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Recommendations for the standardization of light transmission aggregometry: a consensus of the working party from the platelet physiology subcommittee of sscisth

Recommendations for the Standardization of Light Transmission
Aggregometry: A Consensus of the Working Party from the Platelet Physiology
Subcommittee of SSC/ISTH
M. Cattaneo,1 C. Cerletti,2 P. Harrison,3 C.P.M. Hayward,4 D. Kenny,5 D. Nugent,6 P.
Article Nurden,7 A.K. Rao,8 A.H. Schmaier,9 S.P. Watson,10 F. Lussana,1 M.T. Pugliano,1 and
A.D. Michelson11
1Unita di Medicina III, Ospedale San Paolo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy; 2Laboratori di Ricerca, Università Cattolica, 86100 Campobasso Italy; 3School of Immunity and Infection, University of Birmingham Medical School, Birmingham; 4Department of Medicine, McMaster University, Hamilton, Canada; Hamilton Regional Laboratory Medicine Program, Hamilton, Canada ; 5Department of Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland ; 6CHOC Children’s Hospital, Hematology Research, Orange, CA, USA ; 7Centre de Référence des Pathologies Plaquettaires, Plateforme Technologique et d'Innovation Biomédicale, Hôpital Xavier Arnozan, Pessac, France ; 8Sol Sherry Thrombosis Research Center, Temple University School of Medicine, Philadelphia, PA, USA ; 9 Department of Medicine, Case Western Reserve University and University Hospitals Case Medical Cente, Cleveland, OH, USA ; 10Centre for Cardiovascular Sciences, Institute of Biomedical Research, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK; 11Center for Platelet Research Studies, Division of Hematology/Oncology, Boston Children’s Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA *The Working Party of experts was composed by: Marco Cattaneo (Chairman), Alan D. Michelson (Co-chairman), Chiara Cerletti, Paul Harrison, Cathrine P.M. Hayward, Dermot Kenny, Diane Nugent, Paquita Nurden, A.Koneti Rao, Alvin H. Schmaier, Stephen P. Watson Accepted This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process which may lead to differences between this version and the Version of Record. Please cite this article as an 'Accepted Article', doi: 10.1111/jth.12231 This article is protected by copyright. All rights reserved. Correspondence: Marco Cattaneo, Unita di Medicina III, Ospedale San Paolo; Dipartimento di Scienze della Salute, Università degli Studi di Milano. Via di Rudinì 8, 20142 Milan, Italy. Tel.: +39 0250323095; fax: +39 0250323090. Summary.
Light transmission aggregometry (LTA) is the most common method used to assess platelet function. However, there is no universal standard for its performance. The Platelet Article Physiology Subcommittee of the Scientific and Standardization Committee (SSC) of the
International Society on Thrombosis and Haemostasis formed a working party of experts with the aim of producing a series of consensus recommendations for standardizing LTA. Due to a lack of investigations that directly compared different methodologies to perform LTA studies, there were insufficient data to develop evidence-based guidelines. Therefore, the RAND method was used, which obtains a formal consensus among experts about the appropriateness of health care interventions, particularly when scientific evidence is absent, scarce and/or heterogeneous. Using this approach, each expert scored as “appropriate”, “uncertain” or “inappropriate” a series of statements about the practice of LTA, which included pre-analytical variables, blood collection, blood processing, methodological details, choice of agonists and the evaluation and reporting of results. After presentation and public discussion at SSC meetings, the assessments were further refined to produce final consensus recommendations. Before delivering the recommendations, a formal literature review was performed using a series of defined search terms about LTA. Of the 1830 potentially relevant studies identified, only 14 publications were considered to be actually relevant for review. Based upon the additional information, 6 consensus statements were Accepted slightly modified. The final statements were presented and discussed at the SSC Meeting in
Cairo (2010) and formed the basis of a consensus document, which is the subject of the This article is protected by copyright. All rights reserved. Keywords: platelet aggregation, platelet disorders, platelet function, platelets,
Introduction
Light transmission aggregometry (LTA), which was independently developed in 1962 by Born [1] and O’Brien [2] is considered the gold standard for testing platelet function, because it provides important information that is essential for the diagnostic work-up of patients with platelet function defects. LTA measures the transmission of light through a sample of platelets in suspension (platelet-rich plasma [PRP], washed platelets or gel-filtered Article platelets), which increases when platelets are aggregated by an agonist. LTA is a time-
