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Immigration and Pharmacy – Success Stories

Pharmacy practice is filled with amazing individuals.  We all know Pharmacists that stand out for various reasons. Lately there has been a climate of intolerance towards those that come to Canada or the U.S. from another country. This confuses me given the history of successful immigration not only in Canada but other countries as well. Pharmacy practice is no stranger to this and I have found it necessary to share the brief stories of just a few of the many immigrants to Canada that have and continue to contribute to the profession of Pharmacy.  My regrets are that I couldn’t include more people here and that their stories are so abbreviated in the interest of space.  These are the stories of just 3 such individuals to spotlight their paths of immigration and contribution to Pharmacy and to Canada.

KYRO

My first call was with Kyro Maseh, a Pharmacist from the Toronto area.  He came to Canada in August 1996 with his family from Egypt.  The main reason for their move was the growing religious discrimination they were seeing and decided it was time to leave.  He was 8 years old when they arrived.  His mom was a Pharmacist, which helped their acceptance into Canada.  At the time Canada was looking for Pharmacists from Egypt and his parents read that it was a good place to raise a family. His dad was a well-known and respected vetrinarian of livestock in their area but gave up that profession when they came here.  Kyro had very little English language and no alphabet skills when he came here but you would never know that now.  He now speaks French, English and Arabic.  His early days in Canada were modest by his standards today and back in Egypt.  Their furniture came from what they could scrounge up from the garbage and housing was not luxurious to say the least.  To add to the family’s stress, his mother was diagnosed with cancer after their arrival.

Kyro eventually returned to Cairo for his Pharmacy education.  At a metropolitan centre he wouldn’t experience the same discrimination as his family did in Asyute where he was born.  One day a mother came into the pharmacy and told Kyro that her son didn’t wake up that morning, he had overdosed.  She said to him that she wished someone had warned him. It was in The Beaches area of Toronto where there is a small community feel.  He began to feel at this moment that it was his calling to help educate others, particularly young people about addiction and prevention of addiction.  Mental health and addiction became an area of focus for Kyro from then on.  He feels that as pharmacists we are good at talking to people and we are knowledgeable in science.  Teaching then becomes an important and natural part of our job. His #EndTheCrisis campaign tries to focus on kids on awareness of addiction.  His warning in hesitancy of immigration points to the case of Raymond Schinazi, who was forced from Egypt, only to become instrumental in the development of antiviral medications we use in pharmacy today.  He says there is strength in diversity, something he is living proof of.

Christina

Tina Privado Azzopardi (Christina) grew up in a relatively poor setting with both of her parents, 3 brothers and 1 sister on the beautiful island of Cuyo in the Philippines.  It’s an area that is quite isolated transportation-wise from the urban areas of the Philippines and very much more laid back.  To see this tiny spit of land on a map verifies the isolation they lived in. She moved to the more metropolitan centre of Manila to pursue a degree in Pharmacy and graduated in 1997.   This would not have been possible without the scholarships she received and monetary help from an Aunt she moved in with during that time in Manila.  Her Aunt was a business owner and fairly well to do.  In return, Christina would help out with the bookstore business as was needed. Upon graduation, she was employed as a lab instructor at the private University she had attended and worked there for 5 years.  The pay was not high in this position.  

Pharmacy practice and overall healthcare in the Philippines is quite different than here in Canada.  She recalls the system as very sad and medications can be difficult to obtain with little structure to any healthcare system, little private insurance, and expensive prescriptions.  The Physician is rarely challenged on a prescription when it comes to switching to a generic or dealing with an interaction.  Physicians are held in high regard like they are here, but it is more of an authoritative role.  Collaborative care with a Pharmacist’s input is not common.  Brand name reps often visit the physicians and leave samples. This leads the physician to often write for the brand name of medications and there is no switching to generics unless it is written for.  Christina tells me it is still this way today back home.  It is not uncommon for antibiotic prescriptions to be filled for part of the total days supply due to the cost.  Being on a chronic medication can financially ruin a family that tries to pay for them.  

