Hospitals as One of the Oldest Institutions in the World - Research Paper Example

?Prevention of Dangers Facing Hospitals 0 Introduction Hospitals comprise one of the oldest s in the world. Their history s back to as early as the birth of civilization and medicine. From the accounts of medical anthropologists, hospitals existed in antiquity in Egypt and India. Hospitals in Mesopotamia have been recorded more than 4000 years ago. Meanwhile, the first hospitals were established in the United States during the 1700s. Since then, health care professionals are guided by the philosophy of delivering quality patient care and providing enhanced health care services (Griffin, 2011). To date, health care is primary domestic priority among Americans, and their top financial concern deals with the skyrocketing costs of health care (Newport, Jones, Saad, Gallup & Israel, 2009). In fact, 16 per cent of the US gross national product goes to health care. It should not, therefore, come as a surprise that health care is “a principal issue in the national consciousness of Americans” (Griffin, 2011, p. 3). Ironically, however, Sultz and Young (2011) observed that while the American health care system prioritized health promotion and disease prevention, health care expenses tend to be concentrated on treating what are otherwise preventable diseases. Moreover, it was revealed not too long ago that hospitals are not really the safest place in America, and perhaps around the world, with 48,000 deaths each year reported due to hospital acquired infections (DeNoon, 2010). There is even a big possibility that incidences of hospital acquired infections are not reported as intimated by some medical experts (Doyle, 2011). Infections are just one of the many dangers which put both patients and medical practitioners at risk. Other possible sources of danger in hospitals are direct physical hazards and malfunction of medical electrical devices, exposure to medical radiation, health hazards of mobile phones, human errors, medication errors, unsanitary practices, etc. (Leitgeb, 2010; Peart 2010; Mennen, 2005; Raheja, 2011; Pozgar 2007). Cognizant of such dangers which directly and / or indirectly threaten the safety of patients confined in a hospital or those simply availing of out-patient services, an attempt will be made to propose interventions and courses of action to avoid these two sources dangers in the hospital. Interventions will be framed on the premise of avoiding those which can be prevented, and mitigating the effects of those which are not preventable. 2.0. Available technology 2.1. Air-borne infection Cursue, Popa, Sirbu, and Popa (2009) supports the benefits of engineering control measures for the reduction of the concentration of airborne infections. Prevention of the spread of such particles in a structure lessens contact with infectious pathogens, as well as the threat of illness from this kind of pathogens. However, engineering controls comprise only one-third of the necessary control elements towards the mitigation risks from airborne infections in health care settings. As explained in Atkinson, Chartier, Pessoa-Silva, Jensen, Li, and Seto (2009), transmission of airborne infections happens by the spreading of droplet nuclei over a long distance from an infected patient. A number of necessary factors are met for the dissemination of droplet nuclei. These are: (1) presence of viable pathogen inside the droplet at the source of the infection; (2) survival of the pathogen inside the droplet after expulsion from its source, and preservation of its ability to cause infection even after being exposed to evaporation, light, temperature, relative humidity, and / or other physical challenges; (3) reaching a specific infective dose sufficient to infect a susceptible host, and (4) exposure or contact of the droplet to a susceptible host. The Word Health Organization (2007, as cited in Atkinson, et al, 2009) maintained that preventing the spread of airborne infections involves the implementation of the so-called airborne precautions. This is realized with the setting of the following forms of control in the health care facility: administrative, environmental and engineering. Among the recommended interventions by WHO include the use of patient room with special air handling and ventilation, and the use personal protective equipment and particulate respirators by health care personnel. WHO (2007, as cited in Atkinson, et al., 2009) also recommended the use of an airborne precaution room for patients whose illness require airborne isolation safety measures. An airborne precaution room was described as follows: “a room with ? 12 air changes per hour (ACH) (e.g. equivalent to ? 80 l/s for a 4 x 2 x 3 m3 room) and controlled direction of airflow, and can be used to contain airborne infections” (as cited in Atkinson, et al., 2009, p. 5). Meanwhile, the Centers for Disease Control ([CDC] 2003, as cited in Atkinson, et al., 2009) indicated that: “a mechanically ventilated room is equivalent to the airborne infection isolation room … which should have special features in air handling and airflow direction, including: a negative pressure differential of ? 