consuming and technically challenging technique that is affected by many pre-analytical and analytical variables, and these must be carefully controlled for by expert personnel. For this reason, LTA should be performed only in specialized laboratories. Alternative methods to measure platelet aggregation in PRP or whole blood have been developed (e.g., impedance aggregometry, 96-well plate aggregometry, single platelet counting, flow cytometry) [3-7]), several of which enable faster and more user-friendly study of the platelet response to aggregating agents. Despite these potential advantages, the majority of these techniques have not been widely adopted and, at variance with LTA, fail to provide important additional diagnostic information that can identify defect of platelet function, such as platelet shape change, the occurrence of secondary wave of aggregation Although popular and widely used, the LTA technique is not standardized [8], despite the fact that guidelines have been published [9-11]. Surveys organized by proficiency testing organizations identified variations in LTA practices and the need for guidelines to Accepted standardize LTA [12-14]. In July 2006, the Platelet Physiology Subcommittee of the ISTH
formed a Working Party of 11 experts with the aim of producing a series of consensus recommendations for standardizing LTA. As a first step in LTA guideline development, the This article is protected by copyright. All rights reserved. Working Party organized the largest and most detailed worldwide survey on LTA methodology [15]. The survey confirmed the very high variability in LTA practices worldwide, indicating that methodological standardization is necessary. The information gathered in the survey contributed to the development of ISTH methodological guidelines for LTA, which are in the subject of the present report by the Working Party. RAND Method
Article Clinical or laboratory guidelines are traditionally based upon reviewing the evidence of
the medical and scientific literature. However, it is unfortunately common that the literature does not provide definitive answers for a variety of reasons, including absence of evidence, and low quality and/or contradictory evidence. It was clear to the experts of the Working Party that not enough relevant studies had been published that compared different methodologies to perform LTA studies, which would have helped to develop evidence-based guidelines.The Working Party therefore used a formal consensus method (the RAND methodology) [16] to develop its recommendations. The RAND method – developed by the RAND Corporation in the 1980s – is intended to obtain a formal consensus among expert groups about the appropriateness of health care interventions, particularly when scientific evidence is absent, scarce and/or heterogeneous [9]. A series of statements about LTA practice were formulated by the chairman (MC) and the co-chairman (ADM) of the Working Party. For each statement, a form was prepared, which each member of the Working Party scored for appropriateness from 1 (completely inappropriate) to 9 (fully appropriate). Ballots were blinded to the other members. The Accepted extreme scores (highest and lowest) were discarded, the median of the remaining scores
was calculated and the area containing the majority of the ballots defined the classification of This article is protected by copyright. All rights reserved. each statement about LTA practice: inappropriate (scores 1-3), uncertain (4-6) and After the first RAND run, statements were changed according to the comments/suggestions that the reviewers wrote on their RAND forms. A second RAND run was organized to score the revised statements. Recommendations were then presented at the ISTH SSC Meeting in Vienna (2008) and discussed with the audience. Based on the comments and suggestions that were raised during that meeting, statements were revised and a third RAND run was organized among the experts of the Working Party. The revised Article recommendations were again presented at an ISTH SSC Meeting (Boston, 2009) and
discussed with the audience. Based on the comments and suggestions that were raised during that meeting, statements were again revised and a fourth RAND run was organized among the experts of the Working Party. At this point, before final approval of the recommendations, it was decided that a formal, full literature review should be performed, in order to verify, where possible, the recommendations of the Working Party. Literature Review
The Medline electronic database was searched for relevant published studies between 1966 and November 2009, without any language restriction, using the following medical subject headings (MeSH) terms and free text terms: (1) “platelet aggregation” OR “platelet agglutination”; (2) lumiaggregometry” OR "light transmission aggregometry" OR "light transmittance aggregometry" OR "platelet reactivity tests" OR "platelet function tests" OR "platelet function test" OR "Born aggregation". The search was supplemented by manually Accepted reviewing the reference lists from primary or review articles and by direct consultation among