Christina eventually saw a benefit in working in Canada.  With the help of a broker that spearheaded the move for Zellers who was looking for pharmacists, she prepared herself for the transition, which included 3 qualifying exams.  She recalls this as an unsure time as scams were often present with such brokers.  At the time, the internet wasn’t as widely used as today and verification of such scams was more difficult.  Eventually, through friends of hers that knew the friends of the broker she was fairly satisfied this was above board and made the move with a group of 5 others; all academia and non-retail in background.  This particular group came from Centor Escolar University and from the University of the Philippines.  Unfortunately for Christina and her family her father passed away of cancer before her time to leave came.

She recalls her arrival in the GTA after 24 hours of travel when the 3 girls in the group opened the door to their new apartment and realized it was completely devoid of furniture.  It was a feeling of emptiness she recalls.  She recounted having the bed sheets she travelled with that night and they eventually got some furniture that was donated by other Philippino families living in the building.  It was in a building that had many other immigrants from the Philippines.  She lived in Barrie for three years where she worked and paid off her commitment to Zellers.  Making the switch from academia to retail in a corporate environment was tough but she was mentored during that time and felt comfortable becoming a store-owner after that.  She embraced the chance to become involved in the independent Pharmacy world.  She now owns a store on her own and partly owns three others.  She purchased a home, got married and has a 6 year old son in Tottenham, Ontario, about 70 km from Toronto.  Her mom stays with her for ¾ of the year and goes back to the Philippines for the remainder. Her commitment to the pharmacy profession is obvious but her 6-day weeks with 4 stores will hopefully become 4 day weeks to give her more family time eventually.

Johnny

Johnny Marya has no direct recollection of his birth country of Greece.  His parents were Christians living in Syria, a minority group in that country.  His father started work when he was 13 with Johnny’s grandfather in the jewelry business in Syria.  It was a family of 6 children and a life of productive work looked more favorable than school.  Early on they knew that North America offered more potential than they saw in Syria, including education for Johnny.  Before Johnny was born they moved to Greece where they lived for a short time around his birth.  His Father became a jeweler – making a fairly good living there.  They decided to begin the work to start the path to Canada and his father moved his wife and Johnny back to Syria while he went to the U.S. to begin the paperwork to have the family moved over here.  The year was 1989.   This is a process that lasted nearly three years.  During this time he didn’t see his father, who supported the family from the U.S., undoubtedly a long period for Johnny.  Finally, in 1992, when he was 2 ½ he moved to Montreal with his mom to be reunited with his dad.

Growing up in Canada offered Johnny and his family (which also now includes a sister) opportunities and education they would not have had back in Syria.  Johnny saw the value of education.  As an immigrant it was instilled in him to get an education first in order to be successful and to work hard to get what you need.  He went to work at small jobs at the same age his father did as a young boy.  His first job was at a grocery store, receiving orders and preparing fruits and vegetables for sale.  His next jobs included a Subway, a Theatre, a paper route, a duty free shop at the airport, snow removal, a forklift driver at a warehouse, a truck driver for a delivery company, and a clothing salesman for H&M. With his family they also started a tourist agency and a popcorn company, both of which they ended up selling.

As Johnny started his 4 year Bachelor’s degree in finance, he approached his father to rekindle the jewelry business that he had started to wind down.  Johnny developed a business plan and incorporated a proposal that included updated technology and smaller batch custom-made jewelry production with little to no overhead in inventory.  This was a busy time for him, working 40 hours per week while in university.  During this time he interned for a live broadcasting company that expanded and offered him a great job that he couldn’t refuse so he took that job and still offered to help his dad with the jewelry business.  He was 22 years old at this point.  He worked there for a year and turned to a recruiting agency to find a job in finance.  He was immediately offered a job with the recruiting company and within 2 years he was one of the top producers, mainly with pharmaceutical companies.  This is how he started to learn about drug companies, including McKesson.  His sister also became a Pharmacist.  After some extra legwork he convinced his future employers at McKesson that the recipe to a successful hire of a salesman isn’t in the salesman’s background in what they sold in the past (like automation), it’s in the ability of the individual to sell.  After all, Johnny spent a long time with the recruiting company coaching others in how to nail an interview.  Johnny has become Regional Sales Manager for Atlantic Canada and been doing that job for 3 years.  

Johnny’s extended family has also immigrated.  An uncle who was a physiotherapist back home, now works in Canada as a masseuse, another uncle is a successful physician in New York, and a cousin is with the Canadian Army.   Johnny’s story underscores the belief that immigrants often have a strong work ethic, come to Canada because they recognize the simple formula of education and hard work leading to success, and can be hired by companies that recognize this value and potential in this country.  While he not a Pharmacist, Johnny represents one of the many immigrants that have come to this country and contribute immensely to healthcare through their special expertise, not to mention the contribution of his family that also came to North America.  He has contributed to the success of many Pharmacies in this country.

The stories from immigrants were all equally interesting for differing reasons as I interviewed them for this blog.  I soon realized it was going to be difficult to tell their stories fully to and keep the blog’s length appropriate.  Immigration has proven to contribute to the success of Pharmacy in Canada.  Its benefits are seen both directly through immigrants who began here with a Pharmacy career and flourished, but also through the children of descendants that have come here from abroad.  Something I have learned through this exercise is how Pharmacy operates in other parts of the world.  From the examples I have heard, Canada is actually an excellent country to practice this profession, given the complaints we may have here in this country.  The respect given to Pharmacists and the value of pharmacy as a profession is strikingly higher here comparatively.  Thanks to all for their contributions in helping to promote the value of immigration through our profession.

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Common Holiday Season Drug Interaction Warning
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The holidays can increase the consumption of two drugs that we may use in a light to moderate fashion during the year, either at separate occasions or concurrently.   One of these drugs is alcohol and the other is acetaminophen. Sometimes the consumption of alcohol results in adverse effects that require the use of the second drug, or perhaps the acetaminophen is just used regularly for any type of chronic or acute pain you may be experiencing.

The two main organs in our body that help to remove drugs are the liver and the kidneys. A series of chemical reactions occur where drugs are changed or “metabolized” to make them readily removed from the body, often through the intestines or the urinary tract.   Without these organs, most drugs would quickly reach toxic levels, resulting in death.   We are constantly bombarded with online offers to “boost” the detoxifying powers of both organs to improve health – a concept completely unproven and a certain red flag for someone looking to detox your money from your wallet.

It is common knowledge that alcohol is metabolized for removal from the body largely by the liver. Repeated over-consumption of alcohol, especially over the long term, can lead to liver disease. Acetaminophen is also heavily metabolized by the liver, and large doses of this drug, even in a single dose can have devastating effects on this organ.   For the most part, in the average healthy individual, light to moderate intake of alcohol will not cause damage to the kidneys or the liver. The same holds true for acetaminophen in regular doses of 3000-4000 mg per day, even for extended periods of time. In fact we often see studies that seem to indicate that light consumption of alcohol can have some benefits. Keep in mind that this should never be a reason to start consuming alcohol in any amount when you never were before though as alcohol does have some adverse effects on the GI tract associated with it.

Recent evidence however has determined that the consumption of acceptable levels of both of these drugs at the same time can and has lead to serious kidney disease in otherwise healthy people. The effect was of greater probability in older adults (who often have reduced kidney function), males, blacks and Hispanics (over white patients), and those with conditions that can typically reduce kidney function like diabetes, high blood pressure and obesity. This news can come as a shock to those in the medical community who automatically look toward the liver as the weakest link in the metabolism chain for these two drugs. In fact I regularly tell patients to avoid acetaminophen in “hangover” situations as there have been documented cases of liver damage when the two have been taken together. It turns out, that life threatening kidney damage can occur even in the absence of liver disease when they are combined.

The recognized risk is that there is a two-fold increase in kidney dysfunction when these two drugs are combined even at acceptable doses. Keep in mind that many combination products in the over the counter section of the pharmacy contain acetaminophen, including cough and cold and sleep products. There is an increased danger when these medications are consumed and not reported to your pharmacist at the time you are purchasing them. You may be taking acetaminophen already in a prescription product that is combined with an over the counter medication containing the same ingredient. Some patients may also metabolize acetaminophen at a significantly slower rate than others, magnifying the problem. Changing your pain reliever to an anti-inflammatory (NSAID) like ibuprofen or ASA may be no better after alcohol consumption as the increase in inflammation in the lining of the GI tract can result in a serious GI bleed. Using codeine for pain relief is never recommended with alcohol on board.

The take away message here is if you are someone that is taking acetaminophen (or an NSAID or codeine) for pain, you are better off avoiding alcohol consumption even in light amounts. If you are someone with chronic or acute pain to the degree that one of these medications is needed, remember that the adverse effects can be quite sudden rather than gradual, and the use of lower dosages as recommended.

 

 

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Your Pharmacy is Most Likely an Alternative, Complimentary, Off Label, Patient Centred One
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Most Pharmacists rely on the foundation that their “evidence-based” mantra is being followed. A simple Google search shows us that:

“Alternative medicine is any practice that is put forward as having the healing effects of medicine, but does not originate from evidence gathered using the scientific method, is not part of biomedicine, or is contradicted by scientific evidence or established science.”

Just in case you were wondering, Google defines biomedicine as “a branch of medical science that applies biological and other natural-science principles to clinical practice. The branch especially applies to biology and physiology”.

This last one is important as we shall see, because it opens the window for recommendations to be made even in the absence of placebo controlled randomized trials (but yet remain outside of the realm of alternative medicine). It allows biochemistry and physiology and biology to guide recommendations to patients, even though direct studies on humans measuring an effect compared to placebo are lacking. For example, if you are thirsty, drink water or you will eventually die. There really are no such studies to prove this but we believe it anyway. Fair enough. Let’s agree on this for a minute or two as we look at our “go to” recommendations we do every day in the pharmacy.

In 2012 the International Journal of Pharmacy Practice published a research paper that looked into the effect of evidence-based training on Pharmacists everyday recommendations. It found that Pharmacists did not routinely utilize evidence-based resources when making decisions about OTC medicines and some felt uncomfortable discussing the evidence-base for OTC products with patients. (1)

In fact most pharmacists go by three things when making OTC recommendations, what they were taught in school (since most OTC ingredients don’t really change all that much from year to year or decade to decade), what they learn through continuing education and what they see works in their patients over time (also known as clinical experience). This is why I gave up recommending OTC teeth whitening products.   I do however recommend specialized toothpastes for sensitive teeth even though I have never read one independent RCT on either subject – because I routinely hear results from many customers. (2)(3)

These are simple recommendations that on the surface seemed to be a great idea. Not that the success of OTC teeth whitening grew into an urban myth to me but it really didn’t seem right to recommend something I had no scientific proof to back me up and make a profit on it plus lacked the positive feedback from my customers. Perhaps that is alternative therapy?

It’s part of every retail pharmacist’s day, stepping out from behind the dispensary counter and making recommendations that draws from the vast pool of for the most part, unchanging static list of ingredients in the front store. I draw a fair share of comments that claim some recommendations I make are “alternative” or “complimentary”, sometimes referred to as CAM therapies. The definition of this term seems to change with whomever makes up the argument. Some arguments against CAM are certainly legitimate, and some include categories that show some effectiveness but are not mainstream. Some involve treatment, cure or prevention of Health Canada Schedule A disorders, which include many conditions that we try to help daily – we just can’t advertise the products as such. They include obesity, hypertension, diabetes, acute anxiety and others. Either way, there are some regular recommendations made by Pharmacists daily that said Pharmacist assumes is proven to work based on mainstream suggestions, but are you making recommendations based on the same science that backs up the prescriptions you hand out daily. Furthermore, if these therapies do not meet these same evidence based standards, are they automatically shuffled into the CAM category or is there another category they might be moved into? Perhaps urban myths make mainstream otc pharmaceutical suggestions.   Lets look at what the current literature says about common therapies. Are there any studies at all that back up what you are suggesting to your customer as fact? If there are studies, do they have the power to the same? If not, what is your rationale for making these recommendations and at what point do we call the recommendations as alternative or not evidence based. In fact, pharmacists do not always rely on the definition of evidence based in making an OTC recommendation.

Cough Therapy

Turning to the Cochrane Data Base, there are a few reviews for common OTC cough medications. In reviewing 29 trials involving 4835 people (adults and children – studies were current up to March 2014), the Cochrane Library stated “ We found no good evidence for or against the effectiveness of OTC medications in acute cough”.  In a 2006 statement, the American College of Chest Physicians stated that its recommendation for cough due to cold was to treat with an antihistamine/decongestant combination. (4)(5) Also, the findings of using codeine or antihistamines for cough showed neither was superior to placebo. A study in the Archives of Pediatrics and Adolescent Medicine found that in Parent reported cough response to buckwheat honey, a DM cough syrup flavored with honey and a placebo, the honey alone treatment was superior to the DM syrup or the placebo in children. (6)(7) Popular cough syrups that use pine needle oil and Canadian Balsam in a capsicum tincture are popular in all pharmacies but lacking evidence.

 

Narcotics for pain

Marketing by drug companies has been quite successful in the widespread use of narcotics today. In fact when various types of pain are treated with opioids, NSAIDS, and acetaminophen, narcotics’ recommendations often fall at the bottom. Dental pain, while often treated with narcotics, has been shown by the Cochrane Database to be treated more effectively with combination ibuprofen and acetaminophen and back pain has also been shown to have more favorable outcomes when treated with non-opioid medications. (8) Historically pharmacists police OTC meds, sometimes blind while trying to keep patients restricted to a days supply. This is now going to be easier with the dawn of the Drug Information System (DIS) in Nova Scotia, giving more real time data than the triplicate prescription monitoring system. Logging in OTC codeine products allows pharmacists to see in real time the profile of the patient at other pharmacies that are also on the system.

It is becoming more and more clear that opioids are to be the exception rather than the rule when it comes to most pain relief. Terminal conditions involving pain are a clear indication for opioids. The numbers needed to treat are typically higher in the opioids compared to the non-opioid medications and in acute pain to chronic pain conditions the opioids are not preferred unless absolutely necessary. Jumping to OTC codeine has not proven to be the answer with most patients based on science.

 

Antacids

Next to cough and cold, and analgesics, acid suppressing agents are a main staple in a pharmacist’s OTC toolbox. Three main categories are antacids, H2-blockers and PPI’s, all available OTC. Most pharmacists may be under the impression that when these are given, they help neutralize acid in the stomach in their own way and relieve reflux symptoms, and that’s that. It turns out these three medications have differing effects that must be kept in mind to help the patient. Antacids have a role in neutralizing acid in the esophagus transiently but do not significantly affect the pH in the stomach. As a result it has been found that in cases of chronic heartburn, repeated administration of antacids commonly result in erosive esophagitis. For this reason it is important to recommend them only in cases of GERD that is temporary or intermittent in nature and to realize that ulcer healing will be minimal. With the H2 blockers, there is a tolerance that can develop rather quickly with these medications that unfortunately is not dose dependent and there is also a secondary analgesic effect on the tissue of the esophagus. (9)

The key in OTC recommendations is recognizing the strengths and the limitations of each of these medications. Simply giving an antacid for a patient with “heartburn” without knowing the exact details of frequency goes against the indication for that suggestion. Monographs for these medications state a six week course and should not be used long-term for acid suppressing agents. It is important to not continue to give antacids too frequently in order to prevent further damage to the esophagus. In fact there is no evidence to support long-term treatment with H2 blockers or PPI’s.

 

Head Lice

While it was something pharmacists had suspected for years, it has now been shown in clinical trials that the effectiveness of the pediculicide known as permethrin has dropped from 99% in 1996 to 25% in 2009. In 2010 this effectiveness was estimated to be 18% as opposed to 46% for isopropyl myristate, which is now a popular alternative for head lice. This is a case of staying on top of current literature.   (10)   Although something may have been proven to work before, it may not have the same effectiveness now and is continued to be used assuming older data is still appropriate.

 

Chronic Constipation

One of the most commonly recommended laxatives for both occasional and chronic constipation as well as narcotic induced constipation is senna. There are no well designed randomized placebo controlled trials for senna and for the most part I think most pharmacists are unaware of this and go by clinical results in making this recommendation. Also no known studies comparing stand alone efficacy of docusate over placebo exist. Fiber, fluids and exercise show surprisingly little results unless the patient is deficient in any of them. (11)

One of the common arguments against alternative therapy is not so much a lack of studies, but a lack of what is considered quality studies by the one against alternative therapies. Sometimes it is what the majority of us do that removes something from alternative. While there are no lack of studies on nicotine replacement therapy OTC in smoking cessation there are many limitations to many of the studies (12). This is a common argument against treatments that are considered alternative.   At some point however we need to treat somehow and we see clinical results, based on science (RCT or biology) and we use this to guide our recommendations safely.

 

Having said all this, the point is from our experience most over the counter meds really do work for their intended uses. If we required iron clad prescription drug quality studies to flip through on all of our front shop recommendations, we may very well cut the front store medicine section in half, not to mention the prescription medications that are prescribed off label. Certainly a lot of the cosmetic anti-aging and skin cream products would fall away. We also must remember that although we counsel based on past results with patients, we still make recommendations based on our education. Being against alternative medicine, whatever your own definition, may mean supplements, nutraceuticals, hormone therapy or herbal products to you. Maybe you consider selling vitamins as alternative. Some bad examples of irresponsible alternative therapy have painted all therapies with the same brush, and some reported side effects and hospitalizations of patients using alternative therapies fail to mention hospitalizations of patients on conventional medicine. As pharmacists, we value what is considered modern medicine but it’s not all that is out there that works. We must be considered the drug expert in all therapies, whether they are proven and safe to completely unproven and unsafe and everything in between in order to make an informed recommendation. Perhaps “evidence based” is a point we try to achieve but never completely reach until we change our definition of what it is. Based on how we defined alternative medication at the start of this article, perhaps alternative therapies are not as uncommon in pharmacies as is claimed by those that are against them.

 

 

 

 

References

 

1) Lezley-Anne Hanna and Carmel Hughes; The influence of evidence-based medicine training on decision-making in relation to over-the-counter medicines: a qualitative study; International Journal of Pharmacy Practice Volume 20, Issue 6, pages 358–366, December 2012

2) Demarco FF, Meireles SS, Masotti AS. Over-the-counter whitening agents: a concise review. Braz Oral Res. 2009;23 Suppl 1:64-70

3) Ilze Maldupa, Anda Brinkmane, Inga Rendeniece, Anna Mihailova ;Evidence based toothpaste classification, according to certain characteristics of their chemical composition ; Stomatologija, Baltic Dental and Maxillofacial Journal, 14:12-22, 2012

4) Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC) medications for acute cough in children and adults in community settings. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD001831.

5) Smith SM, Schroeder K, Fahey T. Over-the-counter medications for acute cough in children and adults in ambulatory settings. Cochrane Database Syst Rev. 2008;(1)

6) Paul IM, Beiler J, McMonagle A, Shaffer ML, Duda L, Berlin CM Jr Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents Arch Pediatr Adolesc Med. 2007 Dec;161(12):1140-6.

7) An De Sutter. There is no good evidence for the effectiveness of commonly used over-the-counter medicine to alleviate acute cough ; Evid Based Med 2015;20:98 doi:10.1136/ebmed-2014-110156 Systematic review

8) Dr Donald Treater M.D. Evidence for the Efficacy of Pain Medications. National Safety Council (NSC.org)

9) McRorie, J. W., Gibb, R. D. and Miner, P. B. (2014), Evidence-based treatment of frequent heartburn: The benefits and limitations of over-the-counter medications. American Assoc Nurse Prac, 26: 330–339

10) Sanofi-Pasteur , Evidence Based Management of Head Lice 2014

* (Sanofi-Pasteur is a manufacturer of ivermectin lotion)

11) Lawrence Leung, MBBChir, FRACGP, FRCGP, Taylor Riutta, MD, Jyoti Kotecha, MPA, MRSC, and Walter Rosser MD, MRCGP, FCFP Chronic Constipation: An Evidence-Based Review . Journal of the American board of family medicine July-August 2011 Vol. 24 No. 4 pp 436-451

12) Nicotine Replacement Therapy for Smoking Cessation or Reduction: A Review of the Clinical Evidence [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2014 Jan 16. SUMMARY OF EVIDENCE.

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