2.5 Pa (0.01-inch water gauge); an airflow differential > 125 cfm (56 l/s) exhaust versus supply; clean-to-dirty airflow; sealing of the room, allowing approximately 0.5 square feet (0.046 m2) leakage; ? 12 ACH for a new building, and ? 6 ACH in existing buildings (e.g. equivalent to 40 l/s for a 4 x 2 x 3 m3 room) for an old building; and an exhaust to the outside, or a HEPA-filter if room air is recirculated” (p. 5). Ventilation is an important consideration in designing airborne precautions in health care settings. In a general context, ventilation transports air from outdoors into a structure or a room of a structure and distributes air within the structure or a room in it. There are three essential elements of building ventilation: (1) ventilation rate, which refers to the volume of air from outdoors provided into the space, and the quality of this outdoor air; (2) airflow direction, which refers to the overall direction of the flow of air into a building and ideally should be from a zone of clean air to dirty zones; and (3) air distribution or airflow pattern, which requires that outside air be conveyed to each portion of space efficiently, and that the airborne pollutants from each portion of such space is also efficiently eliminated (as cited in Atkinson, et al., 2009). Design of air-handling systems for health care facilities are guided based on construction and environmental specifications published by the American Institute of Architects, and Design Manual for Hospitals and Clinics set by the American Society of Heating, Refrigerating and Air-Conditioning Engineers, as minimum standards, whenever state or local regulations are not available. Likewise, familiarity with the aforementioned guidelines and standards should be developed among individuals and organizations performing environmental human factors analysis (Carayon, 2007). Environmental controls either reduce or remove droplet nuclei carrying infectious pathogens in the air. Among the environmental controls in common use are local exhaust ventilation, general or central ventilation, air filtration with high-efficiency particulate air (HEPA) filters, and air disinfection with UV germicidal irradiation, also known by the initials UVGI (Blumberg, 2010). Local exhaust ventilation. According to Blumberg (2010), local exhaust ventilation (LEV) is a method employed for source control to capture airborne contaminants such as infectious droplet nuclei or other infectious particle before it is dispersed to the general environment. Blumberg (2010) stressed that a local exhaust ventilation which utilizes a booth, hood or tent presents an efficient engineering control technique. Figure 1 shown next page presents a typical configuration of a LEV system. As shown in Figure 1, the hood of a typical local exhaust system collects contaminant in an air stream directed towards the hood. Figure 1: Configuration of a Typical LEV (Stanfill, n.d.) Meanwhile, the duct system conveys the contaminated air to an air cleaning device, if this device is present in the LEV, or to the fan. The stack takes care of diffusing the remaining air contaminants, if any are left (Stanfill, n.d.). General Ventilation. This type of environmental control is composed of mechanisms which dilute and eliminate contaminated air, and prevents an infectious source from further contamination of air in the nearby areas by controlling the direction of airflow. Mechanisms included in general ventilation are those which perform the following functions: maintenance of negative air pressure, and circulation of air to dilute and eliminate droplet nuclei containing infectious particles (Blumberg, 2010). Figure 2 shows a common general ventilation system. As depicted in Figure 2, as air is injected to a given space, the stream of air applies a substantial pulling force on the surrounding air, particularly when the air is injected at high speed. Figure 2: A Typical General Ventilation System (Castejon, n.d.) The surrounding air combines with the injected air, which slows down the combination and forms a measureable turbulence. Forceful mixing of the air in the space and the injected air generates internal air currents (Castejon, n.d.). Portable air filtration units. This environmental control for infection prevention is alternatively called portable room-air recirculation units, portable air filtration units, or portable high efficiency particulate air (HEPA) filters. This method has been found effective in the removal of bioaerosolized and aerosolized particles in the air, which in turn would facilitate in reducing airborne infection. The most ideal portable devices are those which offer high volumetric airflow rates and maximum flow through the HEPA filter (Blumberg, 2010). The Leung and Chan (2006) study indicated that different grades of filters are used to achieve different levels of cleanliness. In a health care setting, Leung and Chan (2006) recommended a pre-filter with 25-30% dust spot efficiency placed upstream to eliminate larger particles in preparation for a clean heat transfer medium; and a final filter with at least 90% efficiency for the collection of all fungal spores 2 – 5 ?m diameter, as well as bacteria in colony forming units of 1 ?m or larger. Leung and Chan (2006) underscored the necessity of HEPA filter with 99.97% efficiency for areas serving immuno-compromised patients. The study of Eckmanns, Ruden and Gastmeier (2006), however, found no significant benefits of HEPA filtration in preventing death of patients afflicted with hematological malignancies and with severe neutropenia, who are commonly exposed to a higher risk of developing nosocomial fungal infections. A diagram of a high efficiency air filtration system is provided in Figure 3. The air filtration system shown in Figure 3 generates HEPA-filtered air which is 99.97% free of particulate matter as small as 0.3 micron in diameter. The filter eliminates bacteria, fungi and other opportunistic micro-biological organisms. The benefits of HEPA found its way not only in health care settings but in households and offices (Allerair, 2011). Figure 3: Diagram of a High Efficiency Air Filtration System (Allerair, 2011) Blumberg (2010) specified that the effectiveness of portable air filtration units is influenced by the configuration of the room / space being covered, furniture, people occupation the space and the location of the HEPA filtration unit with respect to the position of the supply air vent and the exhaust grilles. Additionally, portable air filtration units also include the UVGI. UVGI. Ultraviolet germicidal irradiation refers to an air cleaning technology which may be installed in a room or corridor to irradiate or to expose to ultraviolet radiation the air in the upper part of a room – this is called upper air irradiation. UVGI units may also be installed in a duct to irradiate the air passing through the duct – this is called duct irradiation. The germicidal lamps used in upper room UVGI system are mercury vapor lamps encased in ultraviolet transmitting glass tubes. About 95% of the energy from the mercury – UV lamps gives out radiation at 253.7 nm in the UV-C range (Blumberg, 2010). The CDC however, considers UVGI only as a supplementary measure for the control of the spread of infectious disease from airborne droplets. Additionally, this device or method may not be used as a substitute for negative air pressure or HEPA filters (as cited in Blumberg, 2010). In this regard, it was reported in the Leung and Chan (2006) study that UV radiation in the wavelength range of 220 – 500 nm is able to penetrate cell walls and inactivate microscopic droplet nuclei by interfering with their reproductive system. Hence, UVGI is potent at eliminating airborne pathogens in the likes of the multidrug resisting mycobacterium tuberculosis bacteria, Legionella bacteria and measles viruses, but not fungal spores. Leung and Chan (2006) pointed out that the efficacy of disinfection with UVGI is a function of both the field intensity of the UV radiation and the residence time of the microbes exposed to the radiation field. This implies that the mechanical ventilation system of a room or structure must be able to maintain air speed within the limits specified by the manufacturer of the UVGI system. Administrative Controls Pearson (2010) described administrative controls as the primary safeguard in the prevention of exposure to air-borne infection by direct intervention on potential sources of infection. Administrative controls normally assume top priority in the air-borne infection control hierarchy. It is composed of procedures, policies, and programs that aim to minimize the risk, intensity, and duration of exposure to hazards (Minnesota Department of Health 2010). Healthcare facilities should implement administrative controls as the first priority since these controls provide the most effective protection from nosocomial transmission. Nosocomial infections usually occur due to the failure of healthcare facilities in identifying and isolating potential sources of infection, such as patients with infectious respiratory illnesses (Lautenbach, Woeltje and Malani 2010). Examples of administrative controls include: patient screening, isolation, diagnosis, and treatment; standard procedures for healthcare workers; comprehensive tuberculin skin testing for healthcare workers; and healthcare worker education (Lautenbach, Woeltje and Malani 2010). Administrative controls are implemented on different inpatient settings in a healthcare facility. In patient rooms, patients suffering from infectious respiratory illness are assigned to an airborne infection isolation room. Intensive care units, emergency and urgent care departments should keep infection control plans updated and transfer patients suspected to have infectious respiratory illness to AII rooms for isolation and observation (Rom 2007). Surgery facilities should delay performing procedures on patients suspected of respiratory illness until confirmed as no threat. If surgery is inevitable, facilities should meet AII standards and the number of health care personnel shall be limited. Meanwhile, hospital laboratories should conduct risk assessments and practice BSL-2 for low-risk and BSL-3 for high-risk processing of specimens (Rom 2007). Hospitals should assign dedicated rooms for bronchoscopy, sputum induction, and inhalation therapy. Infection control plans should be reviewed and updated each year and contaminated air should be eliminated before the room is used again. The number of health care workers assigned on these facilities should be limited (Rom 2007). Finally, autopsy and embalming facilities should maintain close coordination with physicians and pathologists when handling and processing specimens from patients suspected or suffering from infectious respiratory illness. In addition, contaminated air should be eliminated before the room is used again. Moreover, infection control planning should be performed on an annual basis (Rom 2007). An example of implementation of administrative controls is the basic infection control strategy for avian influenza for H5N1. Health care workers are educated and reminded on the importance of strict compliance with hygiene guidelines. Also, access to and training on the use of personal protection equipment by health care workers is ensured, including fit-testing of respirators. Affected patients are assigned to negative pressure rooms and treated to standard, contact, droplet or airborne isolation measures (Allegra 2008). Alternatively, single rooms with a closed door may be used. Another option is to provide wards with multiple beds which are 1 meter apart separated with a physical barrier. The number of health care workers with direct contact to the isolation rooms will be limited and should be dedicated to these facilities if possible. If visitors cannot be avoided, proper personal protection equipment should be provided (Allegra 2008). Another example of administrative control implementation involves infection control strategies for preventing nosocomial transmission of tuberculosis. Administrative control is the most essential of all infection control measures. No environmental or engineering control measure has succeeded without an effective administrative control strategy (Frieden 2004). In a tuberculosis infection control program, the implementation of administrative controls receives the highest priority since it is composed of policies and procedures that ensure early diagnosis and treatment of patients. Basic administrative controls for tuberculosis include: prompt diagnostic evaluation of suspected tuberculosis cases; and medication compliance throughout the treatment duration until discharge (Frieden 2004). In addition, all healthcare facility settings should conduct risk assessment for transmission for all departments and sections of the facility. Likewise, creation of an infection control plan should also be considered. Health care workers should be educated and trained in relation to tuberculosis transmission and prevention; Patients should also undergo education in preventing spread of tuberculosis for their benefit (Frieden 2004). Sputum collection should be conducted in well-ventilated areas and patients with suspected tuberculosis should be prioritized to reduce waiting time. In addition, exposure reduction should be observed in laboratory settings. Furthermore, referral-level facilities are recommended to promote outpatient management of tuberculosis patients through early discharge and avoidance of hospitalization (Frieden 2004). The administrative aspect of infection control is made possible with the coordination of several components, namely: infection control doctor, infection control nurse, infection control team, and infection control committee. The infection control doctor or ICD is a registered medical practitioner serving as leader of the infection control team and the chairman of the infection control committee. The ICD is responsible for the development of plans, policies, and procedures for the prevention of hospital infection, advises the hospital administrator on all aspects of infection control in the hospital, and helps set quality standards, surveillance and audit of hospital infections (Damani 2003). Meanwhile, the infection control nurse or ICN also serves as a specialist advisor on infection prevention concerns and assists in the development, implementation and monitoring of infection control strategies. On the other hand, the infection control team is composed of infection control doctor/s and infection control nurse/s. The team is responsible for the daily operation of infection control programs. Lastly, the infection control committee is responsible for planning, evaluation, prioritization, and resource allocation for infection control activities (Damani 2003). 2.2. Exposure to medical radiation Aside from patients, health care personnel working in radiology, nuclear medicine, nuclear cardiology, radiation oncology, cardiac catheterization laboratory, and dentistry are also at risk of exposure to ionizing radiation. Potential sources of ionizing radiation include: x-ray machines, CAT scans, CT screens, fluoroscopy machines, PET scans, medical accelerators, and radiopharmaceuticals (Farb and Gordon 2005). The use of radiation in medicine normally occurs in the course of diagnosis and treatment of benign or malignant diseases (National Research Council of the National Academes 2006). X-rays. Almost eight out of ten imaging procedures utilize medical x-rays. Diagnostic imaging procedures are used in radiology, cardiology, urology, orthopedics, gastroenterology, and dental clinics. X-rays are also used in the treatment of deep tumors (Farb and Gordon 2005). On the average, a person undergoes x-ray examinations twice per year. Conventional simple x-rays have a radiation dose of 0.02 to 10 mGy. Meanwhile complex x-rays have a radiation dose of 3 to 10 mGy. Even though these numbers are low, the real concern lies on pediatric and adult cases which may require multiple exams such as pulmonary, cardiac, urinary, or orthopedic conditions (National Research Council of the National Academes 2006). CAT scans and CT screens. Similar to x-rays, CAT scans and CT screens are used to obtain cross-sectional images of the body for diagnostic purposes (Farb and Gordon 2005). A single abdominal CT scan has a radiation dose of 10 to 20 mGy which is equivalent to 500 x-rays (Varnholt 2008). Meanwhile, head and whole body scans range from 5 to 15 mGy (National Research Council of the National Academes 2006). Fluoroscopy. Fluoroscopy machines enable taking of x–ray images in video format by continuous exposure to x-rays (Farb and Gordon 2005). Compared with other radiation-based diagnostic techniques, radiation dose for fluoroscopy is relatively low. For example, a fluoroscopic cystogram has a radiation dose of 0.33 mGy (Frush and Applegate 2010). PET scans. Positive emission tomography scans work by injecting a radioactive substance into the patient to enable viewing of metabolic activity and circulation in the brain area. PET scans are used to locate brain tumors, determine the source of epileptic activity, and the study of neurological diseases (Farb and Gordon 2005). In neurological cases, a PET scan is the preferred diagnostic technique because it allows direct assessment of neurotransmitter and dopamine function. However, PET scans have inherent medical risks such as physical side effects related to the venous line, exposure-related stress, and radiation exposure. These risks need to be evaluated, particularly in pediatric cases (Charron 2006). Medical accelerators. Medical accelerators are used in cancer and tumor treatments by delivering high doses of radiation on a tumor around the patient at different angles (Farb and Gordon 2005). However, risks may be involved in the form of malfunctioning equipment and software errors which can lead to under- or over-exposure. For example, a medical accelerator malfunctioned at the Bialystok Oncology Centre in Poland, causing five female patients suffering from breast cancer to sustain painful radiation burns (Malinowska 2003). Radiopharmaceuticals. Radiopharmaceuticals are a class of substances containing radioactive material which are administered to the patient either to diagnose or treat an illness. These substances are taken in orally, intravenously, inhalation, or binded to body fluids. Diagnosis is by the observation of analysis of the distribution and concentration of the radiopharmaceutical in the patient. Since these substances contain radioactive components, utmost care should be exercised in handling, storage, administration and disposal (Farb and Gordon 2005). Radiation safety measures. Safety measures regarding medical radiation should be implemented to protect the patient, health care workers, and the public. Essential radiation protection measures involve compliance with the ALARA or As Low As Reasonably Achievable model. The ALARA model focuses on three components: time, distance, and shielding (Farb and Gordon 2005). Exposure time should be limited to minimize the total amount of radiation absorbed by the body. Keeping one’s distance from radioactive material should also be observed since the amount of radiation absorbed is directly proportional to the distance from the source. Finally, creating a barrier between an individual and a radioactive substance is recommended to ensure that unnecessary exposure (Farb and Gordon 2005). In addition, the use of dosimeters allow the measurement of radiation in a specific area. This ensures that a person does not go above the allowed amount of absorbed radiation. However, dosimeters offer no protection to the user. On the other hand, lead aprons offer excellent protection from x-rays. This would be in contrast with gamma rays because lead aprons block only 15% of gamma radiation. Moreover, handling of radioactive materials should always involve the use of gloves, protective goggles, and lab coats. Eating, drinking, smoking, and application of makeup or cosmetics near sources of radiation are strongly discouraged (Farb and Gordon 2005). In hospital laboratory settings, specific areas should be dedicated to the handling and use of radioactive material. Labels should be properly placed in designated areas and containers. Likewise, proper radiation warning signs should be placed on doors, centrifuges, incubators, hoods, glassware, refrigerators, freezers, and other vessels in which radioactive substances are utilized (Farb and Gordon 2005). In the event of accidental exposure to radiation or spillage of radioactive material, the incident should be reported immediately in order to ensure prompt and effective implementation of containment and decontamination measures. In cases of accidental skin or body contamination, notification of proper authorities should be done immediately (Farb and Gordon 2005). 3.0. Courses of action and interventions The Centers for Disease Control and Prevention has laid out guidelines for the maintenance of air quality to ensure the prevention and control of airborne respiratory illnesses. Healthcare facilities should ensure that heating, ventilation, air conditioning and HVAC filters are properly installed and maintained to avoid leakage of air and accumulation of too many dust particles. Areas which require special ventilation requirements should be monitored in terms of ACH, filtration and pressure differentials. Humidity controls should be incorporated into the HVAC system for moisture removal, taking into consideration how long the facility has been in use and the level of reliability of the HVAC system (Sehulster and Chinn 2003). Meanwhile, steam humidifiers should be used to prevent bacteria from spreading while the use of cool-mist humidifiers should be avoided to prevent microbial growth. Exhaust outlets should be more than 25 feet away from air intake systems. Outdoor air intakes should be constructed at least 6 feet from the ground or at least 3 feet from the roof level. Exhaust outlets from contaminated areas should be constructed above roof level. Air intakes and filters should be checked regularly and used filters should be properly disposed of immediately to prevent the spread of dust and fungal spores. Air intakes should also be checked for nearby bird roosts and nests which might harbor mites and fungal spores (Sehulster and Chinn 2003). Total air output should be monitored and ventilation duct maintenance should be performed on a regular basis. Moreover, portable, industrial-grade HEPA units with a filtration rate of 300 to 800 ft3/min. should be placed in construction zones and patient care areas. In addition, an infection-control risk assessment should be conducted and a sufficient number of protective environment and airborne infection isolation rooms should be allocated based on patient population (Sehulster and Chinn 2003). Furthermore, ultraviolet germicidal irradiation devices should be installed on walls near the ceiling, in the air return duct of an AII area, and sputum induction rooms; Windows with centralized HVAC systems should be sealed and emergency door and exits should be closed and installed with alarms. Contingency plans should be developed for general power failures and HVAC systems should not be shut down except for maintenance, repair, emergency testing, and construction. Also, healthcare facilities should avoid shutting down HVAC systems in acute-care facilities (Sehulster and Chinn 2003). For radiation control, the US Occupational Safety & Health Administration has proposed guidelines regarding the use of ionizing radiation in medical settings. Basic guidelines include compliance to exposure limits in which radiation absorbed by a person should not exceed 5(n-18) rems, wherein n represents an individual’s age from his last birthday. In addition, no one under the age of 18 shall be allowed to be unnecessarily exposed to radioactive material (Occupational Safety and Health Administration 2011). Caution labels, signs, and signals should be posted in conspicuous areas, rooms, equipment, containers and other vessels used in the transport, storage, handling, and processing of radioactive material. Furthermore, automatic alarms generating not less than 75 decibels should be placed on strategic places (Occupational Safety and Health Administration 2011). 4.0. Conclusions High efficiency particulate air (HEPA) filters are shown to be capable of removing 99.97% of bioaerosolized and aerosolized particles as small as 0.3 microns. In addition, the HEPA filter is capable of eliminating bacteria, fungi, and other microbiological organisms. On the other hand, the use of ultraviolet germicidal irradiation in duct irradiation may not be sufficient in providing air ventilation and disinfection. It is believed that using UVGI devices in combination with HEPA filters improves the effectiveness of a medical facility in the prevention and reduction of airborne infections. The advantages of UVGI devices and HEPA filters may be synergized to provide an air filtration and disinfection system which can be used in major and critical healthcare settings where air quality is a priority. This is shown on Figure 4. These measures, tempered with strict administrative controls and sound engineering practices, form an excellent component in disease prevention and control strategies. Figure 4: UVGI Process for Air Filtration (Hoffman, 2011) On the other hand, an effective radiation safety strategy involves the following basic but critical components: prevention of unnecessary exposure; proper labeling and signage for radiation-related facilities, equipment, and containers; use of appropriate protective equipment; regular and thorough maintenance of medical equipment that use ionizing radiation; and proper storage, handling, transport, and disposal of radioactive materials. References Allegra, EP 2008. Avian influenza research progress, Nova Science Publishers, New York. Allerair 2011, Air filtration systems, Ohio, viewed 9 March 2011, http://pages.total.net/ ~espitech/wholehouse.html Atkinson, J, Chartier, Y, Pessoa-Silva, CL, Jensen, P, Li, Y & Seto, WH, Eds 2009, Natural ventilation for infection control in health-care settings, World Health Organization Press, Geneva, CHE. 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