members of working group to identify additional relevant studies. This article is protected by copyright. All rights reserved. All references were reviewed manually and data extracted using the following inclusion criteria: 1) Studies that directly compared different methodological approaches in studying LTA including case control, prospective cohort or retrospective cohort studies; (2) Studies in which one of the outcomes of interest (i.e., the methodological approach to study LTA) was a pre-specified endpoint. By this method 1830 potentially relevant studies were identified and screened for retrieval. The titles and abstracts of these were divided in 5 groups, and each group was reviewed by 2 panel members. Based on their assessments, 1803 studies were excluded, leaving 27 for detailed evaluation. After review of the full manuscripts by the panel Article members, 5 further studies were excluded. These 12 manuscripts, coupled with 2 extra
studies identified by manual review and by consultation among members of the working group, resulted in a total of only 14 relevant studies [17-30] that were used to help refine the RAND survey and write the present recommendations (Figure 1). Disagreement among experts was resolved by consensus and, when necessary, by asking the opinion of the Final refinement of the recommendations
Based on the information that was gathered from the selected 14 publications, 6 consensus statements were slightly changed and a final, fifth RAND run among the Working Party experts was organized. The final statements were presented and discussed at the ISTH Subcommittee Meeting in Cairo (2010) and it was agreed that these could form the basis of a consensus document which is the subject of the present report by the Working Party. Recommendations of the Working Party on Standardization of Light Transmission
Aggregometry, of the SSC Subcommittee of Platelet Physiology of ISTH
Accepted The recommendations of the Working Party on standardization of LTA include 70
statements, which have been grouped into 8 sections: 1) clinical usefulness of LTA; 2) pre- This article is protected by copyright. All rights reserved. analytical variables; 3) blood collection; 4) preparation of PRP and platelet-poor plasma (PPP); 5) assessment of PRP quality; 6) methodology; 7) choice of agonists; 8) evaluation 1. Clinical usefulness of LTA
¾ LTA is clinically useful for the study of subjects with bleeding disorders ¾ LTA should not be used for the identification of subjects at risk of thrombosis, except in research (median score 7, range 5-9). The experts agreed that this is an area that still needs further studies and LTA should not be used for monitoring subjects on antiplatelet therapy, except in research (median score 7, range 4-7). New, faster and more efficient point-of-care tests are available for this purpose, but LTA could be used when the new tests are not available. However, based on the negative results of 3 large randomized trials [31-33], which used the point-of-care test VerifyNow P2Y12, and a large observational study, which used LTA to tailor antiplatelet treatment with clopidogrel [34], convincing data to recommend monitoring antiplatelet therapy by laboratory Accepted Based on the above 3 recommendations, the following recommendations apply only to the
use of LTA for diagnosing patients with bleeding disorders, in whom the presence of a platelet function disorder is suspected. This article is protected by copyright. All rights reserved. 2. Pre-Analytical
Variables
¾ Blood samples for LTA should be collected after a short rest period for the subject (median score 7, range 2-8), to attenuate the effect of exercise- induced adrenaline release on platelet aggregation. ¾ Blood samples for LTA should be collected from subjects who refrain from smoking for at least 30 minutes (median score 7, range 5-8), to attenuate the effect of exercise-induced adrenaline release on platelet aggregation. ¾ Blood samples for LTA should be collected from subjects who abstain from caffeine for at least 2 hours (median score 7, range 3-8). Article ¾ A record of all drugs that the subject has taken in the week prior to testing
should be collected (median score 7, range 7-9). ¾ Treatment with drugs known to reversibly inhibit platelet function (e.g. NSAIDs) should be stopped at least 3 days before sampling (median score ¾ Treatment with drugs known to irreversibly inhibit platelet function (e.g. aspirin, thienopyridines) should be stopped at least 10 days before ¾ When treatment with drugs that inhibit platelet function cannot be stopped before sampling, drug-induced effects on platelet function should be considered when interpreting the LTA results (median score 9, range 8-9). ¾ It is uncertain whether blood samples for LTA should be collected from
fasting subjects (median score 5, range 3-8). Although variations in glycemia and lipidemia might slightly affect the results of LTA studies, it is uncertain whether or not these effects interfere significantly with the diagnosis of platelet function disorders. Accepted The effects of light meals on the results of LTA studies are probably negligible.
However, patients should not be studied after having meals associated with high This article is protected by copyright. All rights reserved. fat content, to avoid the formation of chylomicrons in plasma, which will interfere ¾ It is uncertain whether treatment with any drug should be stopped before
It is impossible for some patients to stop all medications before being sampled for 3. Blood
Collection
Article Blood samples for LTA studies should be collected using the following precautions to
minimize platelet activation during the procedure. ¾ Blood samples for LTA should be drawn with minimal or no venostasis It is also suggested that, if a tourniquet needs to be used, it should immediately be released as soon blood collection begins. ¾ Blood samples for LTA should be drawn using a needle of at least 21 gauge ¾ Blood samples for LTA should be drawn into plastic (polypropylene) or siliconized glass tubes (median score 9, range 8-9). ¾ Blood samples for LTA should be drawn into a buffered anticoagulant to help keep the pH stable during processing and testing (median score 7, ¾ Blood samples for LTA should be drawn into 109 mM sodium citrate, Accepted
buffered anticoagulant (median score 8, range 5-9). ¾ Blood samples for LTA should be drawn into 129 mM sodium citrate, buffered anticoagulant (median score 7, range 4-9). This article is protected by copyright. All rights reserved. Although 5 experts declared their preference for one of the two suggested concentrations of sodium citrate, the final recommendation was that either concentration of sodium citrate is acceptable, as long as its use is consistent in ¾ The first 3-4 mL of blood drawn should be discarded or used for tests other ¾ When difficulties are encountered in obtaining sufficient blood for LTA, underfilled tubes may only be used to exclude severe platelet function disorders, such as Glanzmann thrombasthenia or Bernard-Soulier 4. Preparation of PRP and PPP
¾ Blood samples should be allowed to “rest” at room temperature for 15 min before centrifugation (median score 8, range 6-8). ¾ PRP should be prepared by centrifuging blood samples at 200 x g for 10 This recommendation was recently validated by Femia et al, who demonstrated that centrifugation of blood samples at 200xg (or 250xg) for 10 min appears to be the best condition for preparing PRP for LTA studies, both in terms of the degree of contamination of PRP by other blood cells and of platelet reactivity [35]. Similar results in terms of platelet reactivity were reported by Merolla et al [36]. ¾ PRP should be prepared by centrifuging blood samples at ambient temperature (approximately 21°C) (median score 8, range 8-9) ¾ PRP should be prepared by centrifugation without using a brake (median Accepted ¾ PRP should be prepared by blood sedimentation for samples with very
large platelets (median score 8, range 5-9) This article is protected by copyright. All rights reserved. ¾ It is uncertain whether it is advisable to keep the tubes at a 45° angle
when preparing PRP by sedimentation of blood samples with very large ¾ PPP should be prepared by centrifuging whole blood, or the tubes of blood from which PRP was removed, at ambient temperature at 1500 x g for 15 5. Assessment of PRP quality
Article ¾ Grossly haemolyzed samples should be discarded (median score 9, range
¾ If the sample tested is lipaemic, the final report should indicate this (median ¾ It is necessary to check the platelet count of the PRP sample tested ¾ The results of LTA studies could be inaccurate when the platelet count in the PRP samples is lower than 150 x 109/L (median score 8, range 5-9) ¾ Caution should be taken when interpreting abnormal results in samples with low platelet counts (median score 9, range 7-9) ¾ PRP with low platelet counts may be tested to exclude severe platelet function disorders (Glanzmann thrombasthenia, Bernard-Soulier syndrome, type 2B and platelet-type von Willebrand disease) (median score 8, range ¾ The platelet count of PRP samples should NOT be adjusted to a standardized value with autologous PPP (median score 8, range 3-9) Accepted Recent studies demonstrated that platelet counts in PRP within the range that is
observed in PRP samples from subjects with normal platelet count in whole blood do This article is protected by copyright. All rights reserved. not affect the results of LTA studies [19-22]. Therefore, the common practice of adjusting the platelet count in PRP with autologous PPP is not recommended, because it is unnecessary and may impair the platelet responsiveness to agonists [21]. It remains uncertain what is the best practice to follow when the platelet count in PRP exceeds about 600x109/L. More recently, a study showed that both methods - native and adjusted platelet count - are valid to assess a bleeding disorder [37]. Abnormalities of platelet aggregation were more frequent using adjusted platelet count Article 6. Methodology
¾ LTA studies must include a known normal subject, run in parallel with the subject(s) under study (median score 8, range 7-9) ¾ After centrifugation, PRP samples should be allowed to sit at room temperature for 15 min before testing (median score 7, range 7-9) ¾ PRP should be used to set 0% light transmission in the aggregometer ¾ Autologous PPP should be used to set 100% light transmission in the aggregometer (median score 9, range 8-9) ¾ LTA studies should be performed at 37°C (median score 9, range 8-9) ¾ During LTA testing, PRP samples should be constantly stirred at 1,000 rpm using a disposable stirrer, unless otherwise specified by the manufacturer of the aggregometer (median score 8, range 8-9) ¾ Before adding an agonist, baseline tracings for LTA should be observed for oscillations and stability for at least 1 minute (median score 8, range 7-9) Accepted ¾ The volume of agonist added for LTA should be consistent, and never more
than 10% of the total sample volume (median score 8, range 7-9) This article is protected by copyright. All rights reserved. ¾ Platelet aggregation should be monitored for a minimum of 3 minutes after adding an agonist (median score 8, range 7-9) ¾ Platelet aggregation should be monitored for a minimum of 5 minutes after adding an agonist that does not cause maximal aggregation by 3 minutes with most control samples (median score 8, range 8-9) ¾ Platelet aggregation should be monitored for a minimum of 10 minutes after adding an agonist that does not cause maximal aggregation by 5 minutes with most control samples (median score 8, range 5-9) ¾ LTA studies should be completed within a maximum of 4 hours after blood 7. Choice
of
Agonists
Platelet agonists should be properly stored and checked for stability. The following platelet agonists, at the indicated concentrations, should be used for diagnostic LTA studies: ¾ ADP: 2 µM (median score 7, range 4-9)
• higher concentrations of ADP should be used if abnormal results with ¾ Epinephrine: 5 µM (median score 8, range 5-9)
• higher concentrations of epinephrine should be used if abnormal results with 5 µΜ (median score 8, range 6-9). ¾ Collagen: use a low concentration of collagen, which is sufficient to cause
the aggregation of normal platelets (e.g., 2 µg/mL Horm collagen) (median Accepted
This article is protected by copyright. All rights reserved. • higher concentrations of collagen should be used if abnormal results with 2 µg/mL (median score 8, range 6-9). Reference to Horm collagen (the most widely used collagen preparation for LTA studies) is given as an example and is not intended to bind laboratories to the use of this commercial ¾ Thrombin Receptor (PAR1) Activating Peptide (PAR1-AP): 10 µM
• higher concentrations of PAR1-AP should be used if abnormal results with 10 µΜ (median score 8, range 5-9) thromboxane A2 mimetic U46619: 1 µΜ (median score 7, range 5-9)
• higher concentrations of U46619 should be used if abnormal results ¾ Arachidonic acid: 1 mΜ (median score 8, range 6-9)
• higher concentrations of arachidonic acid should be used if abnormal results with 1 mΜ (median score 7, range 4-9) agent Ristocetin: 1.2 mg/mL (median score 8, range 7-9)
ƒ If platelet agglutination induced by Ristocetin 1.2 mg/mL is normal, testing should be repeated using Ristocetin 0.5-0.7 ƒ If platelet agglutination induced by Ristocetin 1.2 mg/mL is absent, testing should be repeated using Ristocetin 2 mg/mL Accepted
This article is protected by copyright. All rights reserved. 8. Evaluation and Reporting of Results
¾ The platelet aggregation tracing should be evaluated based on: • presence of shape change (median score 8, range 8-9) • length of the lag phase (median score 8, range 5-9) • slope of aggregation (median score 7, range 3-9) • maximal amplitude or % aggregation (median score 9, range 8-9) • amplitude or % aggregation at the end of the monitoring period • deaggregation (median score 8, range 8-9) • visual examination of the aggregation tracings (median score 9, range • the presence of a "secondary wave” induced by epinephrine (median ¾ Studies completed more than 4 hours after blood collection should be reported with a comment on this (median score 8, range 3-9) ¾ Clinical laboratories must establish appropriate reference intervals and validate test performance with each lot of reagents (median score 8, range 7-9) [18]. M. Cattaneo: concept and design of the study, grading of recommendations, analysis of the literature search, analysis and interpretation of the data, writing the manuscript, final approval of the version to be published. Accepted C. Cerletti: grading of recommendations, analysis of the literature search, analysis and
interpretation of the data, revising the manuscript, final approval of the version to be published. This article is protected by copyright. All rights reserved. P. Harrison: grading of recommendations, analysis of the literature search, analysis and interpretation of the data, revising the manuscript, final approval of the version to be published. C.P.M. Hayward: grading of recommendations, analysis of the literature search, analysis and interpretation of the data, revising the manuscript, final approval of the version to be published. D. Kenny: grading of recommendations, analysis of the literature search, analysis and interpretation of the data, revising the manuscript, final approval of the version to be published. Article D. Nugent: grading of recommendations, analysis of the literature search, analysis and
interpretation of the data, revising the manuscript, final approval of the version to be published. P. Nurden: grading of recommendations, analysis of the literature search, analysis and interpretation of the data, revising the manuscript, final approval of the version to be published. A.K. Rao: grading of recommendations, analysis of the literature search, analysis and interpretation of the data, revising the manuscript, final approval of the version to be published. A.H. Schmaier: grading of recommendations, analysis of the literature search, analysis and interpretation of the data, revising the manuscript, final approval of the version to be published. S.P. Watson: grading of recommendations, analysis of the literature search, analysis and interpretation of the data, revising the manuscript, final approval of the version to be published. Accepted F. Lussana: literature search, analysis of the literature search, analysis and interpretation of
the data, revising the manuscript, final approval of the version to be published. This article is protected by copyright. All rights reserved. M.T. Pugliano: literature search, analysis of the literature search, analysis and interpretation of the data, revising the manuscript, final approval of the version to be published. A.D. Michelson: concept and design of the study, grading of recommendations, analysis of the literature search, analysis and interpretation of the data, revising the manuscript, final approval of the version to be published. References
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33. Collet JP, Cuisset T, Rangé G, Cayla G, Elhadad S, Pouillot C, Henry P, Motreff P, Carrié D, Boueri Z, Belle L, Van Belle E, Rousseau H, Aubry P, Monségu J, Sabouret P, O'Connor SA, Abtan J, Kerneis M, Saint-Etienne C, Barthélémy O, Beygui F, Silvain J, Vicaut E, Montalescot G; ARCTIC Investigators. Bedside monitoring to adjust antiplatelet therapy for coronary stenting. N Engl J Med 2012;367:2100-9.
34. Parodi G, Marcucci R, Valenti R, Gori AM, Migliorini A, Giusti B, Buonamici P, Gensini GF, Abbate R, Antoniucci D. High residual platelet reactivity after clopidogrel loading and long-term cardiovascular events among patients with acute coronary syndromes undergoing PCI. JAMA 2011;306:1215-23.
35. Femia EA, Pugliano M, Podda G, Cattaneo M. Comparison of different procedures to Accepted prepare platelet-rich plasma for studies of platelet aggregation by light transmission
aggregometry. Platelets 2012;23:7-10.
This article is protected by copyright. All rights reserved. 36. Merolla M, Nardi MA, Berger JS. Centrifugation speed affects light transmission aggregometry. Int J Lab Hematol 2012;34:81-5
37. Castilloux JF, Moffat KA, Liu Y, Seecharan J, Pai M, Hayward CP. A prospective cohort study of light transmission platelet aggregometry for bleeding disorders: is testing native platelet-rich plasma non-inferior to testing platelet count adjusted samples? Thromb Haemost 2011;106:675-82.
Legends to Figures
Article Figure 1 – Literature search: progression of study selection
Accepted
This article is protected by copyright. All rights reserved.

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