civil rights it is, in many cases, designed to enhance.The Conversation

Sylvia Lu, Faculty Fellow and Visiting Assistant Professor of Law, University of Michigan

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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Awkwardness can hit in any social situation – here are a philosopher’s 5 strategies to navigate it with grace

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theconversation.com – Alexandra Plakias, Associate Professor of Philosophy, Hamilton College – 2024-11-22 07:25:00

‘I don’t even know what to say to that.’
Catherine Falls Commercial/Moment via Getty Images

Alexandra Plakias, Hamilton College

The holidays offer many opportunities for awkward moments. Political discussions, of course, hold plenty of potential. But any time opinions differ, where estrangements have caused lingering rifts, or when behaviors veer toward the inappropriate, awkwardness can set in.

Awkwardness is what happens in social interactions when you suddenly find yourself without a script to guide you through. Maybe the situation is new or catches you off guard. Maybe you don’t know what’s expected of you, or you aren’t sure what role you’re playing in the social drama around you. It’s characterized by feelings of self-consciousness, uncertainty and discomfort.

As a philosopher who studies moral psychology, I’m interested in awkwardness because I wanted to understand the ways social discomfort stops people from engaging with difficult topics and challenging conversations. Awkwardness seems to inhibit people, even when their moral values suggest they should speak up. But it has a positive role to play, too – it can alert people to areas where their social norms are lacking or outdated.

People often blame themselves when things take a turn toward the awkward. But awkwardness is really a collective failure – people aren’t awkward, situations are. And they become awkward because you don’t have the resources to navigate your way through tricky social situations.

Awkwardness is often confused with embarrassment, but the two are different in important ways, and so are their remedies. Embarrassment is a response to a personal failing or gaffe, and the right response is to acknowledge it, own it and move on. Because awkwardness is caused by a lack of social guidance, you can try to anticipate and head it off before it happens, or you can respond to it by trying to develop better or clearer social scripts to help you – and others – navigate similar situations in the future.

After researching and writing an entire book on awkwardness, I’ve come to the conclusion that it’s not something we can – or should – avoid altogether. But there are a few strategies people can use to minimize awkwardness and deal with it when it does, inevitably, happen.

1. Know your goals, know your roles

Uncertainty is the oxygen of awkwardness. Before you engage in a potentially awkward or contentious interaction, ask yourself: What do I want to get out of this?

When you’re clear on your goals for the interaction, not only are you better able to perform your role in it, but you’re also giving clearer signals to others, helping them perform their roles in the unfolding social drama.

So, if you’re worried it’ll be awkward when your uncle starts in on his annual political rant, think about what you want the outcome to be. Do you want to convince him he’s wrong? Unlikely to happen. Do you want other family members to feel less anxious? Do you want your own views to be heard?

I’m not suggesting that some forethought will make things go smoothly or guarantee that no one’s feelings will be hurt. But it will help you feel more confident in your ability to navigate toward your desired outcome.

woman bringing pie to a family dinner table
Serving dessert could provide a lifeline to someone looking for a diversion.
Drazen Zigic/iStock via Getty Images Plus

2. There’s no ‘I’ in awkward

Awkward situations breed intense self-consciousness. This is both uncomfortable and counterproductive. By focusing on yourself, you’re not attuned to the people around you or the signals they’re sending – signals that could offer you a pathway out of the awkward situation. So make sure you’re paying attention to the other players in the drama, not just your own discomfort.

3. Plan, coordinate and be explicit

People do so much planning in other areas of their lives, yet they expect social interactions to just flow effortlessly. But like a vacation or a hike in the woods, sometimes a conversation goes better when you approach it with a map. Have some go-to topics or questions at hand.

And you don’t have to go it alone. If you’re worried about broaching a sensitive topic, or interacting with a particularly prickly guest, coordinate with a friend or relative.

If you expect to see someone with whom you have an unresolved relationship – an estranged family member, an old friend you ghosted – try to do some prep work in advance. Emails or letters can give people a chance to process reactions without putting them on the spot.

Even having a scripted activity on deck can make things less awkward. It doesn’t have to be anything formal, like a board game. Just keep some tasks available for guests who might otherwise lurk uncomfortably – like shaking up the salad dressing or putting forks on the table.

4. Laugh it off

If, despite your best efforts, awkwardness does strike, offer people a way out – they’ll probably grab it. This doesn’t need to be momentous; it could be a little joke, a small-talk topic, or even – and only if things get very desperate – knocking a spoon off the table to break the silence.

5. Consider the alternatives

These strategies might help you avoid awkwardness. But take a moment to consider whether you really want to. Awkwardness is the result of social uncertainty; it slows things down and curbs your confidence.

In its absence, other emotions can set in. Having things out in the open can be a relief, but it can also lead to anger, sadness and other feelings that might best be saved for another occasion.

So if things are awkward, it’s worth looking around to see what role that awkwardness is playing, and what might take its place if it’s gone.The Conversation

Alexandra Plakias, Associate Professor of Philosophy, Hamilton College

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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No need to overload your cranberry sauce with sugar this holiday season − a food scientist explains how to cook with fewer added sweeteners

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theconversation.com – Rosemary Trout, Associate Clinical Professor of Culinary Arts & Food Science, Drexel University – 2024-11-22 07:24:00

Fall means cranberry season − and sweet seasonal holiday dishes.
AP Photo/Sergei Grits

Rosemary Trout, Drexel University

The holidays are full of delicious and indulgent food and drinks. It’s hard to resist dreaming about cookies, specialty cakes, rich meats and super saucy side dishes.

Lots of the healthy raw ingredients used in holiday foods can end up overshadowed by sugar and starch. While adding extra sugar may be tasty, it’s not necessarily good for metabolism. Understanding the food and culinary science behind what you’re cooking means you can make a few alterations to a recipe and still have a delicious dish that’s not overloaded with sugar.

Particularly, if you’re a person living with Type 1 diabetes, the holidays may come with an additional layer of stress and wild blood glucose levels. It’s no time for despair though – it is the holidays, after all.

Cranberries are one seasonal, tasty fruit that can be modified in recipes to be more Type 1 diabetic-friendly – or friendly to anyone looking for a sweet dish without the extra sugar.

I am a food scientist and a Type 1 diabetic. Understanding food composition, ingredient interactions and metabolism has been a literal lifesaver for me.

Type 1 diabetes defined

Type 1 diabetes is all day every day, with no breaks during sleep, no holidays or weekends off, no remission and no cure. Type 1 diabetics don’t make insulin, a hormone that is required to live that promotes the uptake of glucose, or sugar, into cells. The glucose in your cells then supplies your body with energy at the molecular level.

Consequently, Type 1 diabetics take insulin by injection, or via an insulin pump attached to their bodies, and hope that it works well enough to stabilize blood sugar and metabolism, minimize health complications over time and keep us alive.

Type 1 diabetics mainly consider the type and amount of carbohydrates in foods when figuring out how much insulin to take, but they also need to understand the protein and fat interactions in food to dose, or bolus, properly.

In addition to insulin, Type 1 diabetics don’t make another hormone, amylin, which slows gastric motility. This means food moves more quickly through our digestive tract, and we often feel very hungry. Foods that are high in fat, proteins and fiber can help to stave off hunger for a while.

Cranberries, a seasonal treat

Cranberries are native to North America and grow well in the Northeastern and Midwestern states, where they are in season between late September and December. They’re a staple on holiday tables all over the country.

A bowl of cranberries with the zest of an orange on top.
Cranberries are a classic Thanksgiving side dish, but cranberry sauce tends to contain a lot of sugar.
bhofack2/iStock via Getty Images

One cup of whole, raw cranberries contains 190 calories. They are 87% water, with trace amounts of protein and fat, 12 grams of carbohydrates and just over 4 grams of soluble fiber. Soluble fiber combines well with water, which is good for digestive health and can slow the rise of blood glucose.

Cranberries are high in potassium, which helps with electrolyte balance and cell signaling, as well as other important nutrients such as antioxidants, beta-carotene and vitamin C. They also contain vitamin K, which helps with healthy blood clotting.

Cranberries’ flavor and aroma come from compounds in the fruit such as cinnamates that add cinnamon notes, vanillin for hints of vanilla, benzoates and benzaldehyde, which tastes like almonds.

Cranberries are high in pectin, a soluble starch that forms a gel and is used as a setting agent in making jams and jellies, which is why they thicken readily with minimal cooking. Their beautiful red jewel-tone color is from a class of compounds called anthocyanins and proanthocyanidins, which are associated with treating some types of infection.

They also contain phenolics, which are protective compounds produced by the plant. These compounds, which look like rings at the molecular level, interact with proteins in your saliva to produce a dry, astringent sensation that makes your mouth pucker. Similarly, a compound called benzoic acid naturally found in cranberries adds to the fruit’s sourness.

These chemical ingredients make them extremely sour and bitter, and difficult to consume raw. To mitigate these flavors and effects, most cranberry recipes call for lots of sugar.

All that extra sugar can make cranberry dishes hard to consume for Type 1 diabetics, because the sugars cause a rapid rise in blood glucose.

Cranberries without sugar?

Type 1 diabetics – or anyone who wants to reduce the added sugars they’re consuming – can try a few culinary tactics to lower their sugar intake while still enjoying this holiday treat.

Don’t cook your cranberries much longer after they pop. You’ll still have a viscous cranberry liquid without the need for as much sugar, since cooking concentrates some of the bitter compounds, making them more pronounced in your dish.

A line of spoons, each heaped with a pile of powdered spice.
Adding spices to your cranberries can enhance the dish’s flavor without extra sugar.
klenova/iStock via Getty Images

Adding cinnamon, clove, cardamom, nutmeg and other warming spices gives the dish a depth of flavor. Adding heat with a spicy chili pepper can make your cranberry dish more complex while reducing sourness and astringency. Adding salt can reduce the cranberries’ bitterness, so you won’t need lots of sugar.

For a richer flavor and a glossy quality, add butter. Butter also lubricates your mouth, which tends to compliment the dish’s natural astringency. Other fats such as heavy cream or coconut oil work, too.

Adding chopped walnuts, almonds or hazelnuts can slow glucose absorption, so your blood glucose may not spike as quickly. Some new types of sweeteners, such as allulose, taste sweet but don’t raise blood sugar, requiring minimal to no insulin. Allulose has GRAS – generally regarded as safe – status in the U.S., but it isn’t approved as an additive in Europe.

This holiday season you can easily cut the amount of sugar added to your cranberry dishes and get the health benefits without a blood glucose spike.The Conversation

Rosemary Trout, Associate Clinical Professor of Culinary Arts & Food Science, Drexel